ATI N3610 Quiz 1

If the ovum is to be fertilized, where is the most common site of fertilization? A. Uterine wall B. Fimbria C. Ampulla of the fallopian tube D. Isthmus of the fallopian tube

C. Ampulla of the fallopian tube i: This is correct- this is the outer 1/3 of the fallopian tube

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus? A. Calcium B. Iron C. Vitamin C D. Folic acid

D. Folic acid i: Adequate amounts of folic acid before conception and during the first trimester of pregnancy are necessary for fetal neural tube development. This vitamin helps prevent spina bifida and other neurological disorders.

A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (SATA) A. Eczema B. Psoriasis C. Linea nigra D. Chloasma E. Striae gravidarum

C, D, E i: Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy.

A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? A. "You should not receive the rubella vaccine while breastfeeding." B. "You should receive a varicella vaccine before you deliver." C. "You can receive an influenza vaccination during pregnancy." D. "You cannot receive the Tdap vaccine until after you deliver."

C. "You can receive an influenza vaccination during pregnancy." i: It is recommended that pregnant women receive annual influenza vaccinations.

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? A. "I will reduce my stress level." B. "I will tell my doctor before using home remedies for nausea." C. "I will monitor my weight gain during the remaining months." D. "I will use only nonprescription medications while pregnant."

D. "I will use only nonprescription medications while pregnant." i: Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy.

A patient is trying to prevent pregnancy by using the rhythm method. On what cycle day is she the most fertile. A. 21-28 B. 1-6 C. 6-9 D. 9-16

D. 9-16 i: This time period allows for early ovulation and for the egg that lives for 2 days.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. Maintain the client in the lithotomy position. B. Perform vaginal examinations frequently. C. Remind the client to bear down with each contraction. D. Encourage the client to empty her bladder every 2hr.

D. Encourage the client to empty her bladder every 2hr. i: A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

A nurse is caring for a client who is scheduled for a amternal serum-alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? A. This test assesses fetal lung maturity. B. It assesses various markers of fetal well-being. C. This test identifies an Rh incompatibility between the mother and fetus. D. It is a screening test for spinal defects in the fetus.

D. It is a screening test for spinal defects in the fetus. i: The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected neural tube defects (NTDs) and abdominal wall defects. These include spina bifida, microcephaly, and anencephaly. This tool is the basis for further testing, such as amniocentesis and specialized ultrasounds.

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? A. The fetal head is in the left occiput posterior position. B. The largest fetal diameter has passed through the pelvic outlet. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

D. The lowermost portion of the fetus is at the level of the ischial spines. i: The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? A. There is no evidence of cervical incompetence. B. There is no evidence of two or more accelerations in fetal heart rate in 20 min. C. There is no evidence of uteroplacental insufficiency. D. There are less than 3 uterine contractions in a 10 min period.

C. There is no evidence of uteroplacental insufficiency. i: A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations.

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A. "It's a minor inconvenience, which you should ignore." B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." C. "There is no way to predict how long it will last in each individual client." D. "It occurs during the first trimester and near the end of the pregnancy."

D. "It occurs during the first trimester and near the end of the pregnancy." i: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB?

0504 - May 4th i: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format.

A nurse is caring for a client who is at 18 weeks gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? A. Ballottement B. Lightening C. Quickening D. Chloasma

C. Quickening i: Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement.

A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching? A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." B. "The sex of the baby is determined by week 8 of pregnancy." C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy." D. "You will first feel your baby move in week 24 of pregnancy."

A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." i: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation.

A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? A. "This is a presumptive sign of pregnancy." B. "This is a probable sign of pregnancy." C. "This is a possible sign of pregnancy." D. "This is a positive sign of pregnancy."

A. "This is a presumptive sign of pregnancy." i: Presumptive signs of pregnancy include physical changes that are apparent to the client, such as quickening.

A nurse is caring for a client who is primigravida, at term, and having contractions but is statins that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membranes B. Changes in the cervix C. Station of the presenting part D. Pattern of contractions

B. Changes in the cervix i: Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (SATA) A. Fetal breathing B. Fetal motion C. Fetal neck translucency D. Amniotic fluid volume E. Fetal gender

A, B, D i: A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume.

A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? A. 4-0-1-2-2 B. 3-0-2-0-2 C. 2-0-0-2-0 D. 4-2-0-2-2

A. 4-0-1-2-2 i: This response correctly describes the client's current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L).

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? A. Shortly after giving birth B. In the third trimester C. Immediately D. During her next attempt to get pregnant

A. Shortly after giving birth i: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? A. Vertex B. Shoulder C. Breech D. Mentum

C. Breech i: An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? A. Apply fundal pressure. B. Observe for the presence of a nuchal cord. C. Observe for crowning. D. Prepare to administer oxytocin.

C. Observe for crowning. i: In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

A nurse is providing teaching to a client who is planning on becoming pregnant about the changes she should expect. Identify the sequence of maternal changes. A. Quickening B. Lightening C. Goodell's sign D. Amenorrhea

D > C > A > B i: Amenorrhea, a presumptive sign of pregnancy, is one of the first physiological indications of pregnancy that occurs by 4 weeks of gestation. Goodell's sign, a probable sign of pregnancy, is the next of physiological indications to occur. Goodell's sign is the softening of the cervix that typically occurs at 5 to 6 weeks of gestation. Quickening, the mother's perception of the first fetal movement, is a presumptive sign of pregnancy that typically occurs between 16 and 20 weeks of gestation. Lightening is the last of these physiological signs of pregnancy to occur. As the fetus descends into the pelvic cavity the fundal height decreases, which typically occurs between 38 and 40 weeks of gestation.

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? A. "I should drink about 2 liters of fluid each day." B. "I should not drink alcoholic beverages during my pregnancy." C. "I can have a moderate amount of caffeine daily." D. "I should increase my calcium intake to 1,500mg per day."

D. "I should increase my calcium intake to 1,500mg per day." i: A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass.

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? A. 3cm above the umbilicus B. Slightly above the umbilicus C. Slightly below the umbilicus D. 3cm below the umbilicus

B. Slightly above the umbilicus i: At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? A. Vomiting B. Tachycardia C. Respiratory depression D. Hypotension

D. Hypotension i: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.

A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15weeks of gestation. Which of the following should be included in the teaching? A. "The test will be performed if your baby's heart beat is heard." B. "This test will determine if your baby's lungs are mature." C. "This test requires the presence of amniotic fluid." D. "After the test, you will be given Rh0 immune globulin since you are Rh positive."

C. "This test requires the presence of amniotic fluid." i: Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? A. Monitor the client's temperature. B. Assess the fetal heart rate. C. Assess the odor of the amniotic fluid. D. Provide clean, dry underpads.

B. Assess the fetal heart rate. i: The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mmHg and the fetal heart rate is 140/min. Which of the followign is the priority nursing action? A. Elevate the client's legs. B. Monitor vital signs every 5 min. C. Notify the provider. D. Place the client in a lateral position.

D. Place the client in a lateral position. i: Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications? A. Hearing loss B. Intrauterine growth restriction C. Type 1 diabetes mellitus D. Congenital heart defects

B. Intrauterine growth restriction i: Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death.

A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? A. "Ambivalent feelings are quite common for women early in pregnancy." B. "Perhaps you should see a counselor to discuss these feelings further." C. "Have you spoken to your mother about these feelings?" D. "Don't worry. You'll be fine once the baby is born."

A. "Ambivalent feelings are quite common for women early in pregnancy." i: This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy.

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she in in labor. Which of the following findings confirm to the nurse that the client is in labor? A. Cervical dilation B. Reports of pain above the umbilicus C. Brownish vaginal discharge D. Amniotic fluid in the vaginal vault

A. Cervical dilation i: Cervical dilation and effacement are indications of true labor.

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse? A. February 11, 2016 B. February 27, 2016 C. April 27, 2016 D. April 11, 2016

A. February 11, 2016 i: Subtracting 3 calendar months and adding 7 days plus one year will result in this estimated date of delivery.

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse? A. "Fertilization takes place in the outer third of the fallopian tube." B. "Implantation occurs between 2 to 3 weeks after conception." C. "Sperm remain viable in the woman's reproductive tract for 2 to 3 days." D. "Bleeding or spotting can accompany implantation."

B. "Implantation occurs between 2 to 3 weeks after conception." i: This statement requires clarification because implantation occurs between 6 to 10 days following conception.

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a durtiong of 1min and a frequency of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54mmHg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Have the client void.

B. Position the client with one hip elevated. i: Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.

A nurse is caring for a client who is in active labor with 7cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? A. Assist the client into a comfortable position. B. Observe the perineum for signs of crowning. C. Have the client pant during the next contractions. D. Help the client to the bathroom to void.

C. Have the client pant during the next contractions. i: Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? A. "This will determine is there is more than one fetus." B. "It is useful for estimating fetal age." C. "It assists in identifying the location of the placenta and fetus." D. "This is a screening tool for spina bifida."

C. "It assists in identifying the location of the placenta and fetus." i: Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A. "This will occur during the last trimester of pregnancy." B. "This will happen by the end of the first trimester of pregnancy." C. "This will occur between the fourth and fifth months of pregnancy." D. "This will happen once the uterus begins to rise out of the pelvis."

C. "This will occur between the fourth and fifth months of pregnancy." i: Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks.

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? A. A client who has mitral valve prolapse B. A client who has been exposed to AIDS C. All of the clients D. A client who has a history of preterm labor.

C. All of the clients i: MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9C/102F. Besides notifying the provider, which of the following is the appropriate nursing action? A. Recheck the client's temperature in 4 hr. B. Administer glucocorticoids intramuscularly. C. Assess the odor of the amniotic fluid. D. Prepare the client for emergency cesarean section.

C. Assess the odor of the amniotic fluid. i: Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid.

A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching? A. "You will need to increase your calcium intake during breastfeeding." B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy." C. "Vitamin E requirements decline during pregnancy due to the increase in body fat." D. "You will need to double your intake of iron during pregnancy."

D. "You will need to double your intake of iron during pregnancy." i: During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client's red blood cell volume.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse perform? A. Prepare for a cesarean birth. B. Assist the client to an upright position. C. Prepare for an immediate vaginal delivery. D. Assist the client to turn onto her side.

D. Assist the client to turn onto her side. i: Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? A. Leukorrhea B. Urinary frequency C. Nausea and vomiting D. Facial edema

D. Facial edema i: Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider.

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? A. The presenting part is 1cm above the ischial spines. B. The presenting art is 1cm below the ischial spines. C. The cervix is 1cm dilated. D. The cervix is effaced 1cm.

A. The presenting part is 1cm above the ischial spines. i: Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus 1, then the presenting part is 1cm above the ischial spines.

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? A. "These exercises help prevent constipation." B. "These exercises help pelvic muscles to stretch during birth." C. "They can help reduce back aches." D. "They can prevent further stretch marks."

B. "These exercises help pelvic muscles to stretch during birth." i: Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth.

A nurse is teaching a group of clients who are in their first trimester about exercising during pregnancy. Which of the following statements should the nurse include in the teaching? A. "Refrain from exercises that include stretching." B. "Moderate exercise improves circulation." C. "It is recommended to increase your weight-bearing exercises." D. "It is recommended to rest for 30 minutes before each new exercise."

B. "Moderate exercise improves circulation." i: Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone.

A nurse in a clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? A. Decreased vaginal discharge B. A surge of energy C. Urinary retention D. Weight gain of 0.5 to 1.5 kg

B. A surge of energy i: Prior to the onset of labor, the pregnant client experiences a surge of energy.

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? A. Two veins and one artery B. One artery and one vein C. Two arteries and one vein D. Two arteries and two veins

C. Two arteries and one vein i: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta.

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately? A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions. B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors. C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes. D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache.

D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache. i: These findings indicate that the client's condition is worsening and are signs of severe preeclampsia. They should be reported to the provider immediately. Other manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant pain.

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? A. "It would be best if you gained about 11 to 20 pounds." B. "The recommendation for you is about 15 to 25 pounds." C. "A gain of about 25 to 35 pounds is recommended for you." D. "A gain of about 1 pound per week is the best pattern for you."

B. "The recommendation for you is about 15 to 25 pounds." i: Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb). The pattern of weight gain is also important, with minimal gain in the first trimester.

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula. B. Assist the client to breathe into a paper bag. C. Have the client tuck her chin to her chest. D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.

B. Assist the client to breathe into a paper bag. i: This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? A. The client reports weakness of the lower extremities. B. Blood pressure 80/56 mmHg C. Temperature 38.2C / 100.8F D. The client reports perfuse itching.

B. Blood pressure 80/56 mmHg i: When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep four side rails up while the client is in bed. B. Check the cervix prior to analgesic administration. C. Monitor the fetal heart rate (FHR) every hour. D. Insert an indwelling urinary catheter.

B. Check the cervix prior to analgesic administration. i: Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? A. Expulsion of a blood-tinged mucous plug B. Continuous contraction lasting 2 min C. Pressure on the perineum causing the client to bear down D. Expulsion of clear fluid from the vagina

B. Continuous contraction lasting 2 min i: A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate is 130 to 150/min, but there has been no fetal movement for 15min. Which of the following actions should the nurse perform? A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Encourage the client to walk around without the monitoring unit for 10min, then resume monitoring. C. Offer the client a snack of orange juice and crackers. D. Turn the client onto her left side.

C. Offer the client a snack of orange juice and crackers. i: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement.

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make? A. Retained bile in the liver results in delayed digestion. B. Increased estrogen production causes increased secretion of hydrochloric acid. C. Pressure from the growing uterus displaces the stomach. D. Increased progesterone production causes decreased motility of smooth muscle.

D. Increased progesterone production causes decreased motility of smooth muscle. i: Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn.

A charge nurse observes a nurse checking fetal heart tones (FHT) for a client who is at 12 weeks of gestation. Which of the following actions by the nurse indicates a need for intervention by the charge nurse? A. Places a pillow under the client's head B. Counts the fetal heart rate for a full minute C. Auscultates about the symphysis pubis D. Listens with a fetoscope

D. Listens with a fetoscope i: A fetoscope is not able to detect FHT this early in the pregnancy. The nurse should use a Doppler or ultrasound stethoscope. Typically at 12 weeks, the heart tones will be heard midline just above the symphysis pubis with a Doppler or ultrasound device. A fetoscope can be used to assess FHT later in the pregnancy, around 16 to 20 weeks.

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A. Left lower B. Right lower C. Left upper D. Right upper

D. Right upper i: Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.

A nurse is preparing a client who is in active labor for an epidural analgesia. Which of the following actions should the nurse take? A. Have the client stand at the bedside with her arms at her side. B. Administer a 500mL bolus of 5% dextrose in water prior to induction. C. Inform the client the anesthetic effect will last for approximately 6hr. D. Obtain a 30min electronic fetal monitoring (EFM) strip prior to induction.

D. Obtain a 30min electronic fetal monitoring (EFM) strip prior to induction. i: The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. B. The client is immune to the rubella virus. C. The client requires a rubella vaccination at this time. D. The client requires a rubella immunization following delivery.

D. The client requires a rubella immunization following delivery. i: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.