ATI NSG 4525 Antepartum
A nurse is reinforcing teaching with a group of adolescent females who are pregnant about expected changes related to pregnancy. Which of the following client statements indicates understanding of the teaching? -"It is normal to have white vaginal discharge." -"I should recognize fetal movement by 12 weeks." -"I will take fluid pills if my ankles begin to swell." -"My nipples and areolae will become pale as my breasts enlarge."
"It is normal to have a white vaginal discharge." - Hormone stimulation causes leukorrhea, in which the cervix produces excess mucous. The nurse should instruct the client to use good perineal hygiene and report any discharge that is foul-smelling or a different color.
A nurse is caring for a client who is receiving magnesium sulfate to treat severe preeclampsia and asks the nurse "Is the medication working?" Which of the following responses should the nurse make? -"The medication is working because there are no contractions." -"The medication is working, because there is no seizure activity." -"The medication is working, because all your lung fields are clear." -"The medication is working, because your blood pressure is normal."
"The medication is working, because there is no seizure activity." - Magnesium sulfate can be used for various reasons, including antacid, antiarrhythmic, anticonvulsant, electrolyte replacement and laxative. The primary indication for the client who is being treated for preeclampsia is the anticonvulsant properties. It is the preferred drug to prevent seizures in preeclampsia and treat seizures associated with eclampsia.
A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? -"There is an increased risk of introducing infection." -"This could initiate preterm labor." -"This could result in profound bleeding." -"There is an increased risk of rupture of the membranes."
"This could result in profound bleeding." - "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.
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? -"You should not receive the rubella vaccine while breastfeeding." -"You should receive a varicella vaccine before you deliver." -"You can receive an influenza vaccination during pregnancy." -"You cannot receive the Tdap vaccine until after you deliver."
"You can receive an influenza vaccination during pregnancy." - It is recommended that pregnant women receive annual influenza vaccinations.
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement. (SATA) -Administer magnesium sulfate IV -Provide a dark, quiet environment -Assess respiratory status every 4 hr -Evaluate neurologic status every 8 hr -Ensure that calcium gluconate is readily available
-Administer magnesium sulfate IV -Provide a dark, quiet environment -Ensure that calcium gluconate is readily available
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) -Fetal breathing -Fetal motion -Fetal neck translucency -Amniotic fluid volume -Fetal gender
-Fetal breathing -Fetal motion -Amniotic fluid volume
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) -Eczema -Psoriasis -Linea nigra -Chloasma -Striae gravidarum
-Linea nigra -Chloasma -Striae gravidarum
A nurse is conducting nutritional counseling with a client who is in her trimester of pregnancy. The nurse should recommend the client increase her caloric intake by how many calories during this trimester? -110 cal/day -225 cal/day -340 cal/day -450 cal/day
340 cal/day - The nurse should recommend the client increase her calorie intake by 340 cal/day.
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 tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions. -A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors -A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes -A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache
A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache - 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 during a nonstress test (NST). At the end of a a30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two declarations of 15/min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? -A negative test -A nonreactive test -A positive test -A reactive test
A nonreactive test - An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds.
A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? -Assess deep tendon reflexes every hour. -Obtain a daily weight. -Continuous fetal monitoring -Ambulate twice daily.
Ambulate twice daily. - A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental blood flow.
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. -Quickening -Lightening -Goodell's sign -Amenorrhea
Amenorrhea Goodell's sign Quickening Lightening
A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? -Monitor vaginal bleeding. -Administer glucocorticoids. -Insert an IV catheter. -Apply an external fetal monitor.
Apply an external fetal monitor. - Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress.
A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder? -Increased urine output -Vaginal discharge -Elevated blood pressure -Joint pain
Elevated blood pressure - Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.
A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include? -Breast tenderness -Fatigue -Fetal heart tones detected by ultrasound -Positive urine pregnancy test
Fetal heart tones detected by ultrasound - Fetal heart tones are a positive sign of pregnancy because the presence of fetal heart tones can only be explained by pregnancy.
A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic during pregnancy? -Gradual lordosis -Increased abdominal muscle tone -Posterior neck flexion -Decreased mobility of pelvic joints
Gradual lordosis - Clients who are pregnant can develop a gradual, forward curving of the spine as the growth of the fetus pulls the pelvis forward. This lordosis resolves after delivery.
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? -Cocaine use -Hypertension -Blunt force trauma -Cigarette smoking
Hypertension - Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.
A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? -Painless red vaginal bleeding -Increasing abdominal pain with a nonrelaxed uterus -Abdominal pain with scant red vaginal bleeding -Intermittent abdominal pain following passage of bloody mucus
Painless red vaginal bleeding - Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester.
A nurse is caring for a client who is at 18 weeks of gestation. The client should interpret this finding as which of the following? -Ballottement -Lightening -Quickening -Chloasma
Quickening - 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 admitting a client who is at 36 weeks gestation and has a painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? -Abruptio placentae -Placenta previa -Precipitous labor -Threatened abortion
Placenta previa - Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.
A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? -Examination to determine cervical status -A magnesium sulfate infusion -Initiation of pushing -Preparation for cesarean birth
Preparation for cesarean birth - A cesarean birth is indicated for all clients who have a confirmed placenta previa.
A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods? -Milk and cheese -Red meat and organ meat -Fresh fruits -Whole grain breads
Red meat and organ meat- This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? -Tachycardia -Absence of clonus -Polyuria -Report of headache
Report of headache - Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.
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? -3 cm above the umbilicus -Slightly above the umbilicus -Slightly below the umbilicus -3 cm below the umbilicus
Slightly above the umbilicus - 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 caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? -The client is not experiencing a rubella infection at this time. -The client is immune to the rubella virus. -The client requires a rubella vaccination at this time. -The client requires a rubella immunization following delivery.
The client requires a rubella immunization following delivery. - 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.
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as a consistent with the diagnosis? -Severe nausea and vomiting -Large amount of vaginal bleeding -Unilateral, cramp-like abdominal pain -Uterine enlargement greater than expected for gestational age
Unilateral, cramp-like abdominal pain - An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix.
