Maternity Nclex questions Test#1

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

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.

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, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?

July 27, 2017

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 should recommend 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.

The client at 38 weeks of gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client:

Measuring the fundal height.

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 which is observed?

Petechiae, oozing from injection sites, and hematuria

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 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 client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

The bladder must be full during the exam.

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

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?

28 cm

A couple comes to the family planning clinic and asks about sterilization procedures. Which questions by the nurse would determine whether this method of family planning would be appropriate?

"Do you plan to have any other children?"

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 makes which statement?

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

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 makes which statement?

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

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

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

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which would indicate successful learning?

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

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

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

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."

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 should consult with the dietitian to ensure which dietary measure?

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

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.)

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.

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

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

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 which?

A softening of the cervix

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

Ballottement. Chadwick's sign. Uterine enlargement. Braxton Hicks contractions.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. if the client progresses from preeclampsia to eclampsia, the nurse's first action should be to:

Clear and maintain an open airway.

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 which?

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

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

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:

where fertilization occurs

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

Fetal heart rate of 180 beats per minute

The nurse is collecting data during an 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 tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

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

The nurse is collecting data from 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 should document which gravida and para status on this client?

Gravida II, para I

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?.

The client complains of a headache and blurred vision.