Obstetrics

Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby.

3 Rationale: The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta.

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid.

3 Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

267l A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest? 1. Swimming 2. Scuba diving 3. Low-impact gymnastics 4. Bicycling with the legs in the air

1 Rationale: Non-weight-bearing exercises are preferable to weight-bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because 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 exercises such as swimming are allowable.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." f. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1 Rationale: Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast.feeding. Clients who have HlV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 ml. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breastfeeding or breast pump.

1, 2, 3, 4 Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses 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

1, 2, 4 Rationale: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, or increased respiration rate is not associated with preeclampsia.

When teaching a primigravid client at 24 weeks' gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include? 1. A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. 2. A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography. 3. Contraction stress testing, performed· on most pregnant women, can be initiated as early as 16 weeks' gestation. 4. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample.

1. The fetal biophysical profile includes fetal breathing movements, fetal body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. A reactive nonstress test is a sign of fetal well-being and does not require further evaluation. A no1u-eactive nonstress test requires further evaluation. A contraction stress test or oxytocin challenge test should be performed only on women who are at risk for fetal distress during labor. The contraction stress test is rarely performed before 28 weeks' gesta- tion because of the possibility of initiating labor. Percutaneous umbilical cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood san1ple.

When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay pregnancy test, the nurse should tell the client which of the following about this test? 1. It has a high degree of accuracy within 1 week after ovulation. 2. It is identical in nature to an over-the-counter home pregnancy test. 3. A positive result is considered a presumptive sign of pregnancy. 4. A urine sample is needed to obtain quicker results.

1. The radioimmunoassay pregnancy test, which uses an antiserum with specificity for the b-subunit of human chorionic gonadotropin (hCG) in blood plasma, is highly accurate within 1 week after ovulation. The test is performed in a laboratory. Over-the-counter or home pregnancy tests are performed on urine and use the hemagglutination inhibition method. Radioimmunoassay tests usually use blood serum. A positive pregnancy test is considered a probable sign of pregnancy. Certain conditions other than pregnancy, such as choriocarcinoma, can cause increased hCG levels.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 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 on the birth record.

2 Rationale: Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do nto acknowledge the client's feelings.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3 Rationale: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3 Rationale: Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsal is pedis pulses is a normal finding.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4 Rationale: Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessarily.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 ° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4 Rationale: The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38 ° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breastfeeding." 4. "I should wash my nipples daily with soap and water."

4 Rationale: Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such, as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of handwashing and that she should breast-feed every 2 to 3 hours.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. l. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age.

4, 5, 6 Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

Using Nagele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of childbirth would be which of the following? 1. January 13. 2. January 17. 3. February 13. 4. February 17.

4. When using Nagele's rule to determine the estimated dale of childbirth, 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 February 17.

A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which of the following feelings? 1. Ambivalence. 2. Anxiety. 3. Fear. 4. Guilt.

4. With a spontaneous abortion, many clients and their partners feel an acute sense of loss. Their grieving commonly includes feelings of guilt, which may be expressed as wondering whether the woman couId have done something to prevent the loss. Anger, sadness, and disappointment are also common emotions after a pregnancy loss. Ambivalence, anxiety, and fear are not common emotions after a spontaneous abortion.

The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

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

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

1 Rationale: A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.

The 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/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

1 Rationale: A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? 1. Normal 2. Abnormal 3. The need for further evaluation 4. That findings were difficult to interpret

1 Rationale: A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range ( 120 to 160 beats/minute) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 beats/minute must occur, each with a duration of at least 15 seconds, in a 20-minute interval.

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

1 Rationale: A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

When caring for a primigravid client at 9 weeks' gestation who immigrated to North America from Vietnam 1 year ago, the nurse would assess the client's diet for a deficiency of which of the following? 1. Calcium. 2. Vitamin E. 3. Vitamin C. 4. Iodine.

1. The diet for Vietnamese clients typically consists of small portions of meat and ample amounts of rice. Fresh milk may not have been readily available in Vietnam, and many Asian clients are lactose intolerant. Therefore, the nurse would need to assess the client's diet for deficiencies of calcium and possibly iron. Traditionally, Southeast Asian diets have an abundance of dark green leafy vegetables, such as mustard greens and bok choy, which contain adequate amounts of vitamin E and vitamin C. Seafood, which contains iodine, is usually adequate in the diets of Southeast Asian women.

During a 2-hour childbirth preparation class focusing on the labor and birth process for primigravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is the presenting part. In which order do these maneuvers occur? 1. Engagement 2. Flexion 3. Descent 4. Internal rotation

1. Engagement 3. Descent 2. Flexion 4. Internal rotation Engagement refers to the fetus' entering the true pelvis and occurs before descent in primiparas and con-currently in multiparnus women. If the head is the presenting part, the normal maneuvers during labor and birth are (in order): descent, flexion, internal rotation, extension, external rotation, and expulsion. These maneuvers are called the cardinal movements. They occur as the fetal head passes through the maternal pelvis during the normal labor process.

The nurse should include which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pubic arch." 2. "Your type of pelvis is the most favorable for labor and birth." 3. "Your type of pelvis is a wide pelvis, but has a short diameter." 4. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

2 Rationale: A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable 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. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm i

2 Rationale: A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is II to l3g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings 10 facilitate increased cardiac output, oxygen transport, and kidney filtration. While blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 10 15,000 cells/mm3 (up to 18,000 cells/mm3). During the immediate postpartum period, the while blood cell count may be 25,000 10 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.

A 20-year-old married client with a positive pregnancy test states, "Is it really true? I can't believe I'm going to have a baby!" Which of the following responses by the nurse would be most appropriate at this time? 1. "Would you like some booklets on the pregnancy experience?" 2. "Yes it is true. How does that make you feel?" 3. "You should be delighted that you are pregnant." 4. "Weren't you and your husband trying to have a baby?"

2. This client is expressing a feeling of surprise about having a baby. Therefore, the nurse's best response would be lo 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 experienced 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 lo pregnancy. Telling the client that she should be delighted may lead to feelings of guilt. Asking the client if she and her husband were trying to have a baby is a "yes-no" question and is not helpful. In addition, it ignores the client's underlying feelings.

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3 Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection.

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? 1. Hematocrit 38% 2. Glucose 86 mg/dL 3. Hemoglobin 9.1 g/dL 4. White blood cell count 12,400 cells/mm3

3 Rationale: Pica practices often lead to iron deficiency anemia, resulting in a decreased hemoglobin level. The laboratory values in options I, 2, and 4 are normal for the pregnant client.

Which of the following would be included in the teaching plan about pregnancy-related breast changes for a primigravid client? 1. Growth of the milk ducts is greatest during the first 8 weeks of gestation. 2. Enlargement of the breasts indicates adequate levels of progesterone. 3. Colostrum is usually secreted by about the 16th week of gestation. 4. Darkening of the areola occurs during the last month of pregnancy.

3. Colostrum is usually secreted by about the 16th week of gestation in preparation for breastfeeding. Growth of the milk ducts is greatest in the last trimester, not in the first 8 weeks of gestation. Enlargement of the breasts is usually caused by estrogen, not progesterone. Darkening of the areola can occur as early as the sixth week of gestation.

Which of the following client statements indicates a need for additional teaching about selfcare during pregnancy? 1. "I should use nonskid pads when I take a shower or bath." 2. "I should avoid using soap on my nipples to prevent drying." 3. "I should sit in a hot tub for 20 minutes to relax after working." 4. "I should avoid douching even if my vaginal secretions increase."

3. The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the first trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk of infection.

A nurse is assigned to the obstetrical triage area. When beginning the assignment, the nurse is given a report about four clients waiting to be seen. Place the clients in the order in which the nurse should see them. 1. A primigravid client at 10 weeks' gestation stating she is not feeling well with nausea and vomiting, urinary frequency, and fatigue. 2. A mulliparous client at 32 weeks' gestation asking for assistance with finding a new primary health care provider. 3. A single mother at 4 months postpartum fearful of shaking her baby when he cries. 4. An antenatal client at 16 weeks' gestation who has occasional sharp pain on her left side radiating from her symphysis to her fundus.

3. A single mother at 4 months postpartum fearful of shaking her baby when he cries. 4. An antenatal client at 16 weeks' gestation who has occasional sharp pain on her left side radiating from her symphysis lo her fundus. 1. A primigravid client at 10 weeks' gestation staling she is not feeling well with nausea vomiting, urinary frequency, and fatigue. 2. A multiparous client at 32 weeks' gestation asking for assistance with finding a new primary health care provider The first client to be seen should be the postpartum mother who is fearful of shaking her infant. Postpartum depression is a disorder that may occur during the first year postpartum but peaks at 4 weeks postpartum, prior to menses, or upon weaning. As a single mother, this client may not have support, a large factor putting women at risk. Other factors accentuating risk include prior depressive or bipolar illness and self-dissatisfaction. Second, the nurse should see the 16-week antenatal client, who is likely experiencing round ligament syndrome. Al this point in the pregnancy, the uterus is stretching into the abdomen causing this type of pain. The pain is on the wrong side to be attributed to appendicitis or gallbladder disease. Nursing interventions to ease the pain include a heating pad or bringing the legs toward the abdomen. The nurse should next sec the primigravid client who states she is not feeling well because she is exhibiting signs and symptoms of discomfort experienced by most women in the first trimester. The multiparous client at 32 weeks' gestation is the lowest priority as she is physically well, while the other clients have physical and psychological problems. In most emergency department situations, she may not be seen by medical or nursing staff but would be given the names of health care providers in the reception area.

A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 2. 8 and 10 3. 10 and I 2 4. 14 and 18

4 Rationale: Quickening is fetal movement that is felt by the mother. In the multiparous woman this may occur as early as the fourteenth 10 sixteenth weeks. The nulliparous woman may not notice these sensations until the eightenth week or later. Options l, 2, and 3 are incorrect time frames because quickening does not occur this early during pregnancy.

After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is produced by the placenta? 1. Estrogen. 2. Progesterone. 3. Human chorionic gonadotropin (hCG). 4. Testosterone.

4. The placenta does not produce testosterone. Human placental 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 prenatal class about endocrine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? 1. Human placental lactogen maintains the corpus luteum. 2. Progesterone is responsible for hyperpigmentation and vascular skin changes. 3. Estrogen relaxes smooth muscle in the respiratory tract. 4. The thyroid enlarges with an increase in basal metabolic rate.

4. Thyroid enlargement and increased basal body metabolism are common occurrences during pregnancy. Human placental lactogen enhances miIk production. Estrogen is responsible for hyperpigmentation and vascular skin changes . Progesterone relaxes smooth muscle . 111 the respiratory tract.

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" The nurse should tell the participant which of the following about true labor contractions? 1. "Walking around helps to decrease true contractions." 2. "True labor contractions may disappear with ambulation, rest, or sleep." 3. "The duration and frequency of true labor contractions remain the same." 4. "True labor contractions are felt first in the lower back, then the abdomen."

4. With true labor, the contractions are felt first in the lower back and then the abdomen. They gradually increase in frequency and duration and do not disappear with ambulation, rest, or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase true contractions. False labor contractions disappear with ambulation, rest, or sleep. False labor contractions commonly remain the same in duration and frequency. Clients who are experiencing false labor may have pain, even though the contractions are not very effective.

The nurse is discussing dietary concerns with pregnant teens. Which of the following choices are convenient for teens yet nutritious for both the mother and fetus? Select all that apply. 1. Milkshake or yogurt with fresh fruit or granola bar. 2. Chicken nuggets with tater tots. 3. Cheese pizza with spinach and mushroom topping. 4. Peanut butter with crackers and a juice drink. 5. Buttery light popcorn with diet cola. 6. Cheeseburger with tomato, lettuce, pickle, ketchup, and baked potato.

1, 3, 4 Dairy products, fresh fruit, vegetables, and foods high in protein (like cheese and peanut butler) are excellent choices. Fried foods, such as chicken nuggets and tater tots, and foods such as cheeseburgers and buttered popcorn are high in fat; carbonated drinks such as diet colas, and foods such as pickles and ketchup contain large amounts of sodium. These foods can lead to an increase in ankle edema and promote weight gain from empty calories.

During a childbirth preparntion class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which of the following exercises suggested by the nurse would be most helpful? 1. Pelvic rocking. 2. Deep breathing. 3. Tailor sitting. 4. Squatting.

1. Pelvic rocking helps to relieve backache during pregnancy and early labor· by making the spine more flexible. Deep breathing lung exercises assist with relaxation and pain relief during labor. Tailor sitting and squatting help stretch the perineal muscles in preparation for labor.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2 Rationale: The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids are likely to be withheld at this time.

The nurse instructs a primigravid client about the importance of sufficient vitamin A in her diet. The nurse knows that the instructions have been effective when the client indicates that she should include which of the following in her diet? 1. Buttermilk and cheese. 2. Strawberries and broccoli. 3. Egg yolks and squash. 4. Oranges and tomatoes.

3. Egg yolks and squash and other yellow vegetables are rich sources of vitamin A. Pregnant women should avoid mega doses of vitamin A because fetal malformations may occur. Buttermilk and cheese are good sources of calcium. Strawberries, broccoli, citrus fruits (such as oranges), and tomatoes are good sources of vitamin C, not vitamin A.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.

4 Rationale: If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4 Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse assesses a woman at 24 weeks' gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the client's last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order? 1. Call the health care provider. 2. Explain that the fetal heart beat could not be found at this time. 3. Obtain different equipment and recheck. 4. Ask the client if the baby is or has been moving.

4,3,2,1. While initially continuing to attempt to find the fetal heart beat, 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 heart beat again. A simple statement of fact that the nurse cannot find the heartbeat and is taking steps to rule out equipment error is appropriate. Calling the health care provider would be the last step after it is determined that the baby does not have a heartbeat.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1 Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1 Rationale: After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The 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. This finding is most closely associated with which characteristic? 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 to the maternal pulse during auscultation of the uterus

1 Rationale: At the beginning of the second month of gestation, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening is noted by the examiner during pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin noted in maternal urine is a probable sign of pregnancy. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1 Rationale: Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perinea! tissues.

The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? 1. Increase in pulse rate 2. Increase in blood pressure 3. Frequent bowel elimination 4. Decrease in red blood cell production

1 Rationale: Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/minute, which then persists to term. Options 2, 3, and 4 are incorrect. During pregnancy, the blood pressure usually is the same as the prepregnancy level. but then gradually decreases up to about 20 weeks of gestation. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus. During pregnancy, there is an accelerated production of red blood cells.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery

1 Rationale: Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a IO-minute period. Options 2, 3, and 4 are incorrect interpretations.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? 1. A client who has a history of intravenous drug use 2. A client who has a significant other who is heterosexual 3. A client who has a history of sexually transmitted infections 4. A client who has had one sexual partner for the past 10 years

1 Rationale: Human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals with persistent and recurrent sexually transmitted infections, individuals who have a history of multiple sexual partners, and individuals who have used intravenous drugs. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIY.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely.

1 Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would 1101 be encouraged to ambulate every 30 minutes, but would be encouraged lo rest.

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypenonic 4. Preterm labor

1 Rationale: Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic dystocia usually occurs during the latent phase of labor, and contractions are painful, frequent, and usually uncoordinated. Precipitous labor is labor that lasts in its entirety for 3 hours or less. Preterm labor is the onset of labor after 20 weeks of gestation and before the thirty-seventh week of gestation.

The nurse is assessing a pregnant client with type I diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will likely need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs should return to normal within 7 to 10 days after birth if I am bottlefeeding."

1 Rationale: Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

1 Rationale: Late deceleration are due 10 uteroplacental insufficiency and occur because of decreased blood now and oxygen 10 the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 10 10 L/minute via face mask is necessary. The supine position is avoided because ii decreases uterine blood now to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause futher hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1 Rationale: The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1 Rationale: The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1 Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This 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 position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's position or prone position is not practical for this type of abdominal surgery.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. "What can I do for you?" 2 "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1 Rationale: When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and 10 use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1, 2, 3, 6 Rationale: The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breastfeeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol. or other medications.

The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 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

1,2,3,4 Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. 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 17-year-old gravid client presents for her regularly scheduled 26-week prenatal visit. She appears disheveled, is wearing ill-fitting clothes, and does not make eye contact with the nurse. Which items should the nurse discuss with the client? Select all that apply. 1. Intimate partner violence. 2. Substance abuse. 3. Depression. 4. Glucose tolerance screening test. 5. HCG (Human chorionic gonadotropin) levels.

1,2,3,4. Anyone could be a victim of intimate partner violence. Health care workers should routinely assess women for intimate partner violence. Pregnant teens have increased risk for not finishing school, smoking, and substance abuse. It is possible that the client is depressed and her appearance and lack of eye contact are symptoms of her depression. The nurse expects the glucose tolerance screening test to be prescribed between 24 and 28 weeks' gestation to screen for gestational diabetes. HCG levels can identify the presence of a pregnancy or give information about an abnormal pregnancy. It would not be done at this time in a normal pregnancy.

A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the incidence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods? Select all that apply. 1. Leafy green vegetables. 2. Strawberries. 3. Beans. 4. Milk. 5. Sunflower seeds. 6. Lentils.

1,2,3,5,6. The pregnancy requirement for folic acid is 600 mcg/day. Major sources of folic acid include leafy green vegetables, strawberries and oranges, beans, particularly black and kidney beans, sunflower seeds, and lentils. Milk and fats contain no folic acid.

The antenatal clinic nurse is educating a gestational diabetic soon after diagnosis. Outcome evaluation for this client session will include which of the following? Select all that apply. 1. The client states the need to maintain blood glucose levels between 70 and 110 mg/dL (3.9 to 6.2 mmol/L). 2. The client describes her planned walking program while pregnant. 3. The client will strive to maintain a hemoglobin A1C of less than 6% (0.06). 4. The client verbalizes the need to maintain a dietary intake of less than 1,500 cal/day to prevent hyperglycemia. 5. The client will continue her prenatal vitamins, iron, and folic acid.

1,2,3,5. The gestational diabetic needs lo maintain blood glucose levels as close to "normal" as the nondiabetic pregnant woman. Walking is an excellent form of exercise for anyone and works well for pregnant diabetics as it burns calories, accelerates the heart rate, and as a result maintains the blood sugar at a lower level. During pregnancy continuously high blood glucose levels measured by a hemoglobin A1C of greater than 6 mg/dL (60 g/L) carry risks for the dyad. The suggested diet for a gestational dibetic is 1,800 to 2,400 cal/clay to avoid the body breaking down maternal fat to maintain blood glucose levels. Continuing prenatal vitamins, iron, and folic acid (800 mcg/day) are general nutritional recommendations for pregnancy.

A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. 1. Walk in the hospital room. 2. Use slow chest breathing. 3. Request pain medication on a regular basis. 4. Lightly massage her abdomen. 5. Sip ice water.

1,2,4. Pain during the first stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching. of the lower uterine segment, dilatation of the cervix and perineum, and pressure on adjacent structures. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles. Slow chest breathing is appropriate during the first stage of labor Lo promote increased oxygenation as well as relaxation. The woman or her coach can lightly massage the abdomen (effleurage) while using slow chest breathing. Chest breathing and massaging increase oxygenation and relaxation of uterine muscles. Pain medication is not used during the first stage of labor because most medications will slow labor; anesthesia may be considered during the second stage of labor. Sipping ice water, while helpful for maintaining hydration, will not be useful as a pain management strategy.

A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which of the following? Select all that apply. 1. Hepatitis B immune globulin at birth. 2. Series of three hepatitis B vaccinations per recommended schedule. 3. Hepatitis B screening when born. 4. Isolation of infant during hospitalization. 5. Universal precautions for mother and infant. 6. Contraindication for breast-feeding.

1,2,5. The test result indicates that the mother has an active hepatitis infection and is a carrier. Hepatitis B immune globulin at birth provides the infant with passive immunity against hepatitis B and serves as a prophylactic treatment. Additionally, the infant will be started on the vaccine series of three injections. The infant should not be screened or isolated because the infant is already hepatitis B positive. As with all clients, universal precautions should be used and are sufficient to prevent transmission of the virus. Women who are positive for hepatitis B surf ace antigen are able to breast-feed.

A primiparous client at 10 weeks' gestation questions the nurse about the need for an ultra sound. She states "I don't have health insurance and I can't afford it. I feel fine, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply. 1. "We must view the gross anatomy of the fetus." 2. "We need to determine gestational age." 3. "We want to view the heart beating to determine that the fetus is viable." 4. "We must determine fetal position." 5. "We must determine that there is a sufficient nutrient supply for the fetus."

1,2. Although ultrasounds are not considered part of routine care, the ultrasound is able to confirm the pregnancy, identify the major anatomic features of the fetus and possible abnormalities, and determine the gestational age by measuring crown-to-rump length of the embryo during the first trimester. At this time, the ultrasound cannot confirm that the fetus is viable. The ultrasound will provide information about fetal position; however, this information would be more important later in the pregnancy, not during the first trimester. The ultrasound would provide no information about nutrient supply for the fetus.

A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated birth. The nurse should tell the woman: 1. "The maximum blood loss considered within normal limits is 500 mL." 2. "The minimum blood loss considered within normal limits is 1,000 mL." 3. "Blood loss during childbirth is rarely estimated unless there is a hemorrhage." 4. "lt would be very unusual if you lost more than 100 mL of blood during childbirth."

1. ln a normal birth and for the first 24 hours postpartum, a total blood loss not exceeding 500 mL is considered normal. Blood loss during childbirth is almost always estimated because it provides a valuable indicator for possible hemorrhage. A blood loss of 1,000 mL is considered hemorrhage.

When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? 1. External genitalia. 2. Myelinization of nerves. 3. Brown fat stores. 4. Air ducts and alveoli.

1. Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of fetal development. Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approximately 21. to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks.

Which of the following statements by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?" 1. "This usually disappears after childbirth." 2. "It is a sign of skin melanoma." 3. "The discoloration is due to dilated capillaries." 4. "It will fade if you use a prescribed cream."

1. Discoloration on the face that commonly appears during pregnancy, called chloasma (mask of pregnancy), usually fades postpartum and is of no clinical significance. The client who is bothered by her appearance may be able to decrease its prominence with ordinary makeup. Chloasma is not a sign of skin melanoma. It is not caused by dilated capillaries. Rather, it results from increased secretion of melanocyte-stimulating hormones caused by estrogen and progesterone secretion. No treatment is necessary for this condition.

Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn? 1. Eat smaller and more frequent meals during the clay. 2. Take a pinch of baking soda with water before meals. 3. Decrease fluid intake to four glasses daily. 4. Drink several cups of regular tea throughout the day.

1. Eating smaller and more frequent meals may help prevent heartburn because acid production is decreased and stomach displacement is reduced. Heartburn can occur at any time during pregnancy. Contributing factors include stress, tension, worry, fatigue, caffeine, and smoking. Certain spicy foods (eg, tacos) may trigger heartburn in the pregnant client. The client should be advised to avoid sodium bicarbonate antacids (eg, AlkaSeltzer). baking soda, Bicitra or sodium citrate, and fatty foods, which are high in sodium and can contribute to fluid retention. Increasing, not decreasing, fluid intake may help to relieve heartburn by diluting gastric juices. Caffeinated products such as coffee or tea can stimulate acid formation in the stomach, further contributing to heartburn.

A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: 1. "Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers." 2. "Eating foods with moderate amounts of folic acid helps regulate blood glucose levels." 3. "Folic acid consumption helps with the absorption of iron during pregnancy." 4. "Folic acid is needed to promote blood clotting and collagen formation in the newborn."

1. Folic acid supplementation is recommended to prevent neural tube defects and anemia in pregnancy. Deficiencies increase the risk of hemorrhage during birth as well as infection. The recommended dose prior to pregnancy is 400 mcg/day; while breast-feeding and during pregnancy, the recommended dosage is 500 to 600 mcg/day. Blood glucose levels are not regulated by the intake of folic acid. Vitamin C potentiates the absorption of iron and is also associated with blood clotting or collagen formation.

When developing a teaching plan for a client who is 8 weeks pregnant, which of the following foods would the nurse suggest to meet the client's need for increased folic acid? 1. Spinach. 2. Bananas. 3. Seafood. 4. Yogurt.

1. Green, leafy vegetables, such as asparagus, spinach, brussel sprouts, and broccoli, are rich sources of folic acid. The pregnant vvoman needs to eat foods high in folic acid to prevent folic acid deficits, which may result in neural tube defects in the newborn. A well-balanced diet must include whole grains, dairy products, and fresh fruits; however, bananas are rich in potassium, seafood is rich in iodine, and yogurt is rich in calcium, not folic acid.

When providing care to the client who has undergone a dilatation and curettage (D&C) after a spontaneous abortion, the nurse administers hydroxyzine as prescribed. Which of the following is an expected outcome? 1. Absence of nausea. 2. Minimized pain. 3. Decreased uterine cramping. 4. Improved uterine contractility.

1. Hydroxyzine has a tranquilizing effect and also decreases nausea and vomiting. It does not decrease fluid retention, reduce pain, decrease uterine cramping, or promote uterine contractility. One of the adverse effects of the medication is sleepiness. Ibuprofen may decrease pain from uterine cramping. Oxytocin may be used to increase uterine contractility.

A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the following suggestions would be most helpful? 1. Practice relaxation techniques before bedtime. 2. Drink a cup of hot chocolate before bedtime. 3. Drink a small glass of wine with dinner. 4. Exercise for 30 minutes just before bedtime.

1. Insomnia in the later part of pregnancy is not uncommon because the client has difficulty getting into a position of comfort. This is further compounded by frequent nocturia. The best suggestion would be to advise the client to practice relaxation techniques before bedtime . The client should avoid caffeine products such as chocolate and coffee before going to bed because caffeine is a stimulant. Alcohol consumption, regardless of the type or amount, should be avoided. Exercise is advised during the day, but it should be avoided before bedtime because exercise can stimulate the client and decrease the client's ability to fall asleep.

An antenatal client is discussing her anemia with the nurse in the prenatal clinic. After a discussion about sources of iron to be incorporated into her daily meals, the nurse knows the client needs further instruction when she responds with which of the following? 1. "I can meet two goals when I drink milk, lots of iron and meeting my calcium needs at the same time." 2. "Drinking coffee, tea, and sodas decreases the absorption of iron." 3. "I can increase the absorption of iron by drinking orange juice when I eat." 4. "Cream of wheat and molasses are excellent sources of iron."

1. Milk contains a large amount of calcium but contains no iron. Coffee, tea, and caffeinated soft drinks inhibit the absorption of iron. The vitamin C found in orange juice enhances the absorption of iron. Cream of wheat (1 cup/10 mg iron) and molasses (1 tbsp/3.0 mg iron) are considered excellent sources of iron as they contain the indicated amounts of iron.

Which of the following statements best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client? 1. Pregnant adolescents are at high risk for pregnancy-induced hypertension. 2. Gestational diabetes during pregnancy commonly develops in adolescents. 3. Adolescents need additional instruction related to common discomforts. 4. The father of the baby is rarely involved in the pregnancy

1. Prenatal care is commonly the most critical factor influencing pregnancy outcome. This is especially true for adolescents, because the most significant medical complication in pregnant adolescents is pregnancy-induced hypertension. Continued prenatal care helps to allow for early detection and prompt intervention should the complication arise. Other risks for adolescents include low-birth-weight infant, preterm labor, iron-deficiency anemia, and cephalopel vie disproportion. Gestational diabetes can occur with any pregnancy regardless of the age of the mother. Generally, all first-time mothers need instruction related to discomforts. Adolescent mothers have better nutrition when they attend group classes and are subject to peer pressure. No evidence demonstrates that most adolescents lack support systems. Fathers may abandon mothers at any time during the pregnancy; other fathers, regardless of age, are supportive throughout the pregnancy.

While caring for a 24-year-old primigravid client scheduled for emergency surgery because of a probable ectopic pregnancy, the nurse should: 1. Prepare to witness an informed consent for surgery. 2. Assess the client for massive external bleeding. 3. Explain that the fallopian tube can be salvaged. 4. Monitor the client for uterine contractions.

1. The client may need surgery to remove a ruptured fallopian tube where the pregnancy bas occurred, and the nurse is usually responsible for witnessing the signature on the informed consent. Typically, if bleeding is occurring, it is internal and there is only scant vaginal bleeding with no discoloration. The nurse cannot determine whether the fallopian tube can be salvaged; this can be accomplished only during surgery. If the tube has ruptured, it must be removed. If the tube has not ruptured, a linear salpingostorny may be done to salvage the tube for future pregnancies. With an ectopic pregnancy, although the client is experiencing abdominal pain, she is not having uterine contractions.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2 Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2014 2. July 26, 2015 3. August 12, 2015 4. August 26, 2015

2 Rationale: Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2014; subtract 3 months, July 19, 2014; add 7 days, July 26, 2014; add 1 year, July 26, 2015.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2 Rationale: Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options I and 4 are important lo assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2 Rationale: Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 ° F 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2 Rationale: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding? 1. 22 cm 2. 30cm 3. 36 cm 4. 40cm

2 Rationale: During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus' age in weeks ±2 cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

2 Rationale: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the diem'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 would be the priority.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

2 Rationale: If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? l. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 Rationale: In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fund us of the uterus, and this site is more prone to bleeding. Options I, 3, and 4 are 1101 risks that are related specifically Lo placenta previa.

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client Lo provide relief from the leg cramps? 1. "Bend your foot toward your body while flexing the knee when the cramps occur." 2. "Bend your foot toward your body while extending the knee when the cramps occur." 3. "Point your foot away from your body while flexing the knee when the cramps occur." 4. "Point your foot away from your body while extending the knee when the cramps occur."

2 Rationale: Leg cramps occur when the pregnant client stretches her leg and plamar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contacting, and stops the cramping. Options 1, 3, and 4 are not measures that provide relief from leg cramps.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately." 4. "Use tampons if the discharge is bothersome, but to be sure to change the tampons every 2 hours."

2 Rationale: Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report 10 the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.

2 Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is iniliated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

The nurse is collecting data during an 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 tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G=3, T =2, P=O, A=O, L=1 2. G=2,T=1, P=O, A=O, L=1 3. G=1, T=1, P=1, A=O, L=1 4. G=2,T=0, P=O,A=O, L=1

2 Rationale: Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks' gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks' gestation; included in parity [number of births] if past 20 weeks' gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida 2. The client has a history of cardiac disease 3. The client's hemoglobin level is 13.5g/dL 4. The client is a 20-year-old primigravida of average weight and height

2 Rationale: Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? l. "I will watch for the evidence of the passage of tissue." 2. "I will maintain strict bed rest throughout the remainder of the pregnancy." 3. "I will count the number of perineaI pads used on a daily basis and note the amount and color of blood on the pad." 4. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

2 Rationale: Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider. The client is instructed to count the number of perinea! pads used daily and to note the quantity and color of blood on the pad. The client also should watch for the evidence of the passage of tissue.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

2 Rationale: The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. Thee client needs to notify her health care provider if she feels fewer than 10 kicks over two, 2-hour time intervals or as instructed by her HCP.

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 1. Avoid wearing a bra. 2. Wash the breasts with warm water and keep them dry. 3. Wear tight-fitting blouses or dresses to provide support. 4. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.

2 Rationale: The pregnant client should be instructed to wash the breasts with warm water and keep them dry. The client should be instructed to avoid using soap on the nipples and areolar area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-filling blouses or dresses cause discomfort. The client is instructed to wear soft-textured clothing to decrease nipple tenderness and to use breast pads inside the bra to prevent leakage through the clothing if colostrum is a problem.

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin (Pitocin). 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

2 Rationale: The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Applying oxygen, increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation. Contacting the client's primary support person(s) is not the priority action at this time.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

2 Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call 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 reduce blood flow further. The examiner may place a gloved hand into the vagina, however, and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation.

A rubella titer result of a I-day postpartum•!• client is less than 1 :8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure lo immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for I week.

2, 3, 4, 5 Rationale: Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for I to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

A primigravid client at 32 weeks' gestation is enrolled in a breast-feeding class. Which of the following statements indicate that the client understands the breast-feeding education? Select all that apply. 1. "My milk supply will be adequate since I have increased a whole bra size during pregnancy." 2. "I can hold my baby several different ways during feedings." 3. "If my infant latches on properly, I won't develop mastitis." 4. "If I breast-feed, my uterus will return to prepregnancy size more quickly." 5. "Breast milk can be expressed and stored at room temperature since it is natural." 6. "I need to feed my baby when I see feeding cues and not wait until she is crying."

2,4,6. Understanding of breast-feeding education is demonstrated by statements involving knowledge of the several positions available for comfortable breast-feeding, oxytocin release from the pituitary leading to a let-down reflex and uterine contractions for involution, and feeding cues helpful in successful breast-feeding (because waiting until the infant is hungry and crying is stressful). Breast size does not ensure successful breast-feeding. Mastitis is an infectious process and is not influenced by latching on. Breast milk needs to be stored in the refrigerator or freezer lo decrease the risk of bacterial growth.

A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which of the following instructions would be helpful? 1. Perform slow contraction and relaxation of the feet and ankles twice daily. 2. Take frequent rest periods with the legs elevated above the hips. 3. Avoid support hose that reach above the leg varicosities. 4. Take a leave of absence from your job to avoid prolonged standing.

2. The client with leg varicosities should take frequent rest periods with the legs elevated above the hips to promote venous circulation. The client should avoid constrictive clothing, but support hose that reach above the varicosities may help alleviate the pain. Contracting and relaxing the feet and ankles twice daily is not helpful because it does not promote circulation. Taking a leave of absence from work may not be possible because of economic reasons. The client should try to rest with her legs elevated or walk around for a few minutes every 2 hours while on the job.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client? 1. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. 2. Refer the client to her health care provider for evaluation and treatment of the pain. 3. Discuss nutritional strategies to decrease the possibility of heartburn. 4. Support the client's use of acetaminophen (Tylenol) to relieve pain.

2. The nurse seeing this client should refer her to a health care provider for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Tylenol is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems.

A 40-year-old client at 8 weeks' gestation has a 3-year-old child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling as genetic screening methods for the expected baby. The nurse is confident that the teaching has been understood when the client states which of the following? 1. "Each test identifies a different part of the infant's genetic makeup." 2. "Chorionic villus sampling can be performed earlier in pregnancy." 3. "The test results take the same length of time to be completed." 4. "Amniocentesis is a more dangerous procedure for the fetus."

2. Chorionic villus sampling (CVS) can be performed from approximately 8 to 12 weeks' gestation, while amniocentesis cannot be performed until between 11 weeks' gestation and the end of the pregnancy. Eleven weeks' gestation is the earliest possible time within the pregnancy to obtain a sufficient amount of amniotic fluid to sample. Because CVS take a piece of membrane surrounding the infant, this procedure can be completed earlier in the pregnancy. Amniocentesis and chorionic villus sampling identify the genetic makeup of the fetus in its entirety, rather than a portion of it. Laboratory analysis of chorionic villus sampling takes less time to complete. Both procedures place the fetus at risk and postprocedure teaching asks the client to report the same complicating events (bleeding, cramping, fever, and fluid leakage from the vagina).

A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She has dyspnea with exertion and is very tired. Her vital signs are 98, 80, 20, BP 116/72. She has +2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac functional classification? 1. Class I. 2. Class II 3. Class III. 4. Class IV.

2. According to both the New York Heart Association and the Canadian Cardiovascular Society, this client would fit under Class II because she is symptomatic with increased activity (dyspnea with exertion). Class II clients have cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of tho client's other symptoms are within normal Ii mi ts.

Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? 1. "The amniotic fluid helps to dilate the cervix once labor begins." 2. "Fetal nutrients are provided by the amniotic fluid." 3. "Amniotic fluid provides a cushion against impact of the maternal abdomen." 4. "The fetus is kept at a stable temperature by the amniotic fluid and sac."

2. Although the amniotic fluid promotes normal prenatal development by allowing symmetric development, it does not provide the fetus with nutrients. Rather, nutrients are provided by the placenta. The amniotic fluid does help dilate the cervix once labor begins by pressure and gravity. forces. The amniotic fluid helps to protect the fetus from injury by cushioning against impact of the maternal abdomen and allows room and buoyancy for fetal movement. The amniotic fluid and sac keep the fetus at a stable temperature by maintaining a neutral thermal environment.

When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? 1. The temperature decreases slightly early in pregnancy. 2. Cardiac output increases by 25% to 50% during pregnancy. 3. The circulating fibrinogen level decreases as much as 50% during pregnancy. 4. The anterior pituitary gland secretes oxytocin late in pregnancy

2. During pregnancy, the circulatory system undergoes tremendous changes. Cardiac output increases by 25% to 50%, and circulatory blood volume increases by about 30%. The client may experience transient hypotension and dizziness with sudden position changes. Early in pregnancy there is a slight increase in the temperature, and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fibrinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported, because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Braxton Hicks contractions or early labor symptoms.

The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan? 1. Decreased plasma volume. 2. Increased risk for urinary tract infections. 3. Increased peripheral vascular resistance. 4. Increased hemoglobin levels.

2. During pregnancy, urinary tract infections are more common because of mi nary stasis. Clients need instructions about increasing fluid volume intake. Plasma volume increases during pregnancy. The increase in plasma volume is more pronounced and occurs earlier than the increase in reel blood cell mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable blood pressure. Hemoglobin levels decrease during pregnancy even though there is an increase in blood volume.

When performing Leopold's maneuvers on a primigravid client at 22 weeks' gestation, the nurse performs the first maneuver to do which of the following? 1. Locate the fetal back and spine. 2. Determine what is in the fundus. 3. Determine whether the fetal head is at the pelvic inlet. 4. Identify the degree of fetal descent and flexion.

2. In the first maneuver, which is done with the nurse facing the client's head, both hands are used to palpate and determine which fetal body part (eg, the head or buttocks) is in the fundus. This first maneuver helps to determine the presenting part of the fetus. In the second maneuver, also done with the nurse facing the client's head, the palms of both hands are used to palpate the sides of the uterus and determine the location of the fetal back and spine. In the third maneuver, one hand gently grasps the lower portion of the abdomen just above the symphysis pubis to determine whether the fetal head is at the pelvic inlet. The fourth maneuver, done with the nurse facing the client's feet, determines the degree of fetal descent and flexion into the pelvis.

After a preparation for parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse's best action is to advise the client to do which of the following? 1. Use an over-the-counter cream for yeast infections. 2. Schedule an appointment at the clinic for an examination. 3. Administer a vinegar douche under low pressure. 4. Prepare for preterm labor and birth.

2. Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge with local itching is associated with infection (e.g., Trichomonas vagina/is). The client's symptoms must be further assessed by a health professional because the client needs treatment for this condition. T. vaginalis infection is commonly treated with metronidazole (flagyl). However, this drug is not used in the first trimester. In the first trimester, the typical treatment is topical clotrimazole. Although a yeast infection is associated with vaginal itching, the vaginal discharge is cheese-like. Furthermore, because the client may have a serious vaginal infection, over-the-counter medications are not advised until the client has been evaluated. Douching is not recommended during pregnancy because it would predispose the client to an ascending infection. The client is not exhibiting signs and symptoms of preterm labor, such as contractions or leaking fluid. And although the client's problems are suggestive of a T. vagina/is infection, which can lead to preterm labor and premature rupture of the membranes, further evaluation is needed to confirm the cause of the infection.

The nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? 1. "I will need to take iron supplements now." 2. "I may have anemia because my family is of Asian descent." 3. "I am considered anemic if my hemoglobin is below 11 g/dL (110 g/L)." 4. "The anemia increases the workload on my heart."

2. 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 anemia, can be associated 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 supplemental iron to avoid iron deficiency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dL (110 g/dL). In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells.

The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrants prompt notification of the health care provider and a further plan of care? 1. Primigravida who reports fetal movement 6 times in 2 hours. 2. Multigravida who had a positive oxytocin challenge test. 3. Primigravida whose infant has a biophysical profile of 9. 4. Multigravida whose infant has a reactive non-stress test.

2. Late decelerations during an oxytocin challenge test indicate that the infant is not receiving enough oxygen during contractions and is exhibiting signs of utero-placental insufficiency. This client would need further medical intervention. Fetal movement 6 times in 2 hours is adequate in a healthy fetus and a biophysical profile of 9 indicates that the risk of fetal asphyxia is rare. A reactive nonstress test informs the health care provider that the fetus has 2 fetal heart rate accelerations of 15 beats per minute above baseline and lasting for 15 seconds within a 20-minute period, which is a normal result and an indication of fetal ,,veil-being.

When performing Leopold's maneuvers, which of the following would the nurse ask the client to do to ensure optimal comfort and accuracy? 1. Breathe deeply for 1 minute. 2. Empty her bladder. 3. Drink a full glass of water. 4. Lie on her left side.

2. Leopold's maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold's maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly.

The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which of the following? 1. Prevention of demineralization of the mother's bones. 2. Synthesis of proteins, nucleic acids, and fats. 3. Amino acid metabolism. 4. Synthesis of neural pathways in the fetus.

2. Magnesium aids in the synthesis of protein, nucleic acids, proteins, and fats. It is important for cell growth and neuromuscular function. Magnesium also activates the enzymes for metabolism of protein and energy. Calcium prevents demineralization of the mother's bones. Vitamin B is important for 6 amino acid metabolism. Folic acid assists in the development of neural pathways in the fetus.

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points? 1. Halfway between the client's symphysis pubis and umbilicus. 2. At about the level of the client's umbilicus. 3. Between the client's umbilicus and xiphoid process. 4. Near the client's xiphoid process and compressing the diaphragm.

2. 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 a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fund us typically reaches the xiphoid process at approximately 36 weeks' 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 tl1e cliaplu·agm 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 primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? 1. Monozygotic twins result from fertilization of two ova by different sperm. 2. Monozygotic twins occur by chance regardless of race or heredity. 3. Dizygotic twins are usually of the same sex. 4. Dizygotic twins occur more often in primigravid than in multigravid clients.

2. Monozygotic twinning is independent of race, age, parity, or heredity. Monozygotic twins result from the fertilization of one ovum by two different sperm. Dizygotic twinning occurs with the fertilization of more than one ovum during conception. Dizygotic twins may be of the same sex or different sexes. Dizygotic twinning is correlated with increased parity, becoming pregnant within 1 month after stopping oral contraception, and infertilily treatments. A primigravid client is less likely to conceive dizygotic twins.

After the nurse reviews the primary health care provider's explanation of amniocentesis with a multigravid client, which of the following indicates that the client understands a serious risk of the procedure? 1. Premature rupture of the membranes. 2. Possible premature labor. 3. Fetal limb malformations. 4. Fetal organ malformations.

2. One of the primary risks of amniocentesis is stimulation of the uterus and subsequent preterm labor. Other risks include hemorrhage f om penetration of the placenta, infection of the amniotic fluid, and puncture of the fetus. There is little risk for rupture of the membranes, fetal limb malformations, or fetal organ malformations, if a practitioner skilled in using ultrasound performs the procedure. Fetal limb malformations have been associated with percutaneous umbilical blood sampling.

A 30-term-old multigravid 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 on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy? 1. Positive. 2. Probable. 3. Presumptive. 4. Diagnostic.

2. 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 processes 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 heartbeat, fetal movement felt by 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 of pregnancy.

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 of the following provides the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? 1. Fetal development needs to be complete before testing. 2. The volume of amniotic fluid needed for testing will be available by 15 weeks. 3. Cells indicating hemophilia A are not produced until 15 weeks' gestation. 4. Fetal anomalies are associated with amniocentesis prior to 15 weeks' gestation.

2. The volume of fluid needed for amniocentesis is 15 mL 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 am not accessible by anmiocentesis until 12 weeks' gestation. Anomalies are not associated with amniocentesis testing.

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3 Rationale: A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring

3 Rationale: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, however.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure. 2. Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.

3 Rationale: Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed 10 rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site dean and to report any complications, such as chills, fever, bleeding. leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in a health care provider's private office or in a special prenatal Jesting unit. Hospitalization is not necessary after the procedure.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3 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 l, 2, and 4 are unnecessary and inappropriate actions.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on the diabetic diet." 2. "I should perform glucose monitoring at home." 3. "I should avoid exercise because of the negative effects on insulin production." 4. "I should be aware of any infections and report signs of infection immediately to my health care provider."

3 Rationale: Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or HCP's office. Signs of infection need to be reported to the HCP.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Elevate the client's legs. 2. Document the findings. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

3 Rationale: If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 m L of blood

3 Rationale: In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3 Rationale: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the clecidua. The following can be used as a guide to determine the amount of flow: scant=less than 2.5cm (<1 inch) on menstrual pad in 1 hour; light=less than 10cm (<4 inches) on menstrual pad in I hour; moderate=less than 15cm (<6 inches) on menstrual pad in I hour; heavy=saturated menstrual pad in I hour; and excessive= menstrual pad saturated in 15 minutes.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids.

3 Rationale: Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

3 Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis

3 Rationale: Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal presenting part is I cm above the ischial spine.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP). 4. Tell the client that the fetal heart rate is normal.

3 Rationale: The fetal heart rate {Fl IR) depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up? 1. Quickening 2. Braxton Hicks contractions 3. Fetal heart rate of 180 beats/minute 4. Consistent increase in fundal height

3 Rationale: The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. Options I, 2, and 4 are normal expected findings.

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 1. "The procedure takes about 2 hours." 2. "It will be necessary to drink 1 to 2 quarts of water before the examination." 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." 4. "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture."

3 Rationale: Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 4 identify components of abdominal ultrasound.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer ampicillin I gas an intravenous piggyback every 6 hours.

3 Rationale: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect 10 monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. 1. Differentiating the fetus from the self. 2. Ambivalence concerning pregnancy. 3. Experimenting with mothering roles. 4. Realignment of roles and tasks. 5. Trying various caregiver roles. 6. Concern about labor and birth.

3,4,5,6. During the third trimester of pregnancy, the woman experiments with maternal and caregiver roles and may make plans for changes in employment, managing household tasks, and/ or childcare. The woman is also concerned about safety and passage through labor and birth. Other psychological tasks include preparation of the nursery, being tired of the pregnancy, and being introspective. A woman will begin to see herself as someone different from the fetus in the second trimester. Additionally, the mother may fantasize about the infant during the second trimester and be concerned about her changing body image. She may experience ambivalence about pregnancy in the first trimester.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones me found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? 1. Abruptio placentae. 2. Placenta previa. 3. Disseminated intravascular coagulation. 4. Threatened abortion.

3. A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," firm consi.stency of the abdomen (abruption) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no cramping or vaginal bleeding.

A primigravid client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? 1. "I need to call if I start to leak fluid from my vagina." 2. "If I start bleeding, I will need to call back." 3. "If my baby does not move, I need to call my health care provider." 4. "If I start running a fever, I should let the office know."

3. At 16 weeks' gestation, a primipara will not feel the baby moving. Quickening occurs between 18 and 20 weeks' gestation for a primipara and between 16 and 18 weeks' gestation for a multipara. Leaking fluid from the vagina should not occur until labor begins and may indicate a rupture of the membranes. Bleeding and a fever are complications that warrant further evaluation and should be reported at any time during the pregnancy.

Which of the following statements by a primigravid client scheduled for chorionic villi sampling indicates effective teaching about the procedure? 1. "A fiberoptic fetoscope will be inserted through a small incision into my uterus." 2. "I can't have anything to eat or drink after midnight on the day of the procedure." 3. "The procedure involves the insertion of a thin catheter into my uterus." 4. "I need to drink 32 to 40 oz (960 to 1,200 mL) of fluid 1 to 2 hours before the procedure."

3. Chorionic villi sampling, which can be performed between 8 and 10 weeks' gestation, involves the insertion of a thin catheter into the vagina and uterus to obtain a sample of the chorionic cells. It is a useful diagnostic test to determine trisomy 13, translocations, fragile X syndrome, and trisomy 18. Fetoscopy is performed with a small fiberoptic fetoscope inserted through a small incision into the client's uterus to inspect the fetus for gross abnormalities. There are no food or fluid restrictions necessary before chorionic villi sampling. Ideally, the client should empty the bladder before this procedure. A full bladder would be needed if the client were scheduled to have an ultrasound examination.

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 of the following? 1. Ptyalism. 2. Mittelschmerz. 3. Couvade syndrome. 4. Pica.

3. 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.

Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps? 1. Change positions frequently throughout the day. 2. Alternately flex and extend the legs. 3. Straighten the knee and flex the toes toward the chin. 4. Lie prone in bed with the legs elevated.

3. Leg cramps are thought to result from excessive amounts of phosphorus absorbed from milk products. Straightening the knee and flexing the toes toward the chin is an effective measure to relieve leg cramps. Also, decreas.ing milk intake and supplementing with calcium lactate may help to reduce the cramping. Keeping the legs warm and elevating them are good preventive mea-sures. Changing positions frequently aids venous return but is not helpful in relieving leg cramps. Alternately flexing and extending the legs will not help to relieve the leg cramp. Lying prone in the bed

A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which of the following would be the nurse's best response? 1. "The effects of alcohol on a fetus during pregnancy are unknown." 2. "You should limit your consumption to beer and wine." 3. "You should abstain from drinking alcoholic beverages." 4. "You may have 1 drink of 2 oz of alcohol per day."

3. Maternal alcohol use may result in fetal alcohol syndrome, marked by mild to moderate mental retardation, physical growth retardation, central nervous system disorders, and feeding 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.

A primigravid client at 28 weeks' gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hours away. Which of the following recommendations by the nurse would be best? 1. "Try to avoid traveling anywhere in the car during your third trimester." 2. "Limit the time you spend in the car to a maximum of 4 to 5 hours." 3. "Taking the trip is okay if you stop every 1 to 2 hours and walk." 4. "Avoid wearing your seat belt in the car to prevent injury to the fetus."

3. The client traveling by automobile should be advised to take intermittent breaks of 10 Lo 15 minutes, including walking, every 1 to 2 hours to stimulate the circulation, which becomes sluggish during long periods of sitting. Automobile travel is not contraindicated during pregnancy unless the client develops complications. There is no set maximum number of hours allowed. The pregnant client should always wear a seat belt when traveling by automobile. The client should be aware of the nearest health care facility in the city to which she is traveling.

On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client crying. Which of the following comments by the nurse would be most appropriate? 1. "Are you having a great deal of uterine pain?" 2. "Commonly spontaneous abortion means a defective embryo." 3. "I'm truly sorry you lost your baby." 4. "You should try to get pregnant again as soon as possible."

3. The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as 'Tm truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappropriate because this is a "yes no" question and doesn't allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus's demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should get pregnant again as soon as possible is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus.

When teaching a primigravid client how to do Kegel exercises, the nurse explains that the expected outcome of these exercises is to: 1. Prevent vulvar edema. 2. Alleviate lower back discomfort. 3. Strengthen the perineal muscles. 4. Strengthen the abdominal muscles.

3. The purpose of Kegel exercises is to strengthen the perinea! muscles in preparation for the labor process . These movements strengthen the pubococcygeal muscle, which surrounds the urinary meatus and vagina. No evidence is available to support the idea that these exercises prevent vulvar edema, alleviate lower back discomfort, or strengthen the abdominal muscles.

A client at a prenatal clinic has missed two appointments. The client calls the nurse to report that she has difficulty with consistent transportation. The nurse should refer the client to: 1. The clinic charge nurse. 2. The primary care provider. 3. The clinic social worker. 4. Her health insurance plan.

3. The social worker is available to assist the client in finding services within the community lo meet client needs. The charge nurse of the clinic or a primary care provider would be able to refer the client to the social worker. The client's insurance company deals with payments for health care and would most likely refer the client back to the local setting to find resources for transportation.

A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, J'm not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which of the following? 1. Fear of pregnancy outcome. 2. Rejection of the pregnancy. 3. Normal ambivalence. 4. Inability to care for the newborn.

3. 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 ambivalent initially accept the reality 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 or imply that the client is rejecting the fetus. The client's statement reflects ambivalence about the pregnancy, not her ability to care for the newborn.

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 1. Auscultate for fetal heart sounds. 2. Assess the cervix for compressibility. 3. Palpate the abdomen for fetal movement. 4. Initiate a gentle upward tap on the cervix.

4 Rationale: Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Options I, 2, and 3 are not assessment techniques to check for ballottement. Option 2 is related to Hegar's sign. Options 1 and 3 are a part of fetal assessment.

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client? 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. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

4 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 it should be used only when a life-threatening infection is present. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients 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 promotes healing.

The nurse evaluates the ability of a hepatitis B- positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4 Rationale: Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option I will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision

4 Rationale: If the client complains of a headache and blurred vision, the HCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal signs.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul smelling odor.

4 Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. "I should avoid between-meal snacks." 2. "I should lie down for an hour after eating." 3. "I should use spices for cooking rather than using salt." 4. "I should avoid eating foods that produce gas and fatty foods."

4 Rationale: Lying down is likely to lead to reflux of stomach contents, especially immediately after a meal. The client should be instructed to avoid spices, along with salt, because spices trigger heartburn. Salt produces edema. The client should be encouraged to eat between-meal snacks and should be instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating three large meals. The client also should limit or avoid gas-producing and fatty foods.

The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? l. "I should avoid straining during bowel movements." 2. "I can gently replace the hemorrhoids into the rectum." 3. "I can apply ice packs to the hemorrhoids to reduce the swelling." 4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

4 Rationale: Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the discomfort from hemorrhoids.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Place the client in a high Fowler's position. 3. Continue the oxytocin (Pitocin) drip if infusing. 4. Administer Oxygen, 8 to 10 L/minute, via face mask.

4 Rationale: Oxygen is administered, 8 10 10 L/minute, via face mask lo optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Option 3 is incorrect because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason.

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura

4 Rationale: Severe preeclampsia can trigger disseminated intravascular coagulation ( DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options l, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent non-reassuring fetal heart rate

4 Rationale: Signs of fetal or maternal compromise include a persistent, non reassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy." 2. "I should lower my blood volume by limiting my fluids." 3. "I should maintain a low-calorie diet to prevent any weight gain." 4. "I should drink adequate fluids and increase my intake of high-fiber foods."

4 Rationale: The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood 10 rush to the heart and overload the cardiac system. Constipation can cause the client to use the Valsalva maneuver. High-fiber foods are important. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients, so adequate fluid intake and high-fiber foods are important. Sodium should be restricted as prescribed by the health care provider because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4 Rationale: The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placemae, overdistemion of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after O>-')'lOcin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options I, 2, and 3 that present the risk for hemorrhage.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4 Rationale: Variable deceleration occur if the umbilical cord becomes compressed, reducing blood now between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. "I should wear panty hose." 2. "I should wear support hose." 3. "I should wear flat nonslip shoes that have good support." 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."

4 Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman 10 maintain proper posture and balance and 10 minimize falls.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's Leaching plan? 1. Therapeutic abortion is required. 2. She will have to stay at home until treatment is completed. 3. Medication will not be started until after delivery of the fetus. 4. lsoniazid plus rifampin (Rifadin) will be required for 9 months.

4 Rationale: More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

Which diagnostic test would be the most important to have for a primigravid client in the second trimester of her pregnancy? 1. Culdocentesis. 2. Chorionic villus sampling. 3. Ultrasound testing. 4. a-fetoprotein (AFP) testing.

4. AFP testing is usually performed between the 15th and 18th weeks of gestation. Abnormally high levels found in maternal serum may be indicative of neural tube defects such as anencephaly and sina bifida. Low levels may indicate trisomy 21 (Down syndrome). Culdocentesis is used to confirm a tubal pregnancy. Chorionic villus sampling is done as early as 10 weeks' gestation to detect anomalies. Ultrasound testing may be done in the first trimester to determine fetal viability and in the third trimester to determine pelvic adequacy and fetal or placental position.

After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which of the following? 1. Denial of the pregnancy. 2. Low-birth-weight infant. 3. Cephalopelvic disproportion. 4. Congenital anomalies.

4. Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents am at greater risk for denial of the pregnancy, lack of prenatal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional deficits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies.

A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. The nurse interprets this as which of the following? 1. The possibility that the client is carrying twins. 2. Unusual because most multiparous clients do not experience quickening until 30 weeks' gestation. 3. Evidence that the client's estimated date of childbirth is probably off by a few weeks. 4. Normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation.

4. Although most multiparous women experience quickening at about 17.5 weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect. Detecting movement early does not suggest a twin pregnancy. If the multiparous client does not experience quickening by 20 weeks' gestation, further investigation is warranted, because the fetus may have died, the client has a hydatidiform mole, or the pregnancy dating is incorrect. There is no evidence that the client's expected date of birth is erroneous.

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perinea! itching or burning. The nurse interprets these findings as a response related to which of the following? 1. A decrease in vaginal glycogen stores. 2. Development of a sexually transmitted disease. 3. Prevention of expulsion of the cervical mucus plug. 4. Control of the growth of pathologic bacteria.

4. An increase in clear, highly acidic vaginal secretions is a normal 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 disease, most likely she would have additional 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 36-year-old primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. The nurse should assess the client's fundal height to: 1. Determine the level of uterine activity. 2. Identify the need for increased weight gain. 3. Assess the location of the placenta. 4. Estimate the fetal growth.

4. Assessment of fundal height is a gross estimate of fetal growth. By 20 weeks' gestation, the height of the fundus should be at the level of the umbilicus, after which it should increase 1 cm for each week of gestation until approximately 36 weeks' gestation. Fundal height that is significantly different from that implied by the estimated gestational age warrants further evaluation (eg, ultrasound examination) because it possibly indicates multiple pregnancy or fetal growth retardation. Fundal height estimation will not determine uterine activity or a need for increased weight gain. Ultrasound examination, not fundal height estimation, wiII locate the placenta.

A woman with asthma controlled through the consistent use of medication is now pregnant for the first time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction? 1. "I need to continue taking my asthma medication as prescribed." 2. "It is my goal to prevent or limit asthma attacks." 3. "During an asthma attack, oxygen needs continue to be high for mother and fetus." 4. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

4. Asthma medications and bronchodilators should be continued during pregnancy as prescribed before the pregnancy began. The medications do not cause harm to the mother or fetus. Regular use of asthma medication will usually prevent asthma attacks. Prevention and limitation of an asthma attack is the goal of care for a client who is or is not pregnant and is the appropriate care strategy. During an asthma attack, oxygen needs continue as with any pregnant client but the airways are edematous, decreasing perfusion. Asthma exacerbations during pregnancy may occur as a result of infrequent use of medication rather than as a result of the pregnancy.

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? 1. Avoid highly seasoned foods. 2. Avoid lying down right after eating. 3. Eat small, frequent meals. 4. Consume liquids only between meals.

4. Consuming most 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 relaxation of the sphincter and the pressure of the fetus against the stomach increases the potential of heartburn. Avoiding highly seasoned foods, remaining in an upright position after eating, and eating small, frequency meals are strategies to prevent heartburn.

During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks' gestation and is now in her third trimester states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." The nurse should tell the mother: 1. "Dreams like the ones that you describe are very unusual. Please tell me more about them." 2. "Commonly when a mother has these dreams, she is trying to cope with becoming a parent." 3. "Dreams about the baby late in pregnancy usually mean that labor is about to begin soon." 4. "It's not uncommon to have dreams about the baby, particularly in the third trimester."

4. During the third trimester, it is not uncommon for clients to have dreams or fantasies about the baby. Sometimes the dreams are about infants who are malformed or, in this example, covered with hair. There is no evidence to suggest that the client is trying to cope with becoming a parent. Having cl.reams about the baby does not mean that labor will begin soon.

An antenatal client receives education concerning medications that me safe to use during pregnancy. The nurse evaluates the client's understanding of the instructions and determines that she needs further information when she states which of the following? 1. "If I am constipated, magnesium hydroxide (Milk of Magnesia) is okay but mineral oil is not." 2. "If I have heartburn, it is safe to use chewable calcium carbonate (Tums)." 3. "I can take acetaminophen (Tylenol) if I have a headache." 4. "If I need to have a bowel movement, sennosides (Ex-Lax) are preferred."

4. Ex-Lax is considered too abrasive to use during pregnancy. ln most instances, a Fleet enema will be given before Ex-Lax. Medications for constipation that are considered safe during pregnancy include compounds that produce bulk, such as Metamucil and Citrucel. Colace, Dulcolax, and Milk of Magnesia can also be used. Mineral oil prevents the absorption of vitamins and minerals within the GI tract. The strategies for heartburn are considered safe and Tylenol may be used as an over the-counter analgesic.

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 of the following? 1. Preterm labor. 2. Twin-to-twin transfusion. 3. Anemia. 4. Group B Streptococcus.

4. 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 that point is reached, labor may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestation. The donor twin may become growth restricted and can have 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 11 mg/dL (110 g/L) is considered anemic.

A primigravid adolescent client at approximately 15 weeks' gestation who is visiting the prenatal clinic with her mother is to undergo alphafetoprotein (AFP) screening. When developing the teaching plan for this client, the nurse should include which of the following? 1. Ultrasonography usually accompanies AFP testing. 2. Results are usually very accurate until 20 weeks' gestation. 3. A clean-catch midstream urine specimen is needed. 4. Increased levels of AFP are associated with neural tube defects.

4. Increased AFP levels are associated with neural tube defects, such as spina bifida, anencephaly, and encephalocele. Ultrasonography is used to confirm a neural tube defect only when AFP levels are increased. Because AFP levels are usually highest at 15 to 18 weeks' gestation, this is the optimum time for testing. Performing the test after this time leads to inaccurate results. The client's blood, not urine, is used for the sample.

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 of the following information about changes the client can anticipate in the first trimester? 1. Differentiating the self from the fetus. 2. Enjoying the role of nurturer. 3. Preparing for the reality of parenthood. 4. Experiencing ambivalence about pregnancy.

4. Many women in their first trimester feel ambivalent about being pregnant because of the significant life changes that occur for most women who have a child. Ambivalence can be expressed as a list of positive and negative consequences of having a child, consideration of financial and social implications, and possible career changes. 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 begins to prepare for parenthood and all of the tasks that parenthood includes.

After instructing participants in a childbirth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which of the following? 1. Biofeedback. 2. Effleurage. 3. Guided imagery. 4. Pelvic tilt exercises.

4. Pelvic tilt exercises are useful to alleviate backache during pregnancy and labor but are not useful for the pain from contractions. Biofeedback (a conscious effort to control the response to pain), effleurage (light uterine massage), and guided imagery (focusing on a pleasant scene) are appropriate pain relief techniques to practice before labor begins. Various breathing exercises also can help to alleviate the discomfort from contraction pain.

A new antenatal G 6, P 4, Ab 1 client attends her first prenatal visit with her partner. The nurse is assessing this couple's psychological response to the pregnancy. Which of the following requires the most immediate follow-up? 1. The couple is concerned with financial changes this pregnancy causes. 2. The couple expresses ambivalence about the current pregnancy. 3. The father of the baby states that the pregnancy has changed the mother's focus. 4. The father of the baby is irritated that the mother is not like she was before pregnancy.

4. Pregnancy creates changes in the mother and father. Being considerate, accepting changes, and being supportive of the current situation are considered acceptable responses by the father, rather than feeling irritation about these changes. Expressing concern with the financial changes pregnancy and an expanded family include is normal.The first trimester involves the .client and family feeling ambivalent about pregnancy and moving toward acceptance of the changes associated with pregnancy. Maternal acceptance of the pregnancy and a subsequent change in her focus are normal occurrences.

Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following? 1. Development of a future Rh-positive fetus. 2. An antibody response to Rh-negative blood. 3. A future pregnancy resulting in abortion. 4. Development of Rh-positive antibodies.

4. Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative mothers do not develop sensitivities if the fetus is also Rh negative.

After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which of the following? 1. "A total weight gain of approximately 20 lb (9 kg) is recommended." 2. "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." 3. "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." 4. "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

4. The National Academy of Sciences Institute of Medicine and Health Canada recommend that women gain 25 to 35 lb (11.5 to 14.5 kg) 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 3.5 lb (1.6 kg) during the first trimester and then 1 lb (0.45 kg)/week during the remainder of the pregnancy (24 weeks) for a total of about 27 to 28 lb (12.2 to 12.7 kg). A weight gain of only 6.6 lb (3 kg) in the second and third trimesters is not normal because the client should be gaining about 1 lb (0.45 kg)/week, or 12 lb (5.4 kg) during the second and third trimesters. Gaining 12 lb (5.4 kg) during each trimester would total 36 lb (16.2 kg), 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.

A primigravid client at 8 weeks' gestation tells the nurse client since having had sexual relations with a new partner 2 weeks ago, she has noticed flu like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which of the following sexually transmitted diseases? 1. Gonorrhea 2. Chlamydia trachomatis infection. 3. Syphilis. 4. Herpes genitalis.

4. The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. C. trachomatis infection in women is commonly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre.

A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which of the following responses would be most helpful? 1. "Today's modern technology has resulted in a low maternal mortality rate." 2. "Don't concern yourself with things that happened in the past." 3. "In North America, mothers seldom die in childbirth." 4. "What is it that concerns you about pregnancy, labor, and childbirth?"

4. The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Asking the client about these concerns would be most helpful to determine the client's knowledge base and to provide the nurse with the opportunity lo answer any questions and clarify any misconceptions. Although the maternal mortality rate is low in the United Stales and Canada, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States and Canada include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring the client's need for a discussion about complications of pregnancy may further increase the client's anxiety.

After instructing a female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states that which of the following hormones is evaluated by this test? 1. Prolactin. 2. Follicle-stimulating hormone. 3. Luteinizing hormone. 4. Human chorionic gonadotropin (hCG).

4. The hormone analyzed in most pregnancy tests is hCG. In the pregnant 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 multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following? 1. Placental blood. 2. Amniotic fluid. 3. Fetal blood. 4. Maternal blood.

4. for the Rh-negative client who may be pregnant with an Rh-positive fetus, an indirect Coombs test measures antibodies in the maternal blood. Titers should be performed monthly during the first and second trimesters and biweekly during the third trimester and the week before the clue elate.