Maternity (Antepartum)

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which of the following statements by the client would identify the need for further teaching regarding the hemorrhoids?

"Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born."

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?

"The uterus weighs about 2 ounces."

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be appropriate?

"You were wise to call. I will check your rubella titer screening results and we can identify immediately if interventions are needed."

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign(s) of pregnancy that the nurse should recognize? Select all that apply. all 4

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions

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?

150 beats per minute

The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following?

A diet that is high in fluids and fiber to decrease constipation

A nurse is collecting data from a prenatal client. The nurse determines that which of the following places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

A history of intravenous (IV) drug use in the past year

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

A softening of the cervix

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:

Acute anxiety and the need for support

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

Avoid further stress on the maternal immune system.

A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:

Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and tells the partner to:

Dorsiflex the client's foot while extending the knee.

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

Drink decaffeinated coffee and tea.

In the prenatal clinic, a nurse is gathering data from a new client for the health history information. What is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

Establish a therapeutic relationship between the nurse and pregnant client.

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 understands that the hormone responsible for the development of this sign is which of the following?

Estrogen

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?

Human chorionic gonadotropin (hCG)

A nurse is collecting data on a pregnant woman who is human immunodeficiency virus (HIV) positive during the 32nd gestational week. The nurse reviews the data and determines that which finding requires further follow up?

Increased shortness of breath and bilateral rales

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

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

A maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phase, if stated by the nursing student, indicates a need to further research this area?

Proliferative phase

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta:

Provides an exchange of nutrients and waste products between the mother and the fetus

A nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to:

Reduce excessive maternal stress and fatigue.

A pregnant client asks a nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following?

Swimming

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse teaches the client about the signs that need to be reported to the health care provider (HCP) and tells the client to call the HCP if:

Weight increases by more than 1 pound in a week.

The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term?

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

A nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at gestational week:

20

A nurse is preparing to instruct a pregnant client about nutrition. The nurse plans to include which of the following in this client's teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

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."

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

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?

"This is an emergency; you should come to the clinic within the hour."

A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which of the following statements by the nurse indicates an understanding of the problem?

"You feel you are having difficulty fulfilling your role as a wife."

A nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?

How to check for signs of hypoglycemia and the required treatment

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is:

Oxytocin

A nurse is providing instructions to a pregnant woman regarding measures that will strengthen the perineal floor muscles. The nurse instructs the client to:

Perform Kegel exercises in 10 repetitions, three times per day.

A 38-week gestational pregnant woman arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing:

Placenta previa

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:

Placing external fetal monitors so that each fetal heart rate is monitored separately

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?

Signs of fetal distress

A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to:

Strengthen the pelvic floor in preparation for delivery.

A nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in this area?

Vulva

A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which of the following is appropriate to suggest to the client?

Wear a perineal pad to the play.

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:

Wedge-shaped and narrow and nonfavorable for a vaginal birth

A pregnant client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the sex of the fetus can usually be determined by:

Weeks 12 to 16

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week?

wk 28

A nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement by the client indicates an immediate need for further investigation?

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

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 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."

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process?

"Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."

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:

"Breast-feeding after delivery is best for my baby."

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?

"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:

"FSH and LH are released from the anterior pituitary gland."

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between:

16 and 20 weeks' gestation

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately:

18 weeks of gestation

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?

28 cm

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

5

A perinatal client is at risk for toxoplasmosis. The nurse should teach the client which of the following to prevent exposure to this disease?

Avoid exposure to litter boxes used by cats.

A nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse tells the client that she will:

Feel some pressure when the vaginal probe is moved

A nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination will not be performed on the client primarily because it could do which of the following?

Cause profound hemorrhage

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, the nurse should first:

Check for signs of thrombophlebitis.

A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client?

Client exhibits no signs of fetal distress.

A nurse is instructing a pregnant client on dietary sources of iron. Which of the following food selections made by the client demonstrates an understanding of teaching?

Fresh spinach

A nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds to the client, knowing that the sex of the fetus can be visually recognizable as early as week:

12

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which of the following observations by the nurse indicates a need for teaching?

The client is wearing knee-high hose.

A nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is a cephalic presentation. The nurse understands that this is:

The common presentation

A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse determines that:

HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.

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?

Nuts and green, leafy vegetables

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes:

Petechiae, oozing from injection sites, and hematuria

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?

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

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving?

The client complains of a headache and blurred vision.

The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is:

The most favorable for labor and birth

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:

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

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."

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client states:

"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone?

"It increases during pregnancy to stimulate basal metabolic rate."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following?

"The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. all4

1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus

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. all 3

1. Proteinuria 2. Hypertension 3. Generalized edema

A nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. The nurse tells the client that:

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

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:

Compression of the vena cava

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:

Connects the umbilical vein to the inferior vena cava

A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which of the following, if identified by the student, indicates an understanding of this process?

Fallopian tube

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

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 collecting data on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:

In a sitting position

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?

In the distal third of the fallopian tube

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?

Instruct the client that these are common and may occur throughout the 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?

Irregular, painless contractions

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:

July 27, 2013

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse recommends which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. The nurse tells the woman that the purpose of progesterone is to:

Maintain the uterine lining for implantation.

A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by:

Massaging the abdomen during contractions using both hands in a circular motion

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?

Midway between the symphysis pubis and the umbilicus

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?

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

A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed?

Subcutaneous administration of heparin sodium 5000 units daily

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?

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

The plan of care for a pregnant teen should include teaching regarding which of the following concerning dental care?

Tell the dental office staff that she is pregnant.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client:

That the bladder must be full during the exam

The nurse is collecting data during the admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as:

G = 2, T = 1, P = 0, A = 0, L = 1

A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?

Abdominal pain

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes:

Are where fertilization occurs

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 a platypelloid pelvic shape. The nurse understands that this pelvic shape is:

Flat and nonfavorable for a vaginal birth

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that goal achievement has occurred when the client states which of the following?

"I am eating fresh fruits and vegetables for snacks and for dessert each day."

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands about this infection when the client says:

"I am so glad that I can breast-feed my baby after she has been vaccinated."

A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. The nurse analyzes this data as indicative of:

A normal finding

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

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?

"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."

A nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. The student describes the procedure correctly if the student states to:

Place a rolled blanket under the right abdominal flank and hip area.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of:

Two umbilical arteries and one umbilical vein

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

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:

Turn the client onto her left side.

The nurse is collecting data during the admission assessment of a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse would document which gravida and para status on this client?

Gravida II, para I