Ch 12 Antepartum Nursing Assessment
29) Which serum markers are assessed when conducting a quadruple screen? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Alpha-fetoprotein (AFP) B) Human chorionic gonadotropin (hCG) C) Unconjugated estriol (UE) D) Inhibin-A E) Glycated hemoglobin
Answer: A, B, C, D Explanation: A) A quadruple screen assesses for the serum marker of AFP. B) A quadruple screen assesses for the serum marker of hCG. C) A quadruple screen assesses for the serum marker of UE. D) A quadruple screen assesses the serum marker of inhibin-A. E) A quadruple screen does not assess for glycated hemoglobin. Page Ref: 248
13) The nurse is explaining to a new prenatal client that the certified nurse-midwife will perform clinical pelvimetry as a part of the pelvic exam. The nurse knows that teaching has been successful when the client makes which statement about the reason for the exam? A) "It will help us know how big a baby I can deliver vaginally." B) "Doing this exam is a part of prenatal care at this clinic." C) "My sister had both of her babies by cesarean." D) "I am pregnant with my first child."
Answer: A Explanation: A) By performing a series of assessments and measurements, the examiner assesses the pelvis vaginally to determine whether the size and shape are adequate for a vaginal birth; this procedure is called clinical pelvimetry. B) Although this is a true statement, the estimation of the pelvis size is a better indication of the client's understanding. C) Stating that the client's sister had her babies by cesarean would not indicate that the client understood the teaching. D) Clinical pelvimetry is done with the first pregnancy, but the client's stating that this is her first child does not indicate that the client understood the teaching. Page Ref: 244
20) The nurse at the prenatal clinic has four calls to return. Which call should the nurse return first? A) Client at 32 weeks, reports headache and blurred vision. B) Client at 18 weeks, reports no fetal movement in this pregnancy. C) Client at 16 weeks, reports increased urinary frequency. D) Client at 40 weeks, reports sudden gush of fluid and contractions.
Answer: A Explanation: A) Headache and blurred vision are signs of preeclampsia, which is potentially life-threatening for both mother and fetus. This client has top priority. B) Fetal movement should be felt by 19-20 weeks. The lack of fetal movement prior to 20 weeks is considered normal. This client is a lower priority. C) Increased urinary frequency is common during pregnancy as the increased size of the uterus puts pressure on the urinary bladder. D) A full-term client who is experiencing contractions and a sudden gush of fluid is in labor. Although laboring clients should be in contact with their provider for advice on when to go to the hospital, labor at full term is an expected finding. This client is a lower priority. Page Ref: 249
1) While completing the medical and surgical history during the initial prenatal visit, the 16-year-old primigravida interrupts with "Why are you asking me all these questions? What difference does it make?" Which statement would best answer the client's questions? A) "We ask these questions to detect anything that happened in your past that might affect the pregnancy." B) "We ask these questions to see whether you can have prenatal visits less often than most clients do." C) "We ask these questions to make sure that our paperwork and records are complete and up to date." D) "We ask these questions to look for any health problems in the past that might affect your parenting."
Answer: A Explanation: A) The course of a pregnancy depends on a number of factors, including the past pregnancy history (if this is not a first pregnancy), prepregnancy health of the woman, presence of disease/illness states, family history, emotional status, and past healthcare. B) Prenatal visits follow a set schedule for normal clients without complications. C) Paperwork is a lower priority than client care. D) The psychological history of a client, not the medical or surgical history, can indicate potential problems with parenting. Page Ref: 227—228
22) The nurse is collecting information during the health history assessment for the client profile during the initial prenatal visit. Which question is appropriate when assessing the current pregnancy? A) "What was the date of your last menstrual period?" B) "How many times have you been pregnant?" C) "What were your children's birth weights?" D) "How many living children do you have?"
Answer: A Explanation: A) The nurse would ask the client for the date of the last menstrual period when assessing the current pregnancy as part of the client profile. B) The nurse would ask the client how many times she has been pregnant when assessing past pregnancies as part of the client profile. C) The nurse would assess the birth weights of the client's children when assessing past pregnancies as part of the client profile. D) The nurse would ask the client how many living children she has when assessing past pregnancies as part of the client profile. Page Ref: 241
2) A woman gave birth last week to a fetus at 18 weeks' gestation after her first pregnancy. She is in the clinic for follow-up, and notices that her chart states she has had one abortion. The client is upset over the use of this word. How can the nurse best explain this terminology to the client? A) "Abortion is the obstetric term for all pregnancies that end before 20 weeks." B) "Abortion is the word we use when someone has miscarried." C) "Abortion is how we label babies born in the second trimester." D) "Abortion is what we call all babies who are born dead."
Answer: A Explanation: A) The term abortion means a birth that occurs before 20 weeks' gestation or the birth of a fetus-newborn who weighs less than 500 g. An abortion may occur spontaneously, or it may be induced by medical or surgical means. B) This explanation is only partially correct. C) This explanation is only partially correct. D) This is not a true statement. Page Ref: 227
9) The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings? A) 12 weeks' gestation, with fetal heart tones heard by Doppler fetoscope B) 22 weeks' gestation, client reports no fetal movement felt yet C) 16 weeks' gestation, fundus three finger-breadths above umbilicus D) Marked edema
Answer: A Explanation: A) This is an expected finding because fetal heart tones should be heard by 12 weeks using a Doppler fetoscope. B) At 22 weeks, no fetal movement is an abnormal finding. Fetal movement should be felt by 20 weeks. C) This is an abnormal finding. The fundus should be three finger-breadths above umbilicus at 28 weeks. D) This is an abnormal finding. There may be some edema of hands and ankles in late pregnancy, but marked edema could indicate preeclampsia. Page Ref: 237
30) The nurse is teaching the pregnant client about the symptoms of preeclampsia. Which clinical manifestations will the nurse include in the teaching session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Dizziness B) Blurred vision C) Abdominal pain D) Vaginal bleeding E) Severe headache
Answer: A, B, E Explanation: A) Dizziness is a clinical manifestation associated with preeclampsia. B) Blurred vision is a clinical manifestation associated with preeclampsia. C) Abdominal pain is a clinical manifestation of premature labor or abruptio placentae, not preeclampsia. D) Vaginal bleeding is a clinical manifestation of abruptio placentae or placenta previa, not preeclampsia. E) Severe headache is a clinical manifestation associated with preeclampsia. Page Ref: 249
28) The nurse is conducting an initial prenatal assessment for a pregnant client. Which screenings should the nurse prepare the client for during this visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Complete blood count (C B C) B) Glucose tolerance test (G T T) C) A B O and Rh typing D) H I V screening E) Urinalysis
Answer: A, C, D, E Explanation: A) A C B C is drawn during the initial prenatal visit. B) A G T T is not done until the second trimester of the pregnancy. C) A B O and Rh typing are drawn during the initial prenatal visit. D) An H I V screening is drawn during the initial prenatal visit. E) A urinalysis is conducted during the initial prenatal visit and for every subsequent prenatal visit. Page Ref: 252
19) A nurse examining a prenatal client recognizes that a lag in progression of measurements of fundal height from week to week and month to month could signal what condition? A) Twin pregnancy B) Intrauterine growth restriction C) Hydramnios D) Breech position
Answer: B Explanation: A) A sudden increase in fundal height could indicate twins. B) A lag in progression of measurements of fundal height from month to month could signal intrauterine growth restriction (IUGR). C) A sudden increase in fundal height could indicate hydramnios. D) A fetus in breech position would still have a normal fundal height measurement. Page Ref: 231
15) The nurse is assessing a primiparous client who indicates that her religion is Judaism. Why is this information pertinent for the nurse to assess? A) Religious and cultural background can impact what a client eats during pregnancy. B) It provides a baseline from which to ask questions about the client's religious and cultural background. C) Knowing the client's beliefs and behaviors regarding pregnancy is not important. D) Clients sometimes encounter problems in their pregnancies based on what religion they practice.
Answer: B Explanation: A) Although this can be true, much more than diet is impacted by religious and cultural background. B) Nurses have an obligation to be aware of other cultures and develop a culturally sensitive plan of care to meet the needs of the childbearing woman and her family. C) It is especially helpful if the nurse is familiar with common practices of various religious and cultural groups who reside in the community. D) How a client observes her religion occasionally will cause problems with pregnancy, but this is not the most important reason for obtaining this information. Page Ref: 240, 249
25) The nurse is preparing to assess the pregnant client's fundal height during a routine prenatal visit. Which nursing action is appropriate in this situation? A) Telling the client not to eat or drink for one hour after the procedure B) Asking the client to empty her bladder prior to the procedure C) Obtaining informed consent for the procedure D) Assessing blood pressure after the procedure
Answer: B Explanation: A) It is not necessary for the client to abstain from eating or drinking for one hour after the procedure. This action might be appropriate for a client who is having a glucose tolerance test, not for one undergoing assessment of fundal height. B) It is appropriate for the nurse to ask the client to empty her bladder prior to assessing fundal height. A full bladder may impact the accuracy of the measurement. C) Informed consent is not needed, as assessing fundal height is not an invasive procedure. D) There is no reason to assess the client's blood pressure after measuring fundal height. Page Ref: 243
11) The nurse receives a phone call from a client who claims she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the client's estimated date of delivery (E D D) be if she is pregnant? A) Nov. 13 B) Jan. 17 C) Jan. 10 D) Dec. 3
Answer: B Explanation: A) Nov. 13 is not correct according to Nagele's rule. B) The due date is Jan. 17. Nagele's rule is to add 7 days to the last menstrual period and subtract 3 months. The last menstrual period is April 10, therefore Jan. 17 is the E D D. C) Jan. 10 is not correct according to Nagele's rule. D) Dec. 3 is not correct according to Nagele's rule. Page Ref: 242
8) The nurse begins a prenatal assessment on a 25-year-old primigravida at 20 weeks' gestation and immediately contacts the healthcare provider because of which finding? A) Pulse 88/minute B) Respirations 30/minute C) Temperature 37.4°C (99.3°F) D) Blood pressure 118/82 m m H g
Answer: B Explanation: A) Pulse rate may increase 10-15 beats per minute during pregnancy, with an average of 60-100 beats per minute. B) Tachypnea is not a normal finding and requires medical care. C) A slightly higher temperature is an expected finding during pregnancy, ranging from 36.2°C-37.6°C (97°F-99.6°F). D) A blood pressure of less than or equal to 120/80 m m H g is considered normal. Page Ref: 234
5) The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form? A) Where was the father of the baby born? B) Do genetic diseases run in the family of the baby's father? C) What is the name of the baby's father? D) Are you married to the father of the baby?
Answer: B Explanation: A) The father's place of birth is not important information to include about the pregnancy. B) This question has the highest priority because it gets at the physiologic issue of inheritable genetic diseases that might directly impact the baby. C) Although it is helpful for the nurse to know the name of the baby's father to include him in the prenatal care, this is psychosocial information. D) Although the marital status of the client might have cultural significance, this is psychosocial information. Page Ref: 228
6) A 25-year-old primigravida is at 20 weeks' gestation. The nurse takes her vital signs and notifies the healthcare provider immediately because of which finding? A) Pulse 88/minute B) Rhonchi in both bases C) Temperature 37.4°C (99.3°F) D) Blood pressure 122/78 m m H g
Answer: B Explanation: A) The pulse will increase 10-15 beats/minute during pregnancy, with 60-90 beats/minute being the normal range. B) Any abnormal breath sounds should be reported to the healthcare provider. C) Temperature norms in pregnancy are slightly higher due to fetal metabolism: 36.2-37.6°C (97-99.6°F). D) A blood pressure less than or equal to 120/80 m m H g considered normal. Page Ref: 235
7) The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings? A) Document the findings on the prenatal chart. B) Have the physician see the client today. C) Instruct the client to avoid direct sunlight. D) Analyze previous thyroid hormone lab results.
Answer: B Explanation: A) While all of these findings should be documented on the prenatal chart, additional action is indicated. B) Mottling of the skin is indicative of possible anemia. These abnormalities must be reported to the healthcare provider immediately. C) Instructing the client to avoid direct sunlight is not necessary; rather, additional action is indicated. D) The thyroid gland increases in size during pregnancy due to hyperplasia. Additional action is indicated. Page Ref: 234
10) What signs would indicate that a pregnant client's urinalysis culture was abnormal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) p H 4.6-8 B) Alkaline urine C) Cloudy appearance D) Negative for protein and red blood cells E) Hemoglobinuria
Answer: B, C, E Explanation: A) Urine p H of 4.6-8 is within a normal, healthy range. B) Alkaline urine could indicate metabolic alkalemia, Proteus infection, or an old specimen. C) A cloudy appearance could indicate an infection. D) Positive findings could indicate contaminated specimen, U T I, or kidney disease. E) Hemoglobinuria would be indicated by an abnormal urine color. Page Ref: 239
24) The nurse is providing care to a pregnant client diagnosed with a urinary tract infection (U T I) during a routine prenatal visit. What will the nurse educate the client about based on this data? A) Gestational hypertension B) Gestational diabetes mellitus C) Preterm labor D) Anemia
Answer: C Explanation: A) A diagnosis of a U T I during pregnancy does not increase the risk for gestational hypertension. B) A diagnosis of a U T I during pregnancy does not increase the risk for gestational diabetes mellitus. C) The nurse would provide teaching to the client regarding signs and symptoms associated with preterm labor, as the diagnosis of a U T I increases the risk for developing this complication of pregnancy. D) A diagnosis of a U T I during pregnancy does not increase the risk for anemia. Page Ref: 233
16) What would the nurse include as part of a routine physical assessment for a second-trimester primiparous patient whose prenatal care began in the first trimester and is ongoing? A) Pap smear B) Hepatitis B screening (H Bs A g) C) Fundal height measurement D) Complete blood count
Answer: C Explanation: A) Pap smear is usually done at the initial prenatal appointment. B) Hepatitis B screening is done at the initial prenatal appointment. C) At each prenatal visit, the blood pressure, pulse, and weight are assessed, and the size of the fundus is measured. Fundal height should be increasing with each prenatal visit. D) Complete blood count is done at the initial prenatal appointment. Page Ref: 243
4) The client has delivered her first child at 37 weeks. The nurse would describe this to the client as what type of delivery? A) Preterm B) Postterm C) Early term D) Near term
Answer: C Explanation: A) Preterm births are those that occur between 20 weeks and 37 completed weeks. B) Postterm births are those that occur at 42 weeks and beyond. C) Early term births extend from 37 to 38 weeks' gestation. D) Near term is not terminology used to describe birth. Page Ref: 227
21) Screening for gestational diabetes mellitus (GDM) is typically completed between which of the following weeks of gestation? A) 36 and 40 weeks B) Before 20 weeks C) 24 and 28 weeks D) 30 and 34 weeks
Answer: C Explanation: A) Screening for gestational diabetes mellitus (GDM) is not completed between 36 and 40 weeks' gestation. B) Screening for gestational diabetes mellitus (GDM) is not completed before 20 weeks' gestation. C) Screening for gestational diabetes mellitus (GDM) is typically completed between 24 and 28 weeks' gestation. D) Screening for gestational diabetes mellitus (GDM) is not completed between 30 and 34 weeks' gestation. Page Ref: 246
23) The nurse is assessing an obese pregnant client during a routine prenatal visit. Which is the priority assessment for this client? A) Complete blood count (CBC) B) Basic metabolic panel (BMP) C) Blood pressure D) Fetal heart rate
Answer: C Explanation: A) While it is important to monitor the client's C B C to assess for anemia, this is not the priority assessment for this client. B) The B M P is not commonly monitored during pregnancy. A blood glucose level may be monitored, as the client's weight places her at risk for gestational diabetes mellitus. C) The blood pressure would be monitored closely at each prenatal visit due to the client's weight. Obese clients have a greater risk for gestational hypertension. This is the priority assessment for this client. D) While it is important to monitor the fetal heart rate during every prenatal visit, this is not the priority for this client. Page Ref: 251
3) The clinic nurse is compiling data for a yearly report. Which client would be classified as a primigravida? A) A client at 18 weeks' gestation who had a spontaneous loss at 12 weeks B) A client at 13 weeks' gestation who had an ectopic pregnancy at 8 weeks C) A client at 14 weeks' gestation who has a 3-year-old daughter at home D) A client at 15 weeks' gestation who has never been pregnant before
Answer: D Explanation: A) A pregnant woman who has been pregnant before is called a multigravida. B) A pregnant woman who has been pregnant before is called a multigravida. C) A pregnant woman who has been pregnant before is called a multigravida. D) Primigravida means a woman who is pregnant for the first time. Page Ref: 227
18) Which third-trimester client would the nurse suspect might be having difficulty with psychological adjustments to her pregnancy? A) A woman who says, "Either a boy or a girl will be fine with me" B) A woman who puts her feet up and listens to some music for 15 minutes when she is feeling too stressed C) A woman who was a smoker but who has quit at least for the duration of her pregnancy D) A woman who has not investigated the kind of clothing or feeding methods the baby will need
Answer: D Explanation: A) Acceptance of gender is indicative of healthy adaptation to pregnancy. B) Using stress reduction techniques are indicative of healthy adaptation to pregnancy. C) Quitting smoking is indicative of healthy adaptation to pregnancy. D) By the third trimester, the client should be planning and preparing for the baby (for example, living arrangements, clothing, feeding methods). Page Ref: 253
14) The nurse is assessing a newly pregnant client. Which finding does the nurse note as a normal psychosocial adjustment in this client's first trimester? A) An unlisted telephone number B) Reluctance to tell the partner of the pregnancy C) Parental disapproval of the woman's partner D) Ambivalence about the pregnancy
Answer: D Explanation: A) An unlisted telephone number does not indicate psychosocial adjustment. B) Reluctance to tell the partner about the pregnancy might indicate that the client anticipates disapproval, and is not a normal psychosocial adjustment. C) Parental disapproval of the client's partner does not indicate psychosocial adjustment. D) Ambivalence toward a pregnancy is a common psychosocial adjustment in early pregnancy. Page Ref: 240
12) The primigravida at 22 weeks' gestation has a fundal height palpated slightly below the umbilicus. Which of the following statements would best describe to the client why she needs to be seen by a physician today? A) "Your baby is growing too much and getting too big." B) "Your uterus might have an abnormal shape." C) "The position of your baby can't be felt." D) "Your baby might not be growing enough."
Answer: D Explanation: A) At 22 weeks' gestation, the fundal height should be at about 22 c m. B) Uterine shape can be assessed only with diagnostic imaging techniques such as ultrasound or C T scan. C) The position of the baby is not noted until 36 weeks' gestation. D) The fundal height at 20-22 weeks should be about even with the umbilicus. At 22 weeks' gestation, a fundal height below the umbilicus and a uterine size that is inconsistent with length of gestation could indicate fetal demise. Page Ref: 243
27) The nurse is teaching a pregnant client the clinical manifestations associated with preterm labor. Which client statement indicates the need for further education? A) "Menstrual-like cramps are a sign of preterm labor." B) "A dull low backache is a sign of preterm labor." C) "Diarrhea is a sign of preterm labor." D) "Vomiting is a sign of preterm labor."
Answer: D Explanation: A) Painful menstrual-like cramps are a sign of preterm labor. This statement indicates appropriate understanding of the information presented. B) A dull low backache is a sign of preterm labor. This statement indicates appropriate understanding of the information presented. C) Diarrhea is a sign of preterm labor. This statement indicates appropriate understanding of the information presented. D) Vomiting is not a clinical manifestation associated with preterm labor. This statement indicates the need for further education. Page Ref: 248
26) The nurse is explaining "quickening" to a client who is pregnant for the first time. Which client indicates the need for further education on this topic? A) "It will feel like butterflies in my stomach." B) "It might feel like I have gas." C) "It should occur during the second trimester of my pregnancy." D) "It is an indication that I am experiencing preterm labor."
Answer: D Explanation: A) Quickening is often described as if there are butterflies in the stomach. This statement indicates appropriate understanding of the information presented. B) Quickening is often mistaken for gas. This statement indicates appropriate understanding of the information presented. C) Quickening often occurs during the second trimester of pregnancy, between 16 and 22 weeks' gestation. This statement indicates appropriate understanding of the information presented. D) Quickening is not an indication of preterm labor, but an expected finding during pregnancy. This statement indicates the need for further education. Page Ref: 243
17) If a woman has the pre-existing condition of diabetes, the nurse knows that she would be prone to what high-risk factor when pregnant? A) Vasospasm B) Postpartum hemorrhage C) Episodes of hypoglycemia and hyperglycemia D) Cerebrovascular accident (CVA)
Answer: D Explanation: A) Vasospasm would be a high-risk factor for a client with pre-existing cardiac disease. B) Postpartum hemorrhage would be a high-risk factor for a client with pre-existing hyperthyroidism. C) Episodes of hypoglycemia and hyperglycemia would be a high-risk factor for a client with pre-existing diabetes. D) Cerebrovascular accident (C V A) would be a high-risk factor for a client with pre-existing hypertension. Page Ref: 246—247