Pregnancy at Risk NCLEX Questions

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1. Assess for signs and symptoms of labor. 2. Assess the client's temperature every 2 hours. 3. Schedule a daily ultrasound to assess fetal movement. 4. Schedule a nonstress test every 4 hours to assess fetal well-being.

1. Assess for signs and symptoms of labor.

Methylergonovine is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter? 1. Lochial flow 2. Urine output 3. Temperature 4. Blood pressure

4. Blood pressure

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. Notify the obstetrician. 3. Retake the temperature in 15 minutes. 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in 1 position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

1. "I should apply my antiembolism stockings after breakfast."

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? 1. Maternal infection 2. Gestational hypertension 3. Gestational diabetes mellitus 4. Consumption of recent high-sugar snack

1. Maternal infection

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1. Petechiae 2. Hematuria 3. Increased platelet count 4. Prolonged clotting times 5. Oozing from injection sites 6. Swelling of the calf of 1 leg

1. Petechiae 2. Hematuria 4. Prolonged clotting times 5. Oozing from injection sites

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk? 1. Presence of cats in the home 2. Number of sexual partners during pregnancy 3. Exposure to children with rashes or gastrointestinal symptoms 4. History of high fevers or unusual rashes during the first 6 weeks of pregnancy

1. Presence of cats in the home

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? 1. The client's last baby weighed 10 pounds at birth. 2. The client's previous deliveries were by cesarean section. 3. The client has a family history of cardiovascular disease. 4. The client is 5 feet, 3 inches tall and weighs 165 pounds.

1. The client's last baby weighed 10 pounds at birth.

The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply. 1. A tender and rigid uterus 2. Painless, bright red vaginal bleeding 3. Location in the lower uterine segment 4. Greenish discoloration of the amniotic fluid 5. Vaginal bleeding accompanied by abdominal pain

2. Painless, bright red vaginal bleeding 3. Location in the lower uterine segment

The nurse in the postpartum unit notes that a new mother was given methylergonovine intramuscularly following delivery. What assessment finding indicates that the medication was effective? 1. Lochia that is serous 2. Normal blood pressure 3. Decreased uterine bleeding 4. Decreased uterine contractions

3. Decreased uterine bleeding

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 obstetrician (OB). 4. Place the client in Trendelenburg's position.

3. Notify the obstetrician (OB).

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1. Tongue blade 2. Percussion hammer 3. Potassium chloride injection 4. Calcium gluconate injection

4. Calcium gluconate injection

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? 1. Anxiety 2. Hot flashes 3. Low self-esteem 4. Postpartum infection

4. Postpartum infection

Which data places the client at risk for developing gestational diabetes during pregnancy? 1. The client has a family history of type 1 diabetes. 2. The client is 5 feet tall and weighs 129 lb. 3. The client's previous deliveries were by cesarean section. 4. The client has a history of gestational diabetes with her previous pregnancy.

4. The client has a history of gestational diabetes with her previous pregnancy.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at most risk for development of postpartum thromboembolic disorders? 1. A 39-year-old woman who reports that she smokes 2. A 24-year-old woman with a thin frame who is a vegetarian 3. A 30-year-old woman in her fourth pregnancy who is normal weight 4. A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have not caused any adverse effects

1. A 39-year-old woman who reports that she smokes

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1. A primigravida with abruptio placenta 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida 2 who has just been diagnosed with dead fetus syndrome 4. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

1. A primigravida with abruptio placenta 3. A gravida 2 who has just been diagnosed with dead fetus syndrome 5. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. 1. Assess blood pressure. 2. Check the urine for protein. 3. Assess deep tendon reflexes. 4. Discuss the need for hospitalization. 5. Teach the importance of keeping track of a daily weight.

1. Assess blood pressure. 2. Check the urine for protein. 3. Assess deep tendon reflexes. 5. Teach the importance of keeping track of a daily weight.

The nurse should take which nursing actions when caring for a postpartum client who begins to hemorrhage? Select all that apply. 1. Assess for uterine atony. 2. Prepare to administer blood or blood products as prescribed. 3. Insert an indwelling urinary catheter to monitor kidney perfusion. 4. Administer 8 to 10 L/min of oxygen via non-rebreather face mask. 5. Administer uterotonic medications as prescribed to increase uterine tone.

1. Assess for uterine atony. 2. Prepare to administer blood or blood products as prescribed. 3. Insert an indwelling urinary catheter to monitor kidney perfusion. 4. Administer 8 to 10 L/min of oxygen via non-rebreather face mask. 5. Administer uterotonic medications as prescribed to increase uterine tone.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1. Forceps delivery 2. Schultz presentation 3. Hypotonic contractions 4. Weak bearing-down efforts

1. Forceps delivery

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1. Hypertension 2. Low-grade fever 3. Generalized edema 4. Increased pulse rate

1. Hypertension

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. Proteinuria 2. Hypertension

A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 37.2º C (99º F). The nurse plans care based on which interpretation? 1. The woman requires further evaluation for preterm labor. 2. The woman is suffering from an intestinal bacterial infection. 3. The woman is exhibiting signs and symptoms of gestational hypertension. 4. The woman needs instruction on pelvic tilts to decrease her lower back pain.

1. The woman requires further evaluation for preterm labor.

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 100.4º F (38º C) 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. An increase in the pulse rate from 88 to 102 beats/minute

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock? 1. Complaints of abdominal cramping 2. An increased pulse rate of 80 to 120 beats/min 3. Complaints of feeling tired yet is feeling hungry 4. An increase in the respiratory rate from 18 to 22 breaths/min

2. An increased pulse rate of 80 to 120 beats/min

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2. Ask the client about pain in the calf area.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rho(D) immune globulin 4. Dinoprostone vaginal insert

2. Betamethasone

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate.

2. Clear and maintain an open airway.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1. Proteinuria of 3 + 2. Respirations of 10 breaths per minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 4 mEq/L (2 mmol/L)

2. Respirations of 10 breaths per minute 4. Urine output of 20 mL in an hour

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. 1. Use of diaphragm 2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID)

2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID)

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. Uterine tenderness

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 obstetrician."

3. "I should avoid exercise because of the negative effects on insulin production."

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 primary health care provider (PHCP)."

3. "I should avoid exercise because of the negative effects on insulin production."

The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change."

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client? 1. "Your OGTT results indicate that your baby is at high risk for macrosomia, and special considerations may be necessary at delivery." 2. "Your OGTT results are within normal limits, but continuing your prenatal visits remains essential to monitor fetal growth and development." 3. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." 4. "Your OGTT results indicate that you are positive for gestational diabetes. You will be scheduled for a dietitian consultation to plan your daily dietary intake."

3. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated."

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? 1. "You should avoid all school-age children during pregnancy." 2. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." 4. "Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester."

3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

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

3. A multiparous client who delivered a large baby after oxytocin induction

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? 1. A private room across from the elevator 2. A semiprivate room across from the nurses' station 3. A private room 2 doors away from the nurses' station 4. A semiprivate room with another client who enjoys watching television

3. A private room 2 doors away from the nurses' station

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? 1. Placenta previa 2. Polyhydramnios 3. Abruptio placentae 4. Gestational hypertension

3. Abruptio placentae

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs.

3. Ambulate frequently.

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Ambulation 8 to 10 times daily 2. Administration of anticoagulants 3. Elevation of the affected extremity 4. Application of ice packs to the affected area

3. Elevation of the affected extremity

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 should 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. Enlarged, hardened veins

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1. Perform an abdominal scrub on the client. 2. Prepare the delivery room for a vaginal delivery. 3. Explain to the client why a cesarean delivery is necessary. 4. Call the primary health care provider to obtain a prescription for an antiviral medication.

3. Explain to the client why a cesarean delivery is necessary.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the obstetrician. 2. Assess the client's vital signs. 3. Gently massage the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin solution.

3. Gently massage the uterine fundus.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. 1. Back pain 2. Heavy vaginal bleeding 3. Increase in fundal height 4. Hard, board-like abdomen 5. Persistent abdominal pain 6. Early deceleration on the fetal heart monitor

3. Increase in fundal height 4. Hard, board-like abdomen 5. Persistent abdominal pain

When performing a postpartum assessment on a client, the 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 primary health care provider (PHCP). 4. Encourage increased oral intake of fluids.

3. Notify the primary health care provider (PHCP).

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? 1. "I don't like my figure anymore. My clothes are all too tight." 2. "I don't like my breasts anymore. These silver lines are ugly." 3. "I don't like my stomach anymore. That brown line is disgusting." 4. "I don't like my face anymore. I always look like I have been crying."

4. "I don't like my face anymore. I always look like I have been crying."

A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? 1. "I will need to remain on bed rest for 2 weeks." 2. "I will need to take a full course of antibiotic treatment." 3. "I will need to take tocolytic medication to halt the labor process." 4. "I will need to prepare myself and my family for the loss of this pregnancy."

4. "I will need to prepare myself and my family for the loss of this pregnancy."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates an understanding of self-care for this diagnosis? 1. "I need to eat fruits and vegetables only." 2. "I will go to the laboratory daily for a glucose test." 3. "I cannot exercise because of the negative effects on insulin production." 4. "I will report signs of infection immediately to my primary health care provider."

4. "I will report signs of infection immediately to my primary health care provider."

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? 1. "You will be isolated from your newborn infant after delivery." 2. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3. "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1. 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. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1. Chest pain 2. A rigid abdomen 3. A soft and boggy uterus 4. Complaints of severe abdominal pain

4. Complaints of severe abdominal pain

A client diagnosed with severe preeclampsia is receiving magnesium sulfate by continuous intravenous infusion. Which assessment finding would indicate that the medication should be discontinued? 1. Absence of deep tendon reflexes 2. Respiratory rate of 16 breaths per minute 3. Urinary output of 45 mL during the past hour 4. Decrease in blood pressure from 180/100 mm Hg to 150/90 mm Hg

1. Absence of deep tendon reflexes

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring

1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 5. Increased uterine resting tone on fetal monitoring

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period? 1. A 35-year-old client who reports that she smokes 2. A 26-year-old client with a family history of thrombophlebitis 3. A 37-year-old client in her fourth pregnancy who is overweight 4. A 22-year-old client in her first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

2. A 26-year-old client with a family history of thrombophlebitis

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? 1. The client is 28 years of age. 2. This is the second pregnancy. 3. The client has a history of hypertension. 4. The client performs moderate exercise on a regular daily schedule.

3. The client has a history of hypertension.

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 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. The client complains of a headache and blurred vision.

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? 1. Urinary output of 20 mL 2. Deep tendon reflexes of 2+ 3. Fetal heart rate of 120 beats/minute 4. Respiratory rate of 10 breaths/minute

4. Respiratory rate of 10 breaths/minute

A client with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse is reviewing the laboratory results and determines that which magnesium level is within the therapeutic range? 1. 1 mEq/L (0.5 mmol/L) 2. 3 mEq/L (1.5 mmol/L) 3. 5 mEq/L (2.5 mmol/L) 4. 10 mEq/L (5 mmol/L)

3. 5 mEq/L (2.5 mmol/L) * Therapeutic range: 4 to 7 mEq/L (2 to 3.5 mmol/L)

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. Delivery of the fetus

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? 1. Increased insulin 2. Decreased insulin 3. Increased caloric intake 4. Decreased protein intake

1. Increased insulin

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy

1. Massaging the uterus 3. Assisting the woman to urinate 5. Checking for a distended bladder

A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa? 1. The placenta is implanted in the lower uterine segment. 2. The greatest risk associated with this condition is chronic hypertension. 3. There are two placentas attached to the fetus located in the side of the uterine wall. 4. The placenta is half the size that it is expected to be, presenting a risk for deprivation of nutrients to the fetus.

1. The placenta is implanted in the lower uterine segment.

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client? 1. Administer her prepregnancy dose of metformin. 2. Assess her blood glucose before administering any glucose-lowering medications. 3. Administer 20 units of long-acting insulin, as sufficient time has elapsed since delivery. 4. Keep NPO (nothing by mouth) for an additional 4 hours to allow the blood glucose to normalize.

2. Assess her blood glucose before administering any glucose-lowering medications.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2. Blood pressure

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Hematoma 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? 1. Age 35 years 2. History of syphilis 3. History of genital herpes 4. History of diabetes mellitus

2. History of syphilis

The 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 is 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. Massage the fundus until it is firm.

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 primary 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. Obtain equipment for a manual pelvic examination.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad

2. Palpating the uterine fundus

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1. Restrict food and fluids. 2. Reduce external stimuli. 3. Monitor blood glucose levels. 4. Maintain the client in a supine position.

2. Reduce external stimuli.

A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? 1. Scotomas are present. 2. Seizures do not occur. 3. Ankle clonus is noted. 4. The blood pressure decreases.

2. Seizures do not occur.

The nurse is performing an 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 13.5 g/dL (135 mmol/L). 4. The client is a 20-year-old primigravida of average weight and height.

2. The client has a history of cardiac disease.

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 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 mL of blood 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

3. A gravida II who has just been diagnosed with dead fetus syndrome 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

The nurse suspects the presence of uterine atony and massages the uterus, but this action does not assist in controlling blood loss. Which is the next nursing action? 1. Take the client's blood pressure. 2. Measure the amount of drainage on the peripad. 3. Contact the primary health care provider (PHCP). 4. Ask the blood bank to prepare a unit of blood for the client.

3. Contact the primary health care provider (PHCP).

A pregnant woman of 30 weeks' gestation is admitted to the maternity unit in preterm labor. The woman asks the nurse about the purpose of betamethasone, which has been prescribed by the primary health care provider (PHCP). The nurse should tell the client that the medication will promote which action? 1. Delay delivery. 2. Prevent membrane rupture. 3. Enhance fetal lung maturity. 4. Stop the premature uterine contractions.

3. Enhance fetal lung maturity.

The nurse is reviewing the primary health care provider's (PHCP'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 an antibiotic per prescription and per agency protocol.

3. Perform a vaginal examination every shift.

A client in preterm labor is being started on intravenous magnesium sulfate to stop the contractions. Several hours later, when the nurse is performing an assessment, the following data are obtained: blood pressure, 110/66 mm Hg; pulse, 66 beats per minute; respirations, 10 breaths per minute; and deep tendon reflexes absent. What should the nurse do next? 1. Institute seizure precautions. 2. Prepare for a precipitous delivery. 3. Prepare to administer calcium gluconate as an antidote for magnesium toxicity. 4. Increase the rate of magnesium sulfate, as the desired outcome has not yet been achieved.

3. Prepare to administer calcium gluconate as an antidote for magnesium toxicity.

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's primary health care provider (PHCP) needs to be notified of the finding.

3. The client is experiencing normal lochia discharge.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm, contracted ball 3. The saturation of more than 1 peripad per hour 4. Palpation of the fundus at the level of the umbilicus

3. The saturation of more than 1 peripad per hour

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the primary health care provider (PHCP). The nurse should tell the woman to call the PHCP if which occurs? 1. Urine test is negative for protein. 2. Fetal movements are more than 4 per hour. 3. Weight increases by more than 1 pound in a week. 4. The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.

3. Weight increases by more than 1 pound in a week.

The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? 1. "I do not need to abstain from sexual intercourse." 2. "I need to use vaginal creams after I douche every day." 3. "I need to douche and perform a sitz bath 3 times a day." 4. "It may be necessary to have a cesarean section for delivery."

4. "It may be necessary to have a cesarean section for delivery."

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? 1. "I can douche anytime I want." 2. "I can wear my tight-fitting jeans." 3. "I should avoid the use of condoms." 4. "I should wear underwear with a cotton panel liner."

4. "I should wear underwear with a cotton panel liner."

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the primary health care provider (PHCP).

4. Assess for hypovolemia and notify the primary health care provider (PHCP).

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? 1. Allow family members to name the infant. 2. Encourage the client to talk about the dead fetus. 3. Allow the client and the spouse to hold the infant. 4. Assess the client's and spouse's perception of the event.

4. Assess the client's and spouse's perception of the event.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1. Peripads 2. Tape measure 3. Reflex hammer 4. Blood pressure cuff

4. Blood pressure cuff

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. 1. Plan induction at 35 weeks. 2. Plan amniocentesis at this time. 3. Schedule a biophysical profile immediately. 4. Plan for weekly nonstress tests at 32 weeks. 5. Obtain nutritional counseling with a dietitian.

4. Plan for weekly nonstress tests at 32 weeks. 5. Obtain nutritional counseling with a dietitian.

A client experiencing preterm labor at the 29th week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone but delivers too quickly for medication administration. As a result of not receiving this medication, which condition is most likely to develop in the preterm newborn? 1. Chlamydia 2. Hypoglycemia 3. Hyperbilirubinemia 4. Respiratory depression

4. Respiratory depression

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats per 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. The client with lochia that is red and has a foul-smelling odor

The nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation? 1. The magnesium sulfate is effective. 2. The infusion rate needs to be increased. 3. The woman is experiencing cerebral edema. 4. The woman is experiencing magnesium excess.

4. The woman is experiencing magnesium excess.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1. Measure fundal height. 2. Attach electronic fetal monitoring. 3. Prepare the client for a possible cesarean section. 4. Visually examine the perineum and vaginal opening.

1. Measure fundal height.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Keep the room semi-dark. 2. Initiate seizure precautions. 3. .Pad the side rails of the bed. 4. Avoid environmental stimulation. 5. Allow out-of-bed activity as tolerated.

1. Keep the room semi-dark. 2. Initiate seizure precautions. 3. .Pad the side rails of the bed. 4. Avoid environmental stimulation.

List in order of priority the actions the nurse should take when a client in labor is experiencing eclampsia? 1.Remain with the client . 2.Monitor fetal heart rate patterns. 3.Administer medications to control seizure. 4.Document the occurrence, client's response, and outcome. 5.Insert an oral airway after the seizure ends and suction the client's mouth. 6.Ensure the airway is open, turn on her side, and provide 8 to 10 L/min of oxygen.

1, 6, 2, 3, 5, 4

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1. "My vision for the past 2 days has been really fuzzy." 2. "The swelling in my hands and ankles has gone down." 3. "I had heartburn yesterday after I ate some spicy foods." 4. "I had a headache yesterday, but I took some acetaminophen and it went away."

1. "My vision for the past 2 days has been really fuzzy."

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1. Monitor for fetal movement. 2. Monitor the maternal blood glucose. 3. Instruct the client to maintain complete bed rest. 4. Instruct the client to restrict dietary sodium and any food items that contain sodium.

1. Monitor for fetal movement.

A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction? 1. "I should cook meat thoroughly." 2. "I should drink unpasteurized milk only." 3. "I should avoid contact with materials that are possibly contaminated with cat feces." 4. "I should avoid touching mucous membranes of the mouth or eyes while handling raw meat."

2. "I should drink unpasteurized milk only."

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? 1. "I will watch to see if I pass any tissue." 2. "I will maintain strict bed rest throughout the remainder of the pregnancy." 3. "I will count the number of perineal 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 episode of bleeding."

2. "I will maintain strict bed rest throughout the remainder of the pregnancy."

The senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The co-assigned registered nurse asks the student to describe the actions and effects of this medication. Which statement, if made by the student, indicates the need for further teaching? 1. "It decreases the frequency and duration of uterine contractions." 2. "It increases acetylcholine, blocking neuromuscular transmission." 3. "It decreases the central nervous system activity, acting as an anticonvulsant." 4. "It produces flushing and sweating due to decreased peripheral blood pressure."

2. "It increases acetylcholine, blocking neuromuscular transmission."

A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse should anticipate that which treatment measure would most likely be prescribed next for the mother? 1. An oral hypoglycemic agent 2. A 3-hour glucose tolerance test 3. Humulin N insulin on a daily basis 4. A sliding-scale regular insulin dose

2. A 3-hour glucose tolerance test

The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. 1. Soft uterus 2. Abdominal pain 3. Nontender uterus 4. Firm uterus by palpation 5. Painless vaginal bleeding

2. Abdominal pain 4. Firm uterus by palpation

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 15 minutes. How should the nurse respond to this finding initially? 1. Document the finding. 2. Encourage the client to ambulate. 3. Encourage the client to increase fluid intake. 4. Contact the primary health care provider (PHCP) and inform the PHCP of this finding.

4. Contact the primary health care provider (PHCP) and inform the PHCP of this finding.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventive measure may be prescribed. 2. Administration of subcutaneous heparin postdelivery as prescribed. 3. An overbed lift may be necessary if the client requires a cesarean section. 4. Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

2. Administration of subcutaneous heparin postdelivery as prescribed. 3. An overbed lift may be necessary if the client requires a cesarean section. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs? 1. Afterpains 2. Retained placental fragments from delivery 3. An oral temperature of 99.0º F (37.2º C) following delivery 4. Increased estrogen and progesterone levels as noted on laboratory analysis

2. Retained placental fragments from delivery

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of 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. Evidence of bleeding, such as in the gums, petechiae, and purpura

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? 1. Back pain 2. Abdominal pain 3. Painful vaginal bleeding 4. Painless vaginal bleeding

4. Painless vaginal bleeding

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the primary health care provider who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4. Peripheral vascular disease