module 33 reproduction- exam 1 concept/ antepartum/ intrapartum
The nurse knows that the husband of a pregnant woman understands his role as coach when he states that he will assist his wife with: (Select all that apply) A.Relaxation B.Perineal care C.Breathing techniques D.Supportive posturing E.Timing contractions F.Distraction during contractions
A, C, D, E
The nurse is providing care to a pregnant client who is experiencing ptyalism. Which will the nurse include in the plan of care for this client? A) Use a cool-mist vaporizer B) Suck on hard candy C) Avoid use of nasal sprays and decongestants D) Use low-sodium antacids
Answer: B Explanation: A) Ptyalism is excessive, often bitter salivation that can occur during pregnancy. Appropriate interventions for this client include using astringent mouthwashes, chewing gum, or sucking on hard candy. A cool-mist vaporizer and avoiding nasal sprays and decongestants are appropriate interventions for nasal stuffiness and nosebleed (epistaxis). The use of low-sodium antacids is appropriate for pyrosis, or heartburn.
The nulliparous client states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
Answer: D Explanation: A) Cervical effacement must be nearly complete before cervical dilation takes place in primiparas. This is why the labor and birth of a first baby usually take much more time than for subsequent labor and births. The perineal body thinning primarily occurs during the second stage of labor; it is not expected early in labor. The reply "what did you expect" is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all communication. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.
A client, who is in labor, is placed on a continuous electronic fetal monitor. Nursing care for this client includes: •A. Assessment of the client's knowledge of the monitor. •B. Keeping the client on her left side. •C. Positioning the monitor over the baby's heart and keeping it in place. •D. Maintaining the client in a supine position, raising and lowering the head only.
B
Following surgery, a client needs to increase dietary iron due to blood loss. Which food selection would be best? •A. Yogurt •B. Soybeans •C. Whole milk •D. Celery
B
A newly diagnosed pregnant client tells the nurse, "If I'm going to have all these discomforts, I'm not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which of the following? •A. Fear of pregnancy. •B. Rejection of the pregnancy. •C. Normal ambivalence. •D. Inability to care for the newborn.
c
A client, who is in labor, is placed on a continuous electronic fetal monitor. Nursing care for this client includes: •A. Assessment of the client's knowledge of the monitor. •B. Keeping the client on her left side. •C. Positioning the monitor over the baby's heart and keeping it in place. •D. Maintaining the client in a supine position, raising and lowering the head only.
a
A client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which of the following would be the nurse's best response? •A. "The effects of alcohol on a fetus during pregnancy are unknown." •B. "You should limit consumption to beer and wine." •C. "You should abstain from drinking alcoholic beverages." •D. "You may have 1 drink of 2 oz of alcohol per day."
c
A client at 28 weeks gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hundred miles away. Which of the following recommendations by the nurse would be the best? •A. "Try to avoid traveling anywhere in the care during third trimester." •B. "Limit the time you spend in the car to a maximum of 4 to 5 hours." •C. "Taking a trip is ok if you stop every 1 to 2 hours and walk." •D. "Avoid wearing your seat belt in the car to prevent injury to the fetus.
c
Using Nagele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of Delivery: •A. January 13. •B. January 17. •C. February 13. •D. February 17.
d
A client admitted to the labor suite is suspected of having placenta previa. The nurse should: •A. Assess the client for vaginal bleeding. •B. Assess cervical dilation. •C. Monitor the uterus for board-like rigidity. •D. Force fluids to maintain urinary output.
A
A client in labor tells the nurse, "I think my water broke." The nurse should assess the: •A. Fetal heart tones and color of amniotic fluid. •B. Time since the last contraction. •C. Client's vital signs. •D. Results of the client's CBC with differential.
A
A primigravida client is diagnosed with placenta previa. The client asks the nurse to explain the condition. The nurse's best response would be: •A. "Normally, the baby is positioned near the cervix; your placenta is positioned near or on the cervical opening." •B. "Your placenta is producing too many hormones and is causing vaginal bleeding." •C. "Normally, the entire placenta is attached to the uterine wall; part of the placenta has pulled away from this wall." •D. "Normally your placenta is attached at or near the cervix; your placenta is attached at the fundus."
A
After an examination, the physician informs a woman that she is 10 weeks pregnant. The client has a History of type I Diabetes. She asks the nurse, "how should I regulate my sugar during my Pregnancy?" The nurse responds: •A. "It is important to try to maintain euglycemia during your pregnancy." •B. "Hyperglycemia is normal during the last trimester of pregnancy to protect fetal brain cells." •C. "It is important to maintain a hypoglycemic state to prevent macrosomia." •D. "Ketosis is expected during pregnancy to allow balance between maternal and fetal catabolism."
A
The nurse is caring for a 14-year-old client who is pregnant. What will the nurse need to consider that may affect this client more than older adolescents? A) The client may be more concerned about modesty. B) The client may be more concerned with state marriage laws. C) The client may be more concerned about parents finding out about the pregnancy. D) The client may be more concerned about finding a support person.
Answer: A Explanation: A) A younger client may be more concerned about modesty than older clients, especially as her body changes and grows rapidly. Older adolescents who are pregnant may be more concerned about state marriage laws, parents finding out about the pregnancy, and finding a support person. Younger clients are more likely to involve parents in the early stages of pregnancy for both emotional and financial support.
The nurse is caring for a 36-year-old pregnant woman. She has two children, ages 15 and 13, from a previous marriage, and this is her first child from her second marriage. The client has indicated that her two older children seem very upset by her pregnancy and have been increasingly belligerent the closer she gets to delivery. What can the nurse say to support this family? A) "It may help to remind your older children that you will still make time for them and that you won't expect them be responsible for the baby unless they want to." B) "You could tell your older children that the stress and anxiety that comes with a new baby will help improve your family relationships." C) "They are probably just embarrassed because you are pregnant. They'll get over it once you have the baby." D) "Your older children probably just want to know what their new roles will be once the baby is born. You should tell them what their responsibilities will be in caring for the baby."
Answer: A Explanation: A) Adolescent children, especially children from a previous marriage, may feel jealous that the new baby will take all the attention of the parent or fear that they will be asked to contribute to the newborn's care. The nurse should help the mother understand these feelings and encourage the mother to address these feelings with her older children. Telling the mother that the older children are just embarrassed and will get over it is inappropriate. Encouraging the mother to give newborn care responsibilities to the older children may make the issue worse. Discussing the role of stress and anxiety in improving relationships is more appropriate for a spouse, not older children.
A pregnant adolescent client asks for information about the pregnancy and the baby because she cannot afford prenatal care. Which action by the nurse is the most appropriate? A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery. B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery. C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance. D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery.
Answer: A Explanation: A) Poverty and low education levels are associated with adolescent pregnancy. The nurse should support the client by providing information on resources to assist with medical care during the pregnancy and after delivery. The nurse should not instruct the client on all aspects of the pregnancy, including fetal development, labor, and delivery, as this can be overwhelming to the client. The nurse should not ask the client if the parents are aware of the pregnancy nor tell the client that the baby's father is responsible for her medical care; these actions do not address the client's needs.
A client pregnant with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work. When responding to the client, which should the nurse take into consideration? A) This is a normal reaction by fathers that is seen in the second trimester of pregnancy. B) This is a normal reaction by fathers that is seen in the third trimester of pregnancy. C) This is a normal reaction by fathers that is seen in the first trimester of pregnancy. D) This is an atypical reaction of the father to pregnancy that should be further examined.
Answer: A Explanation: A) Pregnancy produces psychological changes in the mother and father of the child. A reaction seen in the father during the second trimester of pregnancy is a renewed interest in hobbies or activities outside of the family and is usually a sign of stress. This behavior is not typical in the first or third trimesters and is not an atypical reaction that should be further examined.
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? A) Documenting the fetal heart rate B) Preparing for imminent delivery C) Applying oxygen via mask at 10 liters per minute D) Assisting the client into the Fowler position
Answer: A Explanation: A) The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will be occurring soon. The client does not need to be assisted into the Fowler position.
The nurse is providing care to a client whose last menstrual period was 6 weeks ago. The client believes she is pregnant. Which diagnostic test does the nurse anticipate in order to confirm the pregnancy? A) Serum or urine human chorionic gonadotropin (hCG) B) Fetal heartbeat by Doppler C) Fetal heartbeat by fetoscope D) Fetal movement
Answer: A Explanation: A) The most commonly used assay for pregnancy diagnosis is measuring the beta subunit of hCG in either urine or serum. hCG is detectable in more than 97% of clients. A fetal heartbeat is diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th week of gestation and by fetoscope at about the 17th to 20th week. Fetal movement, another objective sign of pregnancy, is palpable around 20 weeks' gestation by a trained examiner; pregnant women may experience movement subjectively, called quickening, around this same time.
The nurse is teaching childbirth exercises to a pregnant client with a history of back pain. Which is most appropriate for this client? A) Perform the pelvic rock exercise only in the standing position. B) Exercise in the supine position throughout the pregnancy. C) Perform the pelvic rock exercise while in the hands and knees position. D) Soak in a hot tub for approximately 30 minutes after exercise.
Answer: A Explanation: A) The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain, as it strengthens the abdominal muscles. The client with a history of back pain should be instructed to perform the exercise in the standing position only. Doing the exercise on the hands and knees may aggravate back strain and cause pain. Pregnant clients should be instructed to avoid exercising in the supine position after the first trimester because it could hinder uterine blood flow and harm the fetus. Pregnant clients should be instructed to avoid hot tubs because of the possible teratogenic effects of hyperthermia on the developing fetus.
A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler. Based on this data, which conclusion by the nurse is the most appropriate? A) The mother is at 8 to 12 weeks' gestation. B) The mother is over 16 weeks' gestation. C) The mother is at 4 to 8 weeks' gestation. D) The mother is at least 20 weeks' gestation.
Answer: A Explanation: A) The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is not available, a fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early as week 16 and almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks' gestation because the Doppler device detected fetal heartbeat. The mother will have likely already heard the heartbeat at least once before 16 to 20 weeks' gestation if her primary care provider has access to a Doppler device.
A client at 16 weeks' gestation is diagnosed with tuberculosis (TB). Which statement by the nurse is appropriate when instructing the client regarding the needs for both the client and fetus? A) "You have been prescribed isoniazid; therefore, you must also take pyridoxine (vitamin B6)." B) "Your contact with the baby will be limited for several months after delivery." C) "You will not be able to breastfeed your baby because of this diagnosis." D) "You are free to have contact with anyone as TB is not contagious when diagnosed during pregnancy."
Answer: A Explanation: A) When teaching a pregnant client diagnosed with TB, the nurse will include information regarding medication administration. Isoniazid, which does cross the placenta but most studies show is not teratogenic, is often the drug of choice to treat TB during pregnancy. When taking isoniazid, the client will also need to take pyridoxine. If TB is active at delivery, the newborn should not have direct contact with the mother while she is infectious. This is not likely going to be the case, as the client is diagnosed early in the pregnancy. If maternal TB is inactive, the mother may breastfeed and care for her infant. Extra rest and limited contact with others are required until the disease becomes inactive.
The nurse is providing care to a pregnant client who will undergo chorionic villus sampling. The client is currently 10 weeks pregnant. When teaching the client about this genetic testing, which layer of the embryonic membrane will the nurse say is tested during this procedure? A) Chorion B) Amnion C) Ectoderm D) Endometrium
Answer: A Explanation: The chorion is the outermost embryonic membrane and develops into chorionic villi, which can be used for early genetic testing of the embryo at 10 to 11 weeks' gestation by chorionic villus sampling. The endometrium is the lining of the uterus and will not be used for genetic testing of the embryo. The ectoderm is a germ layer and will develop into specific structures within the developing fetus. The amnion will develop into amniotic fluid, which can also be sampled for genetic testing but may not be developed by 8 weeks' gestation.
A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now." After assessing and monitoring the client, the healthcare team determines that the client is in "false" labor, and the nurse prepares her for discharge. Which observations support the conclusion of false labor? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.
Answer: A, C, E Explanation: A) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular contractions that do not increase in frequency or intensity, a lack of cervical dilation and effacement, discomfort that is felt mostly in the abdomen rather than in the back and radiating to the front, and the fact that activity does not increase contraction intensity.
A pregnant woman at 41 weeks' gestation has a Bishop score of 5. What does this score indicate? A) The cervix is favorable for a normal vaginal delivery. B) The cervix is unfavorable and induction of labor may be necessary. C) The cervix is unfavorable and a cesarean section may be necessary. D) The cervix is favorable and labor has been successfully induced
Answer: B Explanation: A) A Bishop score less than 6 indicates that the cervix is unfavorable. When a pregnant woman at or near term has an unfavorable cervix, induction of labor may be necessary for medical or obstetric reasons. A Bishop score less than 6 does not indicate that a cesarean section may be necessary.
A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen, a pregnant client in her second trimester has a hemoglobin of 10 g/dL. The client confirms fatigue, but otherwise feels fine. Which action by the nurse is the priority when providing care to this client? A) Tell the client to rest any time she feels fatigued. B) Recommend the client add supplemental iron to her diet. C) Ask the client to return in 2 months for a repeat check of her hemoglobin. D) Order a screening for sickle cell anemia.
Answer: B Explanation: A) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low hemoglobin during pregnancy suggests an inadequate intake of dietary iron as the probable cause of her anemia. Given that the client's anemia is likely from iron deficiency, the nurse needs to emphasize the importance of increased iron supplementation. A screening for sickle cell anemia is not indicated given the information presented. The client should return in 1 month for a recheck of her hemoglobin levels; if improvement is not seen, then further evaluation is indicated. Although adequate rest is important, it does not address the client's physiologic iron deficiency that is causing the fatigue. MNL LO: Analyze the concept of reproduction and its application to nursing care.
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following? A) Drink a glass of water every time nausea occurs. B) Take a multivitamin each day. C) Take over-the-counter Benadryl for the nausea. D) Eat a snack any time nausea occurs.
Answer: B Explanation: A) Multivitamins may reduce the nausea associated with the first trimester of pregnancy. The nurse should not instruct the client to drink a glass of water every time nausea occurs because this could lead to the ingestion of high quantities of water. The nurse should not instruct the client to eat a snack any time nausea occurs, as this could lead to higher than needed calorie intake and inappropriate weight gain, and it also will not likely help the nausea significantly. The nurse should also not instruct the client to ingest an over-the-counter medication without discussing this with her physician.
An adolescent client at 34 weeks' gestation states to the nurse, "I am stressed out about becoming a mother. I hope that I can get back to my normal day to day activities after the baby is born, like hanging out with friends and studying." If the nurse wants to assess whether the client is performing normal developmental tasks for this stage of pregnancy, which question by the nurse is the most appropriate? A) "Are your friends excited about the baby coming and planning a shower for you?" B) "Are you prepared to delay some of your own needs and desires for your baby?" C) "Do you miss going out with your friends on the weekends?" D) "Have you been able to get enough rest while keeping up with your studies?"
Answer: B Explanation: A) One developmental task for the mother is learning to give of oneself on behalf of the child. The statement by this client that she wants to get back to her normal activities indicates that she is still self-focused. The nurse should assess the client's preparedness for putting aside her own wants and needs temporarily for the good of her child. The nurse should not focus on the client's social life and friends because these are not developmental tasks associated with the pregnancy.
The nurse is caring for a 15-year-old pregnant adolescent during the labor and delivery process. The client has no support person with her, and she plans to give up her baby for adoption. What nursing intervention can the nurse implement to facilitate the grieving process for this client? A) Encourage the client to avoid seeing and holding the baby. B) Encourage the client to see and hold the baby. C) Encourage the client to have the adoptive parents present for the birth. D) Encourage the client to sign the adoption papers as soon as possible after the birth.
Answer: B Explanation: A) The adolescent who is planning to give up her baby for adoption should be given the option of seeing and holding her baby. This facilitates the grieving process. However, seeing or holding the newborn should be her choice. The nurse should not discourage the adolescent from seeing her baby and should not encourage the adolescent to sign adoption papers as soon as possible after the birth. Because of privacy concerns, the nurse should not encourage the adolescent to have the adoptive parents present for the birth except for special circumstances as determined by the client, not the nurse.
During which phase of the ovulatory cycle does the ovum get fertilized? A) Follicular phase B) Luteal phase C) Proliferative phase D) Secretory phase
Answer: B Explanation: A) The ovum can be fertilized as it moves through the fallopian tube, which occurs after the graafian follicle ruptures. The rupture of the graafian follicle begins the luteal phase. The ovum is still encapsulated in the graafian follicle in the follicular phase, and it cannot be penetrated by sperm. The proliferative phase and secretory phase are phases of the menstrual cycle, not the ovulatory cycle.
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. Which teaching points are appropriate for this client based on her current diet? Select all that apply. A) Avoid shrimp, salmon, and catfish because these have higher mercury levels. B) Eat up to 12 ounces a week of a variety of fish and shellfish. C) Do not eat more than 6 ounces per week of albacore tuna. D) Eat plenty of fish such as king mackerel while pregnant. E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
Answer: B, C Explanation: A) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system of the fetus at risk and cause negative effects on cognitive functioning. The nurse should instruct the client to eat up to 12 ounces a week of a variety of fish and shellfish. The nurse should advise the client to eat no more than 6 ounces of albacore tuna each week because it has more mercury than other canned tuna. King mackerel should be avoided because it contains high levels of mercury. The nurse should not suggest that the client consume a complete vegetarian diet because this could lead to other nutritional deficiencies. The nurse should encourage the client to consume shrimp, salmon, and catfish, because these fish have the least amount of mercury.
The nurse is providing care to a client with a history of rheumatoid arthritis (RA) who is 5 months pregnant. Which nursing actions are appropriate when providing care to this client? Select all that apply. A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy B) Monitoring the client for anemia due to salicylate therapy C) Suggesting the client begin supplemental pyridoxine D) Educating the client that medication therapy may be discontinued due to remission E) Teaching the client that RA may be contracted by the fetus during pregnancy
Answer: B, D Explanation: A) When providing care to a client with RA during pregnancy, the nurse will monitor the client for anemia due to salicylate therapy and educate the client that medication therapy may be discontinued if the client experiences remission during the pregnancy. Salicylate therapy is associated with prolonged gestation and labor. Supplemental pyridoxine is required for clients being treated with isoniazid for TB during pregnancy. RA cannot be contracted by the fetus during pregnancy.
The nurse is caring for a pregnant client who has asthma. The client has a cold and has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-related complications in the fetus, which medication prescription does the nurse anticipate? A) IV corticosteroid (e.g., prednisone) B) Oral pseudoephedrine (e.g., Sudafed) C) Inhaled beta2-agonist (e.g., albuterol) D) Oral acetylsalicylic acid (e.g., aspirin)
Answer: C Explanation: A) Albuterol, a beta2-agonist, is the medication recommended to treat asthma exacerbations during pregnancy. Steroids, decongestants such as pseudoephedrine, and aspirin should be avoided in pregnancy because of potential harmful effects to the fetus.
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." D) "During labor, the nurse will regularly check my cervix by doing a pelvic exam."
Answer: C Explanation: A) During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound unless complications are present. This is the statement the client should make to prove that education was successful. The nurse will also monitor contractions, bloody show, and the cervix, but these assessments do not monitor the baby's condition.
During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate? A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This is a normal reaction to the ending of the physical exertion of labor. D) The client has a fever from a postpartum infection.
Answer: C Explanation: A) Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? A) Notifying the healthcare provider that birth is imminent B) Changing the client's position in bed C) Beginning continuous fetal heart rate monitoring D) Administering oxygen at 2 liters per minute
Answer: C Explanation: A) Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Changing the client's position is not indicated. Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.
A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data? A) Ineffective Breastfeeding B) Dysfunctional Family Processes C) Nausea D) Fatigue
Answer: C Explanation: A) Of the three physiologic complaints, the one that has the highest priority is nausea because it could directly impact the developing fetus. Breast tenderness does not mean that the client will experience ineffective breastfeeding. Fatigue is a common symptom of pregnancy and would not negatively impact the developing fetus. The husband being upset with the client's complaints does not necessarily mean that she and her husband have dysfunctional family processes.
The nurse is reviewing the immunization record for a client who just learned she is pregnant. Which vaccine is not safe to give during pregnancy? A) Pertussis B) Annual influenza C) Rubella D) Tetanus
Answer: C Explanation: A) Rubella vaccine should never be given to pregnant women (or women trying to conceive) because the vaccine contains the attenuated live virus, which has teratogenic effects on the developing fetus. Pertussis, tetanus, and annual influenza vaccines can safely be given in pregnancy. Safe vaccine recommendations for pregnant women are available from the Centers for Disease Control and Prevention website (http://www.cdc.gov).
The nurse is instructing a client who is at 10 weeks' gestation on avoiding substance abuse. Which is the rationale for why substances of abuse should be avoided during pregnancy? A) Interferes with hormone excretion of the fetus B) Facilitates the transfer of viruses and other diseases into the developing fetus C) Passes into the developing fetus through the placenta very easily D) Stops the synthesis of protein in the developing fetus
Answer: C Explanation: A) Substances of abuse pass from the mother to the fetus through the placenta via simple diffusion. These substances have adverse effects on the developing fetus. Substances of abuse do not interfere with hormone excretion of the fetus or stop the synthesis of protein in the fetus. They do not facilitate the transfer of viruses and other diseases into the developing fetus.
The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and wishes his wife had not gotten pregnant. Which response by the nurse is appropriate? A) "Do you think your wife got pregnant on purpose, without your consent?" B) "Have you considered giving the baby up for adoption?" C) "Tell me more about why you feel this way." D) "Every husband has these feelings, and many times they never go away."
Answer: C Explanation: A) The nurse needs to include the care of the father when providing care to a pregnant client. The husband is expressing uncertainty about his ability to be a father and regrets the pregnancy. The best response by the nurse is to explore the father's feelings. The nurse should not minimize the husband's feelings by stating every husband has these feelings. It is inappropriate for the nurse to say that the feelings may never go away. The nurse should not suggest that the baby be given up for adoption or that the client became pregnant on purpose because neither of these statements supports the client or husband at this time.
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? A) Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured B) Encouraging the client to void every 1-2 hours C) Assessing fetal heart rate every 5 minutes D) Administering antibiotics for a positive group beta strep
Answer: C Explanation: A) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 5 minutes or after every contraction. Assessing temperature every 1 to 2 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.
The nurse is planning for several women who are pregnant for the first time who are in the labor and delivery process. Which woman has the highest risk of labor and delivery complications? A) A healthy 38-year-old woman B) A 24-year-old woman with asthma C) A 36-year-old woman with diabetes D) A 31-year-old woman with hypertension
Answer: C Explanation: A) Women over the age of 35 have an increased risk for complications during labor and delivery, especially when the woman already has preexisting medical conditions such as hypertension or diabetes. However, risks are much lower for women under the age of 35 or women over the age of 35 who do not have preexisting medication conditions.
The nurse is providing care to a client who is experiencing nausea and vomiting during the first trimester of pregnancy. Which actions by the nurse are appropriate based on this data? Select all that apply. A) Notify the healthcare provider that the client is experiencing hyperemesis gravidarum. B) Educate the client to notify the healthcare provider if she vomits once per day. C) Suggest the client use acupressure to pressure points on the wrist. D) Teach the client that ginger may relieve her symptoms. E) Caution the client against using over-the-counter medications such as over-the-counter antihistamines.
Answer: C, D Explanation: A) Nausea and vomiting is a common experience during the first trimester of pregnancy. Acupressure and ginger are two complementary therapies that the nurse can suggest to the client to relieve the symptoms. There is no evidence that the client is experiencing hyperemesis gravidarum. The client should be taught to notify the healthcare provider if vomiting occurs more than once a day. Over-the-counter antihistamines are safe to use during pregnancy to decrease the occurrence of nausea and vomiting if recommended by the doctor.
Which pregnant client would have the greatest need for a nutritional assessment and individualized meal plan? A) A client who is lactose intolerant B) A client who is vegetarian C) A client who requires a Kosher diet D) A client with anorexia nervosa
Answer: D Explanation: A) Although all of these clients will need special considerations related to diet and nutritional requirements, the client with anorexia nervosa, an eating disorder, is at highest risk for inadequate nutrition. When a pregnant woman has an eating disorder, education and individualized meal plans can help the patient increase her dietary intake while maintaining a sense of control.
The nurse is reviewing exercises with a pregnant woman to help the client maintain physical fitness and appropriate weight gain throughout the pregnancy. After the teaching session, the client tells the nurse that she was taught never to reach over the head because this will harm the baby. Based on this data, which action by the nurse is appropriate? A) Provide dietary instruction instead to ensure the client does not gain excessive weight. B) Tell the client to just perform the exercises that don't require her to reach over her head. C) Provide alternative activities to do instead of exercise. D) Assure the client that reaching over the head will not harm the baby.
Answer: D Explanation: A) Clients of European, African, and Mexican descent may believe that reaching over the head during pregnancy can harm the baby. The nurse should assure the client that this is not accurate. Providing activities to do instead of exercise or telling the client to avoid the exercises that require her to reach over her head will not address the misconception that reaching over the head will harm the baby. Dietary instruction during pregnancy is important to ensure a healthy weight gain for a healthy baby, not to ensure the client does not gain excessive weight because of lack of exercise.
The nurse is providing care to a pregnant client and her spouse. The client requires an amniocentesis. Which client statement indicates appropriate understanding of the information presented? A) "The test has to be done before the 14th week of pregnancy." B) "If the test determines our baby has Down syndrome, we will not need to take childbirth classes." C) "It is not unusual for amniocentesis to misdiagnose a problem with the baby." D) "The results of the amniocentesis will take up to 2 weeks."
Answer: D Explanation: A) For couples having an amniocentesis, the first few months of pregnancy can be difficult because the test cannot be performed until the 14th week of pregnancy, and not before. The results of the amniocentesis will not be available for up to 2 weeks, which is evidence that instruction regarding the test has been understood by the client and spouse. Childbirth classes are important in promoting adaptation to the event of childbirth for expectant couples of any age or situation. The results of an amniocentesis are 99% accurate in diagnosing genetic abnormalities.
A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time? A) Health-Seeking Behaviors B) Fear C) Anxiety D) Acute Pain
Answer: D Explanation: A) Many clients experience perineal trauma during the childbirth process, which causes acute pain in the fourth stage of labor. Therefore, Acute Pain is a more appropriate nursing diagnosis related to this condition than Fear or Anxiety. The diagnosis of Health-Seeking Behaviors does not address the client experiencing perineal trauma during labor.
During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline, and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor.
Answer: D Explanation: A) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.
During a routine antepartal visit, a client complains to the nurse that she is experiencing leg cramps during the night. The nurse asks further questions regarding the client's intake of: •A. Fruits and yellow vegetables. •B. Dairy products. •C. Whole grain breads and cereals. •D. Red meat and green leafy vegetable.
B
When measuring the fundal height of a client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points? •A. Halfway between the client's symphysis pubis and umbilicus. •B. At about the level of the client's umbilicus. •C. Between the client's umbilicus and xiphoid process. •D. Near the client's xiphoid process and compressing the diaphragm.
B
When working with the parents of a stillborn baby, the nurse understands that: •A. Privacy is needed to deal with the death. •B. The parents need the presence of others to cope. •C. The nurse's presence is usually seen as an intrusion. •D. Referral should be made to social service.
B
A client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? •A. "I need to call if I start to leak fluid from my vagina." •B. "If I start bleeding, I will need to call back." •C. "If my baby does not move, I need to call my health care provider." •D. "If I start running a fever, I should let the office know."
C
A client comes to the maternity clinic for a pregnancy test that results in positive findings. The client has one son, three years of age. She previously had a spontaneous abortion at 11 weeks gestation. Which statement best describes the client? •A. G2P3 •B. G2P2 •C. G3P1 •D. G2P1
C
A 36-year-old client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. The nurse should assess the client's fundal height to: •A. Determine the level of uterine activity. •B. Identify the need for increased weight gain. •C. Assess the location of the placenta. •D. Estimate the fetal growth.
d
During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" the nurse should tell the participant which of the following about true labor contractions? •A. "Walking around helps to decrease true contractions." •B. "True labor contractions may disappear with ambulation, rest or sleep." •C. "The duration and frequency of true labor contractions remain the same." •D. "True labor contractions are felt first in the lower back, then the abdomen."
d
During labor, the client tells the nurse, "I can't do this anymore." The nurse notes that she is tired, her arms and legs are shaky and she complains of nausea. The next action of the nurse should be to: •A. Ask the physician to prescribe an antiemetic medication. •B. Prepare the client for the delivery room. •C. Take the client's vital signs for possible infection. •D. Provide continual assessment data.
d
At the initial prenatal visit, a client reports that she last started her menstrual period on August 10. Based on Nagele's rule, the baby is due on:
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