Passpoint

During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response? A. "8 days after conception" B. "When the woman misses a menstrual period" C. "2 to 3 weeks after fertilization" D. "As soon as hormone levels decline"

A. "8 days after conception"

The nurse is reinforcing education for a client in the first trimester of pregnancy. What statement made by the client demonstrates an understanding of the education? A. "I need to take supplemental folic acid to prevent neural tube defects." B. "I need to eat a lot of liver so that I won't become anemic." C. "I should limit my activities during the first trimester of pregnancy so that I won't have a miscarriage." D. "I should begin drinking 32 ounces of whole milk daily to increase my calcium intake."

A. "I need to take supplemental folic acid to prevent neural tube defects."

A 15-year-old client who is 26 weeks pregnant has been admitted to the labor and delivery unit with reports of abdominal pain. Her parents want to speak with a nurse about her condition. How should the nurse respond? A. "I'll need a signed consent from your daughter to give you medical information." B. "The health care provider can give you more information without consent." C. "She will be OK. It's just a stomachache." D. "She is experiencing Braxton Hicks contractions and is too young to understand the difference between these contractions and labor pains."

A. "I'll need a signed consent from your daughter to give you medical information."

The nurse is discussing posture with a client who's 18 weeks pregnant. The clients asks why should she avoid the supine position. How does the nurse respond? A. "This position impedes blood flow to the fetus." B. "This position may trigger heart palpitations." C. "This position may cause gastroesophageal reflux." D. "This position promotes pregnancy-induced hypertension (PIH)."

A. "This position impedes blood flow to the fetus."

When discussing nutrition with a pregnant client of normal weight, the nurse will state the caloric requirements will increase by how much during pregnancy? A. 300 kcal B. 400 kcal C. 500 kcal D. 1,000 kcal

A. 300 kcal

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should complete which of the following tasks? A. Ask her to void. B. Instruct her to drink 1 L of fluid. C. Prepare her for I.V. anesthesia. D. Ask her to lie on her left side.

A. Ask her to void.

An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? A. Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. Honor the mother's request. Knowing the client's cultural background, suggest that the family call a meeting to make the decision. Request that an anesthetist administer the epidural because the client is uncomfortable.

A. Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.

A nurse is caring for a primigravida client who is in labor. When does the nurse suspect the client has progressed to the second stage of labor? A. Client has an uncontrollable urge to bear down. B. Client has a decrease in bloody show. C. Client becomes increasingly talkative. D. Client takes three deep, cleansing breaths.

A. Client has an uncontrollable urge to bear down.

A diabetic client in labor tells the nurse she has been feeling nauseous since her labor started and did not take her insulin even after eating some soup and crackers. One hour later, she reports increased nausea and feeling flushed. The nurse notes a fruity odor to her breath. What do these findings suggest? A. Diabetic ketoacidosis B. Hypoglycemia C. Infection D. Transition to the active phase of labor

A. Diabetic ketoacidosis

A client who is 36 weeks pregnant appears anxious and tells the nurse that she will never be able to handle labor and delivery. What is the appropriate action by the nurse? A. Document this common concern during the third trimester. B. Obtain a referral order for psychotherapy. C. Discuss the concern with the client's partner. D. Assess the client for intimate partner violence.

A. Document this common concern during the third trimester.

Which intervention would the nurse recommend to a client having severe heartburn during pregnancy? A. Eat several small meals daily. B. Eat crackers on waking every morning. C. Drink a preparation of salt and vinegar. D. Drink orange juice frequently during the day.

A. Eat several small meals daily.

A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response? A. Explain to the client that the feeling is normal during this stage. B. Assist the client to the bathroom. C. Give enema to help the client move the bowel. D. Tell the client that you will notify the doctor.

A. Explain to the client that the feeling is normal during this stage.

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion? A. Fetal heart rate variability within an acceptable range B. Persistent fetal bradycardia C. Late decelerations D. Variable decelerations

A. Fetal heart rate variability within an acceptable range

A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony? A. Massage the fundus. B. Asses fundal height. C. Measure blood loss. D. Catheterize the client.

A. Massage the fundus.

Which of the following health conditions makes it necessary for the nurse to check blood pressure frequently during labor? A. Preeclampsia B. Seizure disorder C. Diabetes mellitus D. Urinary tract infection (UTI)

A. Preeclampsia

A woman who is 10 weeks pregnant tells the nurse that she is worried about her fatigue and frequent urination. Which nursing intervention should the nurse utilize? A. Recognize these as normal early pregnancy signs and symptoms B. Question her further about these signs and symptoms C. Tell her that she'll need blood work and urinalysis D. Tell her that she may be excessively worried

A. Recognize these as normal early pregnancy signs and symptoms

The nurse is caring for a client in the second stage of labor. The client provided the healthcare team with a birth plan that included no use of analgesia. The client is having strong contractions with pain at 10 out of 10 and asks for something for pain. What is the nurse's best action? A. Remind the client of the desire outlined in the birth plan and clarify if analgesia is desired. Tell the client to use nonpharmacological interventions for pain control to comply with the birth plan. Offer the client a non-opioid, non-invasive pain intervention such as nitrous oxide. Ask if the client wants epidural analgesia to avoid systemic pain medications.

A. Remind the client of the desire outlined in the birth plan and clarify if analgesia is desired.

The nurse is collecting data on a pregnant woman in the clinic. In the course of the data collection, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to: A. assess the client's readiness to stop. B. suggest that the client reduce the daily number of cigarettes smoked by one-half. C. provide the client with the telephone number of a formal smoking cessation program. D. help the client develop a plan to stop.

A. assess the client's readiness to stop.

The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question? A. autonomy B. justice C. nonmaleficence D. jurisprudence

A. autonomy

A client is in the last trimester of pregnancy. The nurse should instruct her to notify her obstetrician immediately if she notices: A. blurred vision. B. hemorrhoids. C. increased vaginal mucus. D. dyspnea on exertion.

A. blurred vision.

A multiparous client admitted to the labor unit has not received prenatal care for this pregnancy. When collecting information from this client, which data would be most important to obtain? A. date of last menstrual period (LMP) B. family history of sexually transmitted diseases (STDs) C. name of insurance provider D. number of siblings

A. date of last menstrual period (LMP)

A client has gestational diabetes. When assisting with developing the plan of care for this client, which therapy would the nurse most likely identify as important for this client to manage glucose levels? A. diet B. long-acting insulin C. oral hypoglycemic drugs D. glucagon

A. diet

A nurse is reinforcing teaching with a client at 24 weeks of gestation regarding a glucose tolerance test to screen for gestational diabetes. The client asks, "What will be done if I have this disorder?" The nurse is correct to state that gestational diabetes is managed by which therapy? A. dietary control of carbohydrates, fats, and proteins B. metformin C. ultralente (long-acting) insulin D. metformin and ultralente (long-acting) insulin

A. dietary control of carbohydrates, fats, and proteins

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal: A. edema. B. fever C. glycosuria D. vomiting

A. edema.

During a routine visit to the clinic, the client informs the nurse that the client may be pregnant. Which pregnancy test result would the nurse identify as most accurate in confirming pregnancy? A. increase in human chorionic gonadotropin B. increase in cortisol C. increase in luteinizing hormone D. decrease in alpha-fetoprotein

A. increase in human chorionic gonadotropin

A nurse is assisting the health care team to develop a plan of care for a 16-year-old client in the prenatal clinic. The client is at highest risk for which complication that should be addressed by the team? A. iron deficiency anemia B. varicosities C. nausea and vomiting D. gestational diabetes

A. iron deficiency anemia

How does the nurse on the obstetrics unit assure client safety? Select all that apply. A. reconciliation of medication prescriptions B. communication among staff C. placing culturally similar clients together D. use of two unique identifiers E. staff training

A. reconciliation of medication prescriptions B. communication among staff D. use of two unique identifiers E. staff training

A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? A. the client's partner B. the client's best friend, who's the sperm donor C. the client's parents, because they're blood relatives D. the court system, because the client isn't married and is legally responsible for the neonate

A. the client's partner

A pregnant client has received dinoprostone for cervical ripening. The nurse would monitor the client for which most common adverse effect of this drug? A. vomiting B. euphoria C. uterine inversion D. constipation

A. vomiting

A pregnant client tells the nurse that she doesn't like milk and can't possibly drink three to four glasses per day as recommended by her health care provider. What is the best response by the nurse? A. "I did not like milk either, but I drank it during pregnancy." B. "Are there any dairy products that you do like?" C. "It is important for the baby that you drink your milk." D. "Do not worry; you can just take calcium supplements."

B. "Are there any dairy products that you do like?"

A client comes to the clinic for her first prenatal visit. While the nurse is obtaining the client's vital signs, the client asks, "When will you be able to hear my baby's heart beat?" Which response by the nurse would be most appropriate? A. "We can usually hear them with a stethoscope at about 7 weeks." B. "At about 11 weeks, we'll be able to hear them with an ultrasound device." C. "We have to wait until you're about 17 weeks before we hear anything." D. "By 21 weeks, we can check the when you have an ultrasound."

B. "At about 11 weeks, we'll be able to hear them with an ultrasound device."

A pregnant client at 28 weeks gestation has been diagnosed with gestational diabetes and is started on insulin therapy.. After reviewing information about the use of insulin with the client, the nurse determines that the teaching was successful based on which client statement? A. "I won't use insulin if I'm feeling sick." B. "I need to use insulin every day." C. "Since I'm taking insulin, I don't need to watch what I eat." D. "I'll monitor my blood glucose levels twice per week."

B. "I need to use insulin every day."

During her fourth clinic visit, a client who is 5 months pregnant tells the health care provider she was exposed to rubella during the past week and asks whether she can be immunized now. How would the nurse expect the health care provider to respond? A. "Yes, I will order the rubella immunization for you." B. "No, because the live viral vaccine is contraindicated during pregnancy." C. "Yes, and you should consider pregnancy termination because rubella has teratogenic effects." D. "No, because the vaccine can be given only during the first trimester."

B. "No, because the live viral vaccine is contraindicated during pregnancy."

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effects." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."

B. "No, it can initiate premature uterine contractions."

A primigravida client in the tenth week of pregnancy calls the clinic to report experiencing slight vaginal bleeding. Which response by the nurse would be best? A. "Lie down on your left side and call again if the bleeding worsens." B. "Save any perineal pads, clots, and tissue and come to the clinic right away." C. "Avoid sexual intercourse for the next 2 weeks." D. "Continue your normal activities and increase your fluid intake."

B. "Save any perineal pads, clots, and tissue and come to the clinic right away."

During a prenatal visit, the nurse measures a client's fundal height at 19 cm. The client asks what does this mean. How should the nurse respond? A. "This measurement indicates that the fetus has reached approximately 12 weeks." B. "This measurement indicates that the fetus has reached approximately 19 weeks." C. "This measurement indicates that the fetus has reached approximately 24 weeks." D. "This measurement indicates that the fetus has reached approximately 28 weeks."

B. "This measurement indicates that the fetus has reached approximately 19 weeks."

A client in the seventh month of pregnancy reports back pain and wants to know what can be done to relieve it. After consulting with the supervising nurse about the client's report, which instruction would the nurse most likely reinforce? A. "You need to lie down more during the day to get off your feet." B. "Try using pelvic tilt exercises while avoiding lifting heavy objects." C. "Let others pick things up for you so you don't have to bend over so much." D. "Your back pain will go away after the baby is born."

B. "Try using pelvic tilt exercises while avoiding lifting heavy objects."

A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, "I haven't been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me." Which response by the nurse is best? A. "That's fine; you can see whichever health care professional you prefer." B. "You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you." C. "You really need to come to each scheduled appointment here; missing appointments could be harmful." D. "Don't you want to continue to be cared for by your clinic health care provider?"

B. "You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you."

A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn't know whether she's ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer? A. "You may want to discuss these concerns with a social worker." B. "You're feeling ambivalent, which is normal during the first trimester." C. "You need to share these feelings with your partner." D. "You may want to consider having an abortion."

B. "You're feeling ambivalent, which is normal during the first trimester."

A client is 33 weeks' pregnant and has had diabetes since age 21. When checking the fasting blood glucose level, which value would indicate the client's disease is controlled? A. 45 mg/dL (2.5 mmol/L) B. 85 mg/dL (4.7 mmol/L) C. 120 mg/dL (6.67 mmol/L) D. 36 mg/dL (7.56 mmol/L)

B. 85 mg/dL (4.7 mmol/L)

The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN? A. client in the second stage of labor who is requesting to go the bathroom. B. A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit. C. A client who is in the fourth stage of labor with fundus above the umbilicus and bleeding with moderate amount of clots. D. A client in the third stage of labor with a moderate amount of blood trickling in a steady stream.

B. A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.

The nurse is documenting a prenatal history of gravida 4, para 2 on the woman's clinic paperwork. The paperwork is sent to the birthing center for review. Upon the expectant mother's admission to the birthing center, the admission nurse is most correct to confirm which prenatal history? A. A client has been pregnant 4 times and had 2 miscarriages. B. A client has been pregnant 4 times and had 2 children born after 20 weeks of gestation. C. A client has been pregnant 4 times and had 2 cesarean deliveries. D. A client has been pregnant 4 times and had 2 spontaneous abortions.

B. A client has been pregnant 4 times and had 2 children born after 20 weeks of gestation.

A client who's 24 weeks pregnant has sickle cell anemia. When preparing the plan of care, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy? A. Sedative use B. Dehydration C. Hypertension D. Tachycardia

B. Dehydration

A famous pregnant client comes to the health care provider's office for a routine prenatal examination. While the client is in the office, the media arrives asking for information about the client. What should the nurse do? A. Immediately notify security to have the media removed. B. Inform the media that you can't comment about whether the person is being seen in the office. C. Phone the police to remove the members of the media from the office. D. Ask the media to wait until the client is finished with her health care provider's visit.

B. Inform the media that you can't comment about whether the person is being seen in the office.

A nurse is preparing a presentation for a pregnant client with diabetes. Which information would the nurse include to explain why a pregnant diabetic client is at risk for having a large-for-gestational-age infant? A. Excess sugar causing reduced placental functioning B. Insulin acting as a growth hormone on the fetus C. Maternal dietary intake of high calories D. Excess insulin reducing placental functioning

B. Insulin acting as a growth hormone on the fetus

A client is in the 8th month of pregnancy. Which body position does the nurse advise the client to assume to enhance cardiac output and renal function when laying down? A. Right lateral B. Left lateral C. Supine D. Semi-Fowler's

B. Left lateral

The nurse is providing care to a pregnant adolescent client in the first trimester. Which intervention would the nurse identify as the highest priority? A. Schedule the client for a screening glucose tolerance test. B. Make sure the client receives nutritional counseling and reinforce the education. C. Teach the client that there is increased risk for having a macrosomic neonate. D. Monitor the client for signs and symptoms of placenta previa.

B. Make sure the client receives nutritional counseling and reinforce the education.

A newly pregnant client tells a nurse that she has not been taking her prenatal vitamins because they make her feel nauseated. What information should the nurse reinforce to the client? A. Switch to another brand of prenatal vitamins. B. Take the vitamin on a full stomach. C. Consume orange juice with it for better absorption. D. Wait until the morning to take the vitamin.

B. Take the vitamin on a full stomach.

The labor and delivery unit has 10 clients in varying stages of labor. Staffing for the upcoming shift consists of four registered nurses (RNs) and one licensed practical nurse (LPN). Which client care assignment is best? A. Each nurse should care for two clients. B. The stable clients in the early stages of labor should be assigned to the LPN. C. The LPN should be allowed to go home because the unit is overstaffed. D. Each RN should care for one client and assist the LPN with the care of the remaining six clients.

B. The stable clients in the early stages of labor should be assigned to the LPN.

A nurse instructs a pregnant client about the importance of doing frequent Kegel exercises. Kegel exercises are important for which reason? A. They promote better breathing by strengthening the diaphragm muscle. B. They help maintain good perineal muscle tone by tightening the pubococcygeus muscle. C. They minimize leg cramps by strengthening the calf muscles. D. They prepare the mother for pushing by strengthening the abdominal muscles.

B. They help maintain good perineal muscle tone by tightening the pubococcygeus muscle.

A pregnant client at 26 weeks' gestation undergoes a glucose tolerance test. The nurse identifies the need for further action based on which results? A. a glucose level of 120 mg/dL (6.67 mmol/L) during a 1-hour glucose tolerance test B. a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test C. a 2-hour glucose level of 150 mg/dL (8.32 mmol/L) during a 3-hour glucose tolerance test D. a 3-hour glucose level of 130 mg/dL (7.22 mmol/L) during a 3-hour glucose tolerance test

B. a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test

A pregnant client is screened for tuberculosis during at the first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. The nurse determines that the result is positive based on which finding? A. an indurated wheal smaller than 10 mm in diameter appearing in 6 to 12 hours B. an indurated wheal larger than 10 mm in diameter appearing in 48 to 72 hours C. a flat, circumscribed area smaller than 10 mm in diameter appearing in 6 to 12 hours D. a flat circumscribed area larger than 10 mm in diameter appearing in 48 to 72 hours

B. an indurated wheal larger than 10 mm in diameter appearing in 48 to 72 hours

A nurse is reinforcing education for a client entering the third trimester of pregnancy. The nurse determines that the client understands the education when the client states which symptom will be immediately reported? A. hemorrhoids B. blurred vision C. dyspnea on exertion D. increased vaginal mucus

B. blurred vision

When determining maternal and fetal well-being, which data collection finding is most important? A. signs of orthostatic hypotension B. fetal heart rate and activity C. the mother's acceptance of the growing fetus D. presence of Braxton Hicks contractions

B. fetal heart rate and activity

A client with preeclampsia is scheduled to undergo a nonstress test (NST) and asks the nurse why this test is being performed. When responding to the client, which condition would the nurse most likely include as the reason? A. anemia B. fetal well-being C. intrauterine growth restriction (IUGR) D. oligohydramnios

B. fetal well-being

A client who is at 32 weeks gestation is diagnosed with mild preeclampsia. Which findings would the nurse expect to note when collecting data on the client? Select all that apply. A. severe headache B. hypertension C. seizures D. blurry vision E. abdominal pain F. edema

B. hypertension F. edema

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to the physician on call. B. the social worker on call. Women in Distress (local provincial/territorial, regional or aboriginal shelter). a lawyer.

B. the social worker on call.

As part of a prenatal nutritional education program for a 17-year-old pregnant client who is concerned about weight gain, a nurse is reinforcing the information. Which statement by the nurse would be most appropriate? A. "If you stay away from fast foods, your weight gain will be minimal." B. "You're young. You'll be able to lose the weight after the baby is born with no problem." C. "During pregnancy, you need to gain weight to help make sure your baby is healthy." D. "Keep your calories to around 1000 per day so you gain only the proper amount of weight."

C. "During pregnancy, you need to gain weight to help make sure your baby is healthy."

The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching? A. "I'll need to lie perfectly still." B. "You won't need to come in and check on me while I'm wearing this monitor." C. "I can lie in any comfortable position, but I should stay off my back." D. "I know that the external monitor increases my risk of a uterine infection."

C. "I can lie in any comfortable position, but I should stay off my back."

The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider? A. "I had a previous miscarriage 4 years ago during my first trimester." B. "I have had indigestion during my pregnancy." C. "My membrane ruptured 2 days ago." D. "I expelled a mucous plug yesterday."

C. "My membrane ruptured 2 days ago."

A client, who is 11 weeks' pregnant and admitted to the facility with hyperemesis gravidarum, is being cared for by a nursing student. The nursing instructor asks the nursing student to discuss hyperemesis gravidarum. How does the student respond appropriately? Select all that apply. A. "It is a neurologic disorder." B. "It is caused by inadequate nutrition." C. "The cause is unknown." D. "It is caused by hemolysis of fetal red blood cells." E. "It is characterized by severe nausea and vomiting during the first half of pregnancy."

C. "The cause is unknown." E. "It is characterized by severe nausea and vomiting during the first half of pregnancy."

A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion? A. 88 beats/minute B. 100 beats/minute C. 135 beats/minute D. 180 beats/minute

C. 135 beats/minute

A client, 8 weeks pregnant, has a history of lactose intolerance. To prevent a nutritional deficiency as a result of lactose intolerance, the nurse teaches her about lactase replacement. Which appropriate teaching point should the nurse include with the teachings? A. Add lactase replacement drops to milk immediately before drinking it. B. Ask the health care provider for a lactase prescription that allows unlimited refills. C. Add lactase replacement drops to milk at least 24 hours before drinking it. D. Warm milk to room temperature before adding lactase replacement tablets

C. Add lactase replacement drops to milk at least 24 hours before drinking it.

A client in the third trimester of pregnancy is having contractions 5 minutes apart that began suddenly. The nurse identifies that it is the client's seventh month. The client is admitted directly to the obstetrics department. Which intervention has priority? A. Call the obstetrician. B. Time the contractions. C. Check fetal heart tones. D. Call the client's spouse.

C. Check fetal heart tones.

A pregnant client is prescribed an iron supplement. Which point should the nurse include when teaching the client about taking the supplement? A. Take the supplement with bran, milk, or eggs to increase absorption of the supplement. B. Avoid taking the supplement on an empty stomach. C. Eat a diet rich in vitamin C to promote iron absorption. D. Avoid taking the supplement at bedtime to prevent GI upset.

C. Eat a diet rich in vitamin C to promote iron absorption.

A client who is 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse provide which information that at 16 weeks' gestation the client's fetus will most likely present? A. Be able to suck and swallow B. Open the eyes C. Have audible heart sounds D. Have open nostrils

C. Have audible heart sounds

The nurse is caring for a client whose first day of the last menstrual period (LMP) was July 29, 2016. When the client asks what the infant's due date is, which date would the nurse give if using the Naegele rule? A. July 29, 2017 B. April 29, 2017 C. May 6, 2017 D. June 1, 2017

C. May 6, 2017

A client who is 34 weeks' pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client is not in labor. Which intervention would be most appropriate at this time? A. Allow the client to ambulate with assistance. B. Assist client to go void. C. Monitor the amount of vaginal blood loss. D. Notify the health care provider if the fetal heart rate is 140 beats/minute.

C. Monitor the amount of vaginal blood loss.

A client with hyperemesis gravidarum is on a clear liquid diet. The nurse instructs the unlicensed assistive personnel (UAP) to observe her tray for which food selections? A. Milk and ice pops B. Decaffeinated coffee and scrambled eggs C. Tea and gelatin dessert D. Apple juice and oatmeal

C. Tea and gelatin dessert

A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? A. Suggesting that she walk for 1 hour twice per day B. Advising her to take over-the-counter calcium supplements twice per day C. Teaching her to dorsiflex her foot during the cramp D. Instructing her to increase milk and cheese intake to 8 to 10 servings per day

C. Teaching her to dorsiflex her foot during the cramp

The client and her partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence? Actions were based on the advice of a more experienced nurse. The nurse holds competencies required for nursing care. C. The national standards of practice were met when providing care. The healthcare provider's (HCP's) written orders were followed.

C. The national standards of practice were met when providing care.

A nurse is gathering neurological data on a 1-day old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply. A. The neonate grasps the nurse's finger when put in the palm of the neonate's hand. B. The neonate does stepping movements when held upright with the sole of the foot touching a surface. C. The neonate's toes do not curl downward when the soles of the feet are touched. D. The neonate does not respond when the nurse claps hands. E. The neonate turns toward the nurse's finger when touching the cheek. F. The neonate displays weak, ineffective sucking.

C. The neonate's toes do not curl downward when the soles of the feet are touched. D. The neonate does not respond when the nurse claps hands. F. The neonate displays weak, ineffective sucking.

A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: A. a neurologic disorder. B. inadequate nutrition. C. an unknown cause. D. hemolysis of fetal red blood cells (RBCs).

C. an unknown cause.

A pregnant client is receiving heparin. While the client is receiving this drug, which data would the nurse immediately report to the supervising nurse? A. change in fetal activity and position B. increase in blood pressure and temperature C. bleeding from an orifice D. change in uterine contraction intensity

C. bleeding from an orifice

A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress? A. maternal weight gain of 30 lb (13.6 kg) B. maternal age of 22 years C. blood pressure of 146/94 mm Hg D. treatment for syphilis at 15 weeks' gestation

C. blood pressure of 146/94 mm Hg

Which findings would be considered positive signs of pregnancy? A. fatigue and skin changes B. quickening and breast enlargement C. fetal heartbeat and fetal movement on palpation D. abdominal enlargement and Braxton Hicks contractions

C. fetal heartbeat and fetal movement on palpation

A pregnant client is obese. The nurse is working as part of the interdisciplinary team developing the client's plan of care. Based on the understanding of potential complications, the nurse would expect to monitor the client closely for which condition on follow-up visits? A. mastitis B. placenta previa C. preeclampsia D. Rh isoimmunization

C. preeclampsia

A nurse is assisting with the development of a plan of care for a client at 34 weeks' gestation experiencing preterm labor. Which intervention would the nurse expect to be included to assist in halting the client's preterm labor? A. encouraging ambulation B. serving a nutritious diet C. promoting adequate hydration D. performing nipple stimulation

C. promoting adequate hydration

A client with pregnancy-induced hypertension (PIH) is admitted to the hospital. The nurse would expect this client to probably exhibit which of the following symptoms? A. proteinuria, headaches, and vaginal bleeding B. headaches, double vision, and vaginal bleeding C. proteinuria, headaches, and double vision D. proteinuria, double vision, and uterine contractions

C. proteinuria, headaches, and double vision

A primigravida client in the fifth month of pregnancy has been receiving regular prenatal care since week 8. During a routine visit, the client reports feeling dizzy, breathless, and clammy when arising from bed in the morning. The nurse should obtain data relevant to which condition? A. shock B. hemorrhage C. supine hypotension D. fainting

C. supine hypotension

A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective? A. "Braxton Hicks contractions begin irregularly and become regular." B. "Braxton Hicks contractions cause cervical dilation and effacement." C. "Braxton Hicks contractions begin in the lower back and radiate to the abdomen." D. "Braxton Hicks contractions begin in the abdomen and remain irregular."

D. "Braxton Hicks contractions begin in the abdomen and remain irregular."

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict? "Your attitude toward the male physician could put the baby at risk." "Please try to understand that the physician is a professional and will be escorted by a female nurse." "Clients cannot always be guaranteed there will be a female physician on call." D. "I will make every effort to work with your cultural beliefs."

D. "I will make every effort to work with your cultural beliefs."

A pregnant client concerned about gaining weight during pregnancy questions the nurse about dietary intake. Which response by the nurse is best? A. "Weight gain is expected, so just enjoy eating for two while you can." B. "Hasn't your health care provider told you about weight gain during pregnancy?" C. "Here are pamphlets about a variety of diets; you can choose the one that looks best to you." D. "I'll ask the dietitian to speak with you about normal weight gain during pregnancy."

D. "I'll ask the dietitian to speak with you about normal weight gain during pregnancy."

A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response? A. "You should gain less than 10 lb." B. "You should gain 10 to 15 lb." C. "You should gain 16 to 24 lb." D. "You should gain 24 to 32 lb."

D. "You should gain 24 to 32 lb."

A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion? A. 31 drops/minute B. 35 drops/minute C. 39 drops/minute D. 42 drops/minute

D. 42 drops/minute

A nurse is collecting data from a client in labor and suspects that the client may have been physically abused by her male partner. Which intervention by the nurse would be most appropriate? A. Confront the male partner. B. Question the woman in front of her partner. C. Contact hospital security. D. Collaborate with the health care provider to make a referral to social services.

D. Collaborate with the health care provider to make a referral to social services.

The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? A. Administer ephedrine to raise her blood pressure. B. Administer oxygen using a mask. C. Place the woman flat on her back with her legs raised. D. Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.

D. Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.

When collecting data on a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). The nurse recognizes which condition makes this client more susceptible to such infections? A. Electrolyte imbalances B. Decreased insulin needs C. Hypoglycemia D. Glycosuria

D. Glycosuria

A nurse in a prenatal clinic is assessing a 28-year-old who's 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? A. Glycosuria, hypertension, seizures B. Hematuria, blurry vision, reduced urine output C. Burning on urination, hypotension, abdominal pain D. Hypertension, edema, proteinuria

D. Hypertension, edema, proteinuria

When teaching a group of pregnant adolescents about reproduction and conception, where does the nurse states that fertilization occurs? A. In the uterus B. When the ovum is released C. Near the fimbriated end D. In the first third of the fallopian tube

D. In the first third of the fallopian tube

A pregnant client's last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as: A. June 5. B. June 19. C. July 5. D. July 19.

D. July 19.

A nurse is caring for a client in active labor who is crying and asking for something for pain. Her medical record shows that she does not tolerate prescribed opioid analgesics. Which of the following nonpharmacologic interventions might be helpful to this client? Turn on the lights in the room. Administer ibuprofen as ordered. Encourage the client to drink very cold tea. D. Provide back massage to the client.

D. Provide back massage to the client.

During an examination, a pregnant client at 32 weeks' gestation becomes dizzy, light-headed, and pale while supine. Which action would the nurse do first? A. Listen to fetal heart tones. B. Take the client's blood pressure. C. Ask the client to breathe deeply. D. Turn the client to the left side.

D. Turn the client to the left side.

On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two periods now." Based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy? A. facing reality B. bonding with the fetus C. accepting the baby D. accepting the pregnancy

D. accepting the pregnancy

A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate? A. continuous monitoring of fetal heart rate B. administration of IV antibiotic C. induction of labor D. cesarean delivery

D. cesarean delivery

A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered? lithotomy supine prone D. lateral

D. lateral

A nurse is caring for a 41-year-old pregnant, black client. The nurse gathers data about the client, based on the understanding that this client is at risk for which condition? A. a low-birth-weight neonate B. a preterm neonate C. umbilical cord prolapse D. placenta previa

D. placenta previa

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan? establishing rapport with the family acting as an advocate for the family attempting to correct any misinformation the family may have received D. recognizing the family as active participants in their care

D. recognizing the family as active participants in their care

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory result would the nurse need to report to the supervising registered nurse? A. urine specific gravity of 1.010 B. serum potassium level of 4.0 mEq/L C. serum sodium level of 140 mEq/L D. urine positive for ketones

D. urine positive for ketones

A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used. acme decrement strong Braxton Hicks contractions relaxation

strong Braxton Hicks contractions acme decrement relaxation