Antepartum

A nurse is reviewing the health history of a pregnant client. Which of the following data, if noted in the client's health history, would indicate a risk for spontaneous abortion?

Answer: Syphilis Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.

A nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse determines that the hormone responsible for the development of this sign is which of the following? (DUPLICATE)

Oxytocin

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?

Answer: Tell the client that these are common and they may occur throughout the pregnancy.

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client would indicate that the client understands her needs?

"I should avoid stressful situations."

A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?(DUPLICATE)

"I should choose underwear with a cotton panel liner."

A nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."

A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which of the following responses, if made by the student, indicates an understanding of the function of this hormone?

"It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus." Rationale: Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus. Relaxin is the hormone that softens the muscles and joints of the pelvis during labor. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production.

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse bases the response on which of the following? (DUPLICATE)

Answer: The breast changes are a result of the secretion of estrogen and progesterone.

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning?

"The iron is needed for the red blood cells."

A woman at 20 weeks of gestation calls the health care provider's office and speaks to a nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which of the following is the least helpful response to the client? (Duplicate)

"This is an emergency; you should come to the clinic within the hour." The woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation. Option 4 addresses the process of data collection and is an important initial component of care.

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Preeclamsia

A potentially dangerous pregnancy complication characterized by high blood pressure.

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

Answer: Oliguria Proteinuria 3+ Blood pressure 168/116 mm Hg Rationale: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria

The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? Select all that apply.

Answer: Proteinuria Hypertension Generalized edema The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria

A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?

Answer :It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Rationale: It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

An adolescent with multiple heterosexual contacts Rationale: Although all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors.

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client states:

Answer: "Breast-feeding after delivery is best for my baby." Rationale: Breast-feeding is contraindicated if the mother is positive for HIV because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertain that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, the nurse determines that the best response would be which of the following?

Answer: "Can you tell me more about what you are eating?"

A nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student states:

Answer: "FSH and LH are released from the anterior pituitary gland." FSH and LH are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the Graafian follicle, and production of progesterone. Options 1, 3, and 4 are incorrect.

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states:

Answer: "I need to increase the fiber in my diet to control my blood glucose and prevent constipation." Rationale: An increase in calories is needed during pregnancy, but concentrated sugars should be avoided, because they may cause hyperglycemia.

A nurse is providing information to a pregnant woman about food items high in folic acid. Which of the following mid-afternoon snacks should be recommended to supply folic acid?

Answer: "I should avoid stressful situations." To avoid infections, visitors with active infections should not be allowed to visit the client. Stress causes increased heart workload. Too much weight gain causes an increase in body requirements and stress on the heart. Resting should be on the side to prevent vena cava syndrome (hypotensive syndrome) and to promote blood return.

A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?

Answer: "I should choose underwear with a cotton panel liner." Rationale: Condoms should be used to minimize the spread of sexually transmitted infectious diseases. Wearing tight clothes irritates the genital area and does not allow for air circulation. Douching is to be avoided. Wearing items with a cotton panel liner allows for air movement in and around the genital area.

Magnesium sulfate is prescribed for a client with severe preeclampsia. Which statement by the student nurse supports the need for further education regarding the action of this medication?

Answer: "It increases acetylcholine and blocks neuromuscular transmission." Magnesium sulfate produces flushing and sweating as a result of decreased peripheral blood pressure; decreases the central nervous system responses and acts an anticonvulsant; decreases the frequency and duration of uterine contractions; and decreases acetylcholine, blocking neuromuscular transmission

A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term?

Answer: "It is the fetal movement that is felt by the mother." Rationale: Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks of gestation, the expectant mother first notices subtle fetal movements that gradually increase in intensity. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, known as "uterine souffle" and is due to the blood circulation to the placenta and corresponds to the maternal pulse.

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

Answer: "Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today." Rationale: Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery. Appropriate antenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up repeat urine cultures. Option 3 is the only therapeutic response and is the response that identifies accurate information.

A pregnant client who is anemic tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?

Answer: "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure that you are providing the best nutrition and growth potential." Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores.

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?

Answer: "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores.

A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which of the following responses, if made by the student, indicates an understanding of the anatomy of this structure?

Answer: "The uterus weighs about 2 ounces." Rationale: Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz), and it has a capacity of about 10 mL (1/3 oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb), and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.

A woman at 20 weeks of gestation calls the health care provider's office and speaks to a nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which of the following is the least helpful response to the client?

Answer: "This is an emergency; you should come to the clinic within the hour." Rationale: the woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted?

Answer: 150 beats per minute Rationale: Fetal heart rate depends on gestational age. It is normally 160 to 170 beats per minute during the first trimester, but it slows with fetal growth to 110 or 120 (low end) to 160 (high end) beats per minute near or at term.

A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother?

Answer: 3-hour glucose tolerance test Rationale: A maternal blood glucose measurement is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes.

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. The nurse interprets these findings as indicating:

Answer: A negative test Rationale: A reactive nonstress test (normal/negative) indicates a healthy fetus. A nonreactive nonstress test is an abnormal test and requires further followup. A suspicious test result also requires further followup. An unsatisfactory test cannot be interpreted because of the poor quality of the fetal heart rate findings.

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign, and the nurse determines that this sign is indicative of:

Answer: A softening of the cervix Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening will be noted during pelvic examination by the examiner. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is due to blood circulation through the placenta.

A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of:

Answer: Acute anxiety and the need for support Rationale: Any of the situations identified in the options may contribute to the reason for the client's behavior, but the most likely reason is anxiety

A client calls the health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which of the following in the urine?

Answer: Human chorionic gonadotropin (hCG) In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests.

A nurse is providing information about health care to a pregnant client who is positive for human immunodeficiency virus (HIV). The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to:

Answer: Avoid further stress on the maternal immune system. The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy.

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of:

Answer: Compression of the vena cava Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states that it:

Answer: Connects the umbilical vein to the inferior vena cava Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

A nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, the nurse should specifically monitor which of the following?

Answer: Deep tendon reflexes Loss of reflexes is often the first sign of developing toxicity. The nurse should assess knee jerk (patellar tendon reflex) for evidence of diminished or absent reflexes

The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to:

Answer: Drink decaffeinated coffee and tea. Rationale: Spices tend to trigger heartburn. Caffeine, like spices, may cause heartburn and needs to be avoided. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which of the following laboratory results indicates a physiological consequence of a result of this practice?

Answer: Hemoglobin 9.1 g/dL Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which of the following problems do the data best support?

Answer: High risk for infection Rationale: Women with anemia have a higher incidence of puerperal complications such as infection than do pregnant women with normal hematological values

A nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which of the following is an unassociated finding with this diagnosis?

Answer: Hypotension Rationale: The most common signs and symptoms of gestational trophoblastic disease include elevated levels of HCG, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of gestational hypertension. An elevated blood pressure would also be noted.

A maternity nurse is providing an inservice educational session to nursing students regarding the process of conception. The nurse determines that a nursing student understands this process if the student states that fertilization of a mature ovum occurs in which of the following areas?

Answer: In the distal third of the fallopian tube Rationale: The mature ovum is transported through the fallopian tube by the muscular action of the tube and the movement of the cilia within the tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovary. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovum. The other options are incorrect.

A nurse in a prenatal clinic is teaching a group of pregnant clients about anemia. Which statement is accurate about the cause of physiological anemia of pregnancy or hemodilution?

Answer: Increased blood volume of the mother During the latter part of the first trimester, the blood volume of the mother increases rapidly, more rapidly than blood cell production, leading to a decrease in the concentration of hemoglobin and erythrocytes.

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate?

Answer: Instruct the client that these are common and may occur throughout the pregnancy. Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some women during pregnancy

A nurse is teaching a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which of the following occurs?

Answer: Irregular, painless contractions Rationale: Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

A nurse is assisting a client who, at 38 weeks of gestation reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. What is the first nursing action?

Answer: Place a wedge pillow under the client's right side. Rationale: The symptoms suggest supine hypotension caused by compression of the aorta and inferior vena cava by the gravid uterus.

A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, what would be the estimated date of delivery (EDD)?

Answer: January 12 Nägele's rule is a noninvasive method of calculating the EDD as follows: subtract 3 months, add 7 days to the first day of the LMP, and add 1 year as appropriate. This is based on the assumption that the cycle is 28 days. April 5 plus 7 days minus 3 months is January 12.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2012. Using Nägele's rule, the nurse determines the estimated date of birth to be:

Answer: July 27, 2013 Rationale: The accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20, 2012. When you subtract 3 months, you get July 20, 2012. If you add 7 days, you get July 27, 2012. Add 1 year to this, and you get the estimated date of birth: July 27, 2013.

A nurse is collecting data from a client who is pregnant with twins. The nurse understands that which of the following complications is likely associated with a twin pregnancy?

Answer: Maternal anemia Rationale: Maternal anemia occurs in a client pregnant with twins because the maternal system is nurturing more than one fetus. Preterm labor, rather than postterm labor is likely to occur. Hydramnios may be associated with a twin pregnancy as a result of increased renal perfusion from cross-vessel anastomosis with monozygotic twins.

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which of the following areas?

Answer: Midway between the symphysis pubis and the umbilicus

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which of the following areas? (DUPLICATE)

Answer: Midway between the symphysis pubis and the umbilicus

A nurse assigned to care for a client with mild preeclampsia would anticipate which specific nursing intervention for this client?

Answer: Monitoring fetal movement

A nurse is reviewing the health care record of a pregnant client at 16 weeks' gestation. The nurse would expect documentation that the fundus of the uterus is noted at which of the following areas?

Answer: Nuts and green, leafy vegetables Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four daily servings of foods rich in folic acid. The food items in option 3 contain folic acid

A nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as the effective teaching method?

Answer: Palpate for uterine contractions at the same time as the client.

A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:

Answer: Placing external fetal monitors so that each fetal heart rate is monitored separately Rationale: In a client with a multifetal pregnancy, each fetal heart rate is monitored separately.

A nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy?

Answer: Pregnancy greatly increases the risk of malnourishment for the mother. Rationale: Although pregnancy poses some nutritional risk for the mother, the client is not at risk for becoming malnourished. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements routinely are encouraged. Good nutrition during pregnancy significantly and positively influences fetal growth and developmen

A nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is:

Answer: Prolactin Prolactin stimulates the secretion of milk, called "lactogenesis." Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding.

A nurse is planning interventions for counseling a maternal client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time would be which of the following?

Answer: Provide emotional support. Rationale: Probably the most important of all nursing functions is providing emotional support to the client and family. Option 1 overwhelms the client with information while the client is trying to cope with the news of the disease. Option 2 is only appropriate if the client requests to be alone if not requested, the nurse is abandoning the client in time of need. Option 4 is nontherapeutic. Supportive therapy allows the client to express feelings, explore alternatives, and make decisions in a safe, caring environment.

A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs?

Answer: Providing the mother with pamphlets and booklets to read about the pregnancy

A client who consumes alcohol frequently is in the first trimester of pregnancy. What is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?

Answer: Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures Rationale: The first trimester, "organogenesis," is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this crucial period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman.

A nurse is collecting data from a client with placenta previa during an office visit. The nurse checks which of the following items as first priority?

Answer: Signs of fetal distress Rationale: Although all of the options may be assessed, the safety of the mother-infant dyad is the priority. Signs of fetal distress is a primary concern, although the information gained through the other assessments may ultimately affect the well-being of the fetus.

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse bases the response on which of the following?

Answer: The breast changes are a result of the secretion of estrogen and progesterone. Rationale: During pregnancy the breasts change in both size and appearance. The increase in size is a result of the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin.

A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate? Postpartum: following child birth

Answer: The client will be able to identify measures to prevent infection. Rationale: The uterus is theoretically sterile during pregnancy until the membrane ruptures, after which it is capable of being invaded by pathogens. Puerperal infection is a major cause of maternal morbidity and mortality.

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?

Answer: The client will not develop an opportunistic infection during the remainder of pregnancy. Rationale: HIV is caused by a retrovirus that infects T lymphocytes. This disables the body's ability to fight infection. Nursing goals are directed at the prevention of infections. Sexual relations are not contraindicated with the proper use of protective devices.

A nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should:

Answer: Turn the client onto her left side. Rationale: When measuring fundal height, the client lies in a supine position, and the nurse instructs the woman to turn onto her left side. The nurse then elevates the left buttock by placing a pillow under the area. This position will assist in preventing supine hypotension.

A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:

Answer: Wedge-shaped and narrow and nonfavorable for a vaginal birth

A nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:

Answer: Wedge-shaped, narrow, and nonfavorable for a vaginal birth Rationale: The android pelvis is wedge-shaped and narrow and is nonfavorable for a vaginal birth

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding would indicate a serious nutritional disorder of pregnancy?

Answer: Weight compared to last visit is a loss of 2.3 pounds. Rationale: Weight loss along with the symptoms described in the question could indicate hyperemesis gravidarum. Ketone bodies, if present, would indicate protein wasting. Patellar reflexes would be used during magnesium sulfate administration. Chadwick's sign may be an indicator of pregnancy.

Braxton Hicks

Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy

A nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse determines that the hormone responsible for the development of this sign is which of the following?

Estrogen The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy.

A nurse is monitoring a client at risk for placental abruption. Which of the following is indicative of this complication?

Fetal distress

A pregnant woman visiting a health care clinic for the first prenatal visit hears the health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the preembryonic period is the:

First 2 weeks of fetal development following conception

A nurse is assigned to care for a client admitted with severe preeclampsia. What is the priority nursing intervention for this client?

Minimizing the client's exposure to external stimuli Rationale: The client with severe preeclampsia is kept on complete bedrest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum.

A 15-year-old client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which of the following treatments for acne will likely be avoided with this client?

Oral tetracycline hydrochloride Rationale: Tetracycline is avoided during pregnancy because it may cause discoloration of the child's teeth when they erupt

spontaneous abortion

Spontaneous loss of a pregnancy before the 20th week, most often before the 12th week.

chadwicks sign

is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy.

gestational trophoblastic disease

is a group of conditions in which tumors grow inside a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta, the organ that develops during pregnancy to feed the fetus.