NCLEX Antepartum

The 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 areas, knowing that venous congestion is commonly noted in which areas? Select all that apply. 1.Legs 2.Vulva 3.Fingers 4.Around the eyes 5.Around the abdomen

1, 2

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement should the nurse provide to the client? 1."The test is an invasive procedure and requires that you sign an informed consent." 2."The fetus is challenged by uterine contractions to obtain the necessary information." 3."The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 4."An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which client problem does the nurse identify as the priority at this time? 1.Altered tissue integrity 2.Urinary tract infection 3.Pain associated with the infection 4.Fear about the well-being of the fetus

Fear about the well-being of the fetus

The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply. 1.Lightening 2.Quickening 3.Fetal heart tones 4.Urinary frequency 5.Positive pregnancy test 6.Fetal movements felt by examiner

3, 6

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones should the nurse identify as present at this time? Select all that apply. 1.Can hear 2.Sex recognizable 3.Blood forming in marrow 4.Testes descend into scrotum 5.Kidneys able to secrete urine

2, 3, 5

The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply. 1.Fetus is able to hear (24 weeks). 2.Earliest taste buds present. 3.Kidneys able to secrete urine. 4.Lecithin begins to appear in amniotic fluid (weeks 27-28). 5.Sex can be determined as internal and external organs are sex specific.

2, 3, 5

A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client? 1."I am sure your baby will be fine." 2."You will not have any problems if you keep your blood sugar in control." 3."Your baby will need to spend most of the time in the nursery after delivery." 4."Better blood glucose control means fewer effects; let's review your plan of care."

"Better blood glucose control means fewer effects; let's review your plan of care."

The nursing instructor asks the nursing student to identify the reason that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which response indicates that the student understands the rationale of this physiological response? 1."An increase in pulse relates to the development of preeclampsia." 2."Blood volume and cardiac output increase resulting in a faster pulse." 3."The pulse rate is an emotional response to the excitement she is experiencing at being pregnant." 4."There should not be an increase in pulse; therefore, the change is most likely related to cardiac malfunction."

"Blood volume and cardiac output increase resulting in a faster pulse."

The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breastfeed the infant after delivery. Which response by the nurse is appropriate? 1."Breastfeeding is contraindicated." 2."Breastfeeding is allowed as long as the mother is taking zidovudine (AZT)." 3."Breastfeeding is allowed as long as the infant receives an immunization for HIV." 4."Breastfeeding is allowed as long as the infant is not showing signs of human immunodeficiency virus (HIV) infection."

"Breastfeeding is contraindicated."

The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking, and the client tells the nurse that she has been taking the herb chamomile. Which statement made by the client demonstrates correct information about this herbal intervention? 1."Chamomile is a known stimulant." 2."Chamomile is always safe for women and children." 3."Chamomile has no side effects or interactions with other medications." 4."Chamomile should not be used while I am pregnant and because I have asthma."

"Chamomile should not be used while I am pregnant and because I have asthma."

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate? 1."Have either of you ever had surgery?" 2."Do you plan to have any other children?" 3."Do either of you have diabetes mellitus?" 4."Do either of you have problems with high blood pressure?"

"Do you plant to have any other children?"

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids? 1."Hemorrhoids can be gently pushed back inside my body using a lubricant." 2."Diet is very important in the treatment of hemorrhoids. Plenty of liquids and a balance of bulk in the diet are needed." 3."Hemorrhoids are aggravated by standing for long periods. I need to lie down periodically during the day to relieve the pressure." 4."Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."

"Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement? 1."Hepatitis B will cause a severe eye infection in my baby." 2."I know my baby will be immune from hepatitis for the first 2 months of life." 3."I am so glad that I can breastfeed my baby after she has been vaccinated." 4."I feel sad that my baby is going to be isolated in the nursery after my delivery."

"I am so glad that I can breastfeed my baby after she has been vaccinated."

The 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 client statement indicates a need for further investigation? 1."I don't like my figure anymore. My clothes are all too tight." 2."I don't like my breasts anymore. These silver lines are ugly." 3."I don't like my stomach anymore. That brown line is disgusting." 4."I don't like my face anymore. I always look like I have been crying."

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

The nurse employed in a primary health care provider's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral? 1."I have terrible mood swings. I will be glad when this is all over." 2."I will never be able to lose my weight and regain a great figure. I feel ugly." 3."I don't like the way I look. My husband could never find me attractive again." 4."I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

The nurse reinforces instructions to a client with mild preeclampsia on home care. Which comment by the client indicates that teaching is effective? 1."I need to check my weight every day at different times during the day." 2."I need to take my blood pressure each morning and alternate arms each time." 3."As long as the health nurse is visiting me daily, I do not have to keep my next primary health care provider's appointment." 4."I need to check my urine with a dipstick every day for protein and call my health care provider if it is 2+ or more."

"I need to check my urine with a dipstick every day for protein and call my health care provider if it is 2+ or more."

The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy? 1."I am not crazy about eating vegetables, but I will do my best." 2."I need to gain only 10 pounds so that my baby will be small like I am." 3."I don't like milk, but I can drink it if it is in a shake mixed with chocolate." 4."I really like to have a root beer float with vanilla ice cream in the afternoon."

"I need to gain only 10 pounds so that my baby will be small like I am."

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? 1."I can eat more sweets now because I need more calories." 2."I need more fat in my diet so that the baby can gain enough weight." 3."I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." 4."I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

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

A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures? 1."I can douche any time I want." 2."I can wear my tight-fitting jeans." 3."I should avoid the use of condoms." 4."I should choose underwear with a cotton panel liner."

"I should choose underwear with a cotton panel liner."

The nurse is reinforcing instructions to 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? 1."I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement." 2."I should drink 8 to 12 glasses of liquid a day, and I can count the coffee that I drink." 3."I should drink 8 to 12 glasses of liquid a day, and I can count the tea, fruit juices, or milk that I drink." 4."I should drink 8 to 12 glasses of liquid a day, and I can count the carbonated soft drinks that I consume."

"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."

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? 1."I know I can never have another child." 2."I am glad I won't have to have these shots if I have another child." 3."I will have to have an injection once a month until the baby is born." 4."I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

The nurse is assisting in conducting a prenatal session with a group of expectant parents. Which comment related to female hormones made by a parent indicates the need for further teaching? 1."Oxytocin may be used to stimulate labor contractions." 2."Prolactin is the hormone responsible for the initiation of labor." 3."Progesterone plays a role in preparing the uterus for embryo implantation." 4."Testosterone in the female helps stimulate pubic and axillary hair growth at puberty."

"Prolactin is the hormone responsible for the initiation of labor."

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. Which response is appropriate for the nurse to make? 1."The breasts become stretched because of weight gain." 2."The increased metabolic rate causes the breasts to become larger." 3."The breast changes are a result of the secretion of estrogen and progesterone." 4."Cortisol secreted by the adrenals plays a factor in increasing the size and appearance of the breasts."

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

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning? 1."Iron supplements will give me diarrhea." 2."The iron is needed for the red blood cells." 3."Meat does not provide iron and should be avoided." 4."My body has all the iron it needs and I don't need to take supplements."

"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? 1."Uterine contractions are stimulated by Leopold's maneuvers." 2."The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." 3."An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." 4."Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions."

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

A woman at 20 weeks of gestation calls the primary health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client? 1."Drink three glasses of water and lie on your left side for 1 hour." 2."This is an emergency; you should come to the clinic within the hour." 3."Tell me about your activity, food, fluid, and medication intake for the past 24 hours." 4."Palpate for contractions and if four or more are felt within 1 hour, you need to be seen by the primary health care provider."

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

A pregnant client is positive for the human immunodeficiency virus (HIV). The nurse educates the client and determines that there is a need for further teaching if the client makes which statement? 1."I can hold and diaper my newborn baby." 2."Breastfeeding my newborn will be the best option for my baby." 3."It may be as long as 2 years before I will know if my baby is HIV positive." 4."If I take the prescribed medications for HIV, it is possible that I may not transfer this disease to my newborn."

"breastfeeding my newborn will be the best option for my baby."

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply. 1.Proteinuria 2.Hypertension 3.Low-grade fever 4.Increased pulse rate 5.Increased respiratory rate

1, 2

A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply. 1.Avoid greasy foods. 2.Eat 5 to 6 small meals each day. 3.Do not drink fluids with meals. 4.Eat highly spiced foods only in evening hours. 5.Refrain from eating anything for 2 to 3 hours after arising.

1, 2, 3

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions should the nurse place on the list? Select all that apply. 1.To note the color of blood on each perineal pad 2.To watch for the evidence of the passage of tissue 3.To note the quantity of blood on each perineal pad 4.To count the number of perineal pads used on a daily basis 5.To avoid any sexual activity for the remainder of the pregnancy 6.To maintain strict bed rest throughout the remainder of the pregnancy

1, 2, 3, 4

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply. 1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Braxton Hicks contractions 5.Outline of fetus via radiography or ultrasound 6.Fetal heart rate detected by a nonelectronic device

1, 2, 3, 4

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply. 1."Maximum level of human chorionic gonadotropin is reached at term." 2."Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3."Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4."Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5."Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

2, 3, 4, 5

The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)? 1.Living in an area where HIV infections are minimal 2.A history of intravenous (IV) drug use in the past year 3.A history of one sexual partner within the past 10 years 4.A heterosexual spouse who has had only one sexual partner in the past 10 years

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

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results? 1.A positive test 2.A negative test 3.A suspicious test 4.An unsatisfactory test

A negative test

A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation? 1.Drinking eight to ten glasses of water daily 2.Daily activity such as walking or swimming 3.Increasing whole grains and fresh vegetables in the diet 4.Adding 1 tablespoon of mineral oil to a bowl of cereal daily

Adding 1 tablespoon of mineral oil to a bowl of cereal daily

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment should be part of the plan of care? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Any bleeding, such as in the gums, petechiae, and purpura

Any bleeding, such as in the gums, petechiae, and purpura

The nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the primary health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention? 1.Relieves anxiety for the pregnant client 2.Eliminates the need for further unnecessary screenings 3.Assists in identifying infections that may need to be treated 4.Minimizes the financial cost of caring for an HIV-positive client

Assists in identifying infections that may need to be treated

The 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 accomplish which goal? 1.Minimize the possibility of preterm labor. 2.Reduce the risks of anemia during pregnancy. 3.Avoid further stress on the maternal immune system. 4.Minimize the risk of premature rupture of membranes.

Avoid further stress on the maternal immune system.

The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence? 1.Cause hemorrhage 2.Initiate premature labor 3.Rupture the fetal membranes 4.Increase the chance of infection

Cause hemorrhage

Which history places a maternity client at risk for uterine rupture? 1.Preterm labor 2.Placenta previa 3.Abruptio placentae 4.Cesarean section birth

Cesarean section birth

The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen? 1.Estrogen maintains the uterine lining for implantation. 2.Estrogen stimulates metabolism of glucose and converts the glucose to fat. 3.Estrogen prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 4.Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

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

When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior? 1.Anticipatory grieving 2.Walking 1 to 2 miles daily 3.Expression of hope for a positive outcome 4.Delaying preparations for finishing the nursery at home

Expression of hope for a positive outcome

The nurse is collecting data from 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 should document which as the GTPAL for this client? 1.G = 3, T = 2, P = 0, A = 0, L = 1 2.G = 2, T = 1, P = 0, A = 0, L = 1 3.G = 1, T = 1, P = 1, A = 0, L = 1 4.G = 2, T = 0, P = 0, A = 0, L = 1

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

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen? 1.It maintains the uterine lining for implantation. 2.It stimulates the metabolism of glucose and converts glucose to fat. 3.It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. 4.It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

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

The nurse is preparing to monitor a fetal heart rate. The nurse locates a round, ballottable shape just above the symphysis pubis. Fetal small parts are located on the right side of the uterus with a concave shape located on the left side of the uterus. Where should the nurse listen to hear the strongest fetal heart tones? 1.Left lower quadrant 2.Left upper quadrant 3.Right lower quadrant 4.Right upper quadrant

Left lower quadrant

A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period? 1.Longest period of fetal development 2.First 3 days of fetal development following conception 3.First 2 weeks of fetal development following conception 4.Fetal development beginning the third week after conception through the eighth week

Longest period of fetal development

The nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record supports this risk factor? 1.Gestational diabetes 2.Maternal hypertension 3.Hyperemesis gravidarum 4.Previous cesarean section

Maternal hypertension

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area? 1.At the umbilicus 2.Just above the symphysis pubis 3.At the level of the xiphoid process 4.Midway between the symphysis pubis and the umbilicus

Midway between the symphysis pubis and the umbilicus

The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client? 1.Minimize the possibility of preterm labor. 2.Reduce the risks of anemia during pregnancy. 3.Minimize the potential for developing infections. 4.Minimize the risk of premature rupture of membranes.

Minimize the potential for developing infections.

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client? 1.Restricting food and fluids 2.Monitoring blood glucose levels 3.Maintaining the client in a supine position 4.Minimizing the client's exposure to external stimuli

Minimizing the client's exposure to external stimuli

The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions? 1.Drink 8 ounces of fluid 6 times per day. 2.Wipe the perineal area anterior to posterior after toileting. 3.Perform Kegel exercises in 10 repetitions, three times per day. 4.Perform pelvic tilt exercises in 10 repetitions, three times per day.

Perform Kegel exercises in 10 repetitions, three times per day

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta? 1.Cushions and protects the fetus 2.Maintains the body temperature of the fetus 3.Surrounds the fetus and allows for fetal movement 4.Provides an exchange of nutrients and waste products between the mother and the fetus

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

The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs? 1.Offering praise and reinforcement for compliance with treatment therapies 2.Using a caring and supportive approach when dealing with a pregnant woman 3.Providing the mother with pamphlets and booklets to read about the pregnancy 4.Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy

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

The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first? 1.Pulse 2.Weight 3.Temperature 4.Abdominal girth measurement

Pulse

The nurse is reinforcing the positive effects of breathing and relaxation techniques to a pregnant client with cardiac issues who has an 18-month-old child. Which primary outcome is the purpose for these interventions? 1.Reducing maternal stress and fatigue 2.Helping the client prepare for labor and delivery 3.Avoiding stress-induced infectious disease processes 4.Preparing for maternal-child separation during hospitalization

Reducing maternal stress and fatigue

A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption? 1.Reducing the potential for fetal growth restriction in utero 2.Promoting the normal psychosocial adaptation of the mother to pregnancy 3.Minimizing the potential for placental abruptions during the intrapartum period 4.Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structure

Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structure

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose? 1.Reduce a backache. 2.Prevent ankle edema. 3.Prevent urinary tract infections. 4.Strengthen the pelvic floor in preparation for delivery.

Strengthen the pelvic floor in preparation for delivery.

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? 1.Contact the health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Tell the client that these are common and they may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

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

The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action should the nurse take before the procedure to ensure fetal safety? 1.Require that the client empty her bladder. 2.Teach the client the signs and symptoms of labor. 3.Test the ultrasound equipment to ensure proper functioning. 4.Prepare a local anesthetic to be used during the insertion of the spinal needle.

Test the ultrasound equipment to ensure proper functioning.

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? 1.The bladder must be full during the examination. 2.The bladder must be empty during the examination. 3.She should not eat or drink anything 4 to 6 hours before the examination. 4.She will be given Rho(D) immune globulin because she is Rh positive.

The bladder must be full during the examination

A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem should initially direct nursing care at this time? 1.The client is blaming herself. 2.The client is experiencing fetal distress. 3.The client is concerned about her appearance. 4.The client lacks knowledge regarding diabetes treatment.

The client is blaming herself

The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur? 1.The client will be placed in the supine position. 2.The client will feel some pain during the procedure. 3.The client will feel some pressure when the vaginal probe is moved. 4.The client will need to drink 2 quarts of water to attain a full bladder.

The client will feel some pressure when the vaginal probe is moved.

The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue? 1.The feelings of guilt that is often associated with grief 2.Grief and loss are usually resolved within 3 months 3.The amount of pain and discomfort as a result of the abortion 4.The other children in the family and the ability to bear children in the future

The feelings of guilt that is often associated with grief

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign? 1.Softening of the cervical tip 2.Softening of the uterine isthmus 3.Violet bluish color of vaginal mucosa and cervix 4.Palpating the floating fetus by bouncing it gently and feeling the rebound

Violet bluish color of vaginal mucosa and cervix

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 reinforces teaching the client about the signs that need to be reported to the primary health care provider (PHCP) and tells the client to call the PHCP if which occurs? 1.Urine output increases. 2.Fetal movements are more than 4 per hour. 3.Weight increases by more than 1 pound in a week. 4.The blood pressure reading is between 122/80 and 138/88 mm Hg.

Weight increases by more than 1 pound in a week.

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, which is the best response by the nurse? 1."Can you tell me more about what you are eating?" 2."If you do not eat regular meals, you will hurt your baby." 3."It does not matter anymore how much weight you gain." 4."I'll have the primary health care provider review your diet history."

"Can you tell me more about what you are eating?"

The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia? 1."Blurred vision is not a normal occurrence." 2."I will report any appearance of facial edema." 3."I will be alert to any change in fetal movements." 4."I should expect that my urine output will decrease."

"I should expect that my urine output will decrease."

A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client indicates the need for further teaching? 1."I need to watch for weight gain." 2."It is best to rest on my right side." 3."I should avoid stressful situations." 4."I need to avoid people with infections."

"It is best to rest on my right side."

The nurse shares with a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine? 1."You are still susceptible to rubella, so your toddler should receive the vaccine." 2."Children do not receive the rubella vaccine until they have had their fifth birthday." 3."It is discouraged that children of pregnant women be vaccinated during the pregnancy." 4."You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply. 1.Reports of fatigue 2.Pink mucous membranes 3.Increased vaginal secretions 4.Hemoglobin level of 10.2 g/dL 5.Increased frequency of voiding

1, 2

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply. 1.Round shape 2.Shallow depth 3.Narrow pubic arch 4.Diagonal conjugate measures 12.5 cm to 13 cm 5.Blunt, somewhat widely separated ischial spines

1, 4, 5

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 which week of gestation? 1.10 2.12 3.14 4.18

18

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components? 1.Two umbilical veins and one umbilical artery 2.Two umbilical arteries and one umbilical vein 3.Arteries that carry oxygenated blood to the fetus 4.Veins that carry deoxygenated blood to the fetus

2.Two umbilical arteries and one umbilical vein

The 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 which situation? 1.Emotional immaturity 2.A stubborn personality 3.An undiagnosed psychiatric disorder 4.Acute anxiety and the need for support

Acute anxiety and the need for support

A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease? 1.Eat raw meats. 2.Wash hands only before meals. 3.Avoid exposure to litter boxes used by cats. 4.Use topical corticosteroid treatments prophylactically.

Avoid exposure to litter boxes used by cats.

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 which should the nurse do first? 1.Check for pedal edema. 2.Check the dorsalis pedis pulses. 3.Check for signs of thrombophlebitis. 4.Tell the client to apply heat to the affected area when cramps occur.

Check for signs of thrombophlebitis

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time? 1.Tell the client not to worry. 2.Refer the client to a counselor. 3.Ignore the client's unfounded concerns and continue. 4.Explain the purpose of the nurse's actions and answer all questions.

Explain the purpose of the nurse's actions and answer all questions.

The nurse is assisting in developing a teaching plan for a pregnant client diagnosed with diabetes mellitus. Which instruction is the priority for this client? 1.How to test for proteinuria 2.How to manage the discomfort of early labor 3.How to check for and manage preterm bleeding 4.How to check for signs of hypoglycemia and the required treatment

How to check for signs of hypoglycemia and the required treatment

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position should the nurse place the client? 1.Lying down 2.On the left side 3.On the right side 4.In a sitting position

In a sitting position

A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion? 1.Septic 2.Inevitable 3.Incomplete 4.Threatened

Inevitable

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs? 1.Facial edema 2.Rapid weight gain 3.Visual disturbances 4.Irregular, painless contractions

Irregular, painless contractions

A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which is the estimated date of delivery (EDD)? 1.January 21 2.January 12 3.January 19 4.December 19

January 12

The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record? 1.Oliguria 2.Gestational diabetes 3.Maternal hypertension 4.Hyperemesis gravidarum

Maternal Hypertension

The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client? 1.Monitoring fetal movement 2.Maintaining complete bed rest 3.Monitoring daily blood glucose 4.Restricting maternal fluid intake

Monitoring fetal movement

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that which primary hormone stimulates postpartum contractions? 1.Prolactin 2.Oxytocin 3.Progesterone 4.Testosterone

Oxytocin

The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action should the nurse perform first? 1.Explain the reason for these symptoms. 2.Place a cool washcloth on the client's forehead. 3.Measure blood pressure, pulse, and respirations. 4.Place a wedge pillow under the client's right side.

Place a wedge pillow under the client's right side.

The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion? 1.Syphilis 2.Age of 45 years 3.Diabetes mellitus 4.Prior history of genital herpes

Syphilis

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presence of HIV? 1.Platelet count 2.Angiotensin levels 3.T lymphocyte levels 4.Glomerular filtration rate

T lymphocyte levels

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal is appropriate? 1.The client is assisted with the grief process. 2.The client is advised of an HIV support group. 3.The client will not have sexual relations during the remainder of pregnancy. 4.The client will not develop an opportunistic infection during the remainder of pregnancy.

The client will not develop an opportunistic infection during the remainder of pregnancy.

The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy? 1.The insulin needs will increase. 2.The insulin needs will decrease. 3.The insulin needs will remain unchanged. 4.The client will require both short- and long-term insulin therapy.

The insulin needs will increase

The nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where? 1.Vulva 2.Fingers 3.Around the eyes 4.Around the abdomen

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 measure is appropriate to suggest to the client? 1.Wear a perineal pad to the play. 2.Have a friend videotape the play for her. 3.Perform Kegel exercises during the play. 4.Limit fluid intake to 500 mL on the day of the play.

Wear a perineal pad to the play

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data? 1.Life stress 2.Self-care needs 3.Support systems 4.Weight and height

Weight and height

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 the goal has been achieved when the client makes which statement? 1."I am drinking 8 ounces of water with each meal." 2."I eat two saltine crackers before I get up each morning." 3."I am eating three servings of cracked-wheat bread each day." 4."I am eating fresh fruits and vegetables for snacks and for dessert each day."

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

A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes? 1."Well, I guess I will just have to deal with this." 2."Oh, well, I guess this isn't the end of the world." 3."I shouldn't have eaten so many sweets before I became pregnant." 4."I have heard that this type of diabetes is first discovered during pregnancy."

"I shouldn't have eaten so many sweets before I became pregnant."

The nurse is conducting a prenatal session with a group of expectant parents. The nurse recognizes that teaching regarding hormones has been successful if a parent makes which statement? 1."Oxytocin assists with the maintenance of pregnancy." 2."Prolactin is the hormone responsible for the secretion of milk." 3."Progesterone is needed for growth of pubic and axillary hair at puberty." 4."Testosterone is produced by the pituitary gland and assists with breast development."

"Prolactin is the hormone responsible for the secretion of milk."

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks? 1.6 to 8 2.8 to 10 3.12 to 16 4.20 to 22

12 to 16

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding? 1.22 cm 2.26 cm 3.32 cm 4.40 cm

26 cm

The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data? 1.Rh incompatibility 2.Fetal cardiomegaly 3.Increase in circulating volume 4.Hypertrophy and increased contractility

3.Increase in circulating volume

A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the primary health care provider to prescribe? 1.Biophysical profile 2.Chorionic villus sampling 3.Ultrasound for amniotic fluid volume 4.Amniocentesis for fetal surfactant level

Amniocentesis for fetal surfactant level

During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which should the nurse check further? 1.The blood glucose level 2.The presence of vaginal discharge 3.Blood pressure changes and the presence of protein in the urine 4.Height of the fundus as compared with the date of the client's last visit

Blood pressure changes and the presence of protein in the urine

A pregnant client is seen in the health care clinic with reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion? 1.Switch to a high-carbohydrate diet. 2.Eat a high-protein snack at bedtime. 3.Consume dry crackers before getting out of bed. 4.Increase fluids with both meals and with snacks.

Consume dry crackers before getting out of bed.

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem do the data best support? 1.Anxiety 2.Low self-esteem 3.High risk for infection 4.Cardiovascular accident (stroke)

High risk for infection

The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery? 1.Weight gain of 25 to 35 pounds 2.Prenatal care beginning at 8 weeks 3.Spontaneous rupture of membranes 2 hours ago 4.History of substance abuse during this pregnancy

History of substance abuse during this pregnancy

A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management? 1.The need for therapeutic abortion is required. 2.Medication will not be started until after delivery of the fetus. 3.Isoniazid plus rifampin will be required for a total of 9 months. 4.The newborn infant must receive medication therapy immediately following birth.

Isoniazid plus rifampin will be required for a total of 9 months.

The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action? 1.Contracting and then consciously relaxing different muscle groups 2.Massaging the abdomen during contractions using both hands in a circular motion 3.Instructing the significant other to stroke or massage a tightened muscle by the use of touch 4.Contracting an area of the body such as an arm or leg and then concentrating on letting tension go from the rest of the body

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

The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid? 1.1½ cups of yogurt 2.One medium banana 3.Nuts and green, leafy vegetables 4.1 cup milk with two graham crackers

Nuts and green, leafy vegetables

The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action? 1.Provide emotional support. 2.Avoid the topic of the disease. 3.Allow the client to be alone if she is crying. 4.Provide all information regarding the disease immediately.

Provide emotional support

The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus? 1.First 2.Second 3.Third 4.Fourth

Second

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding indicates a serious nutritional disorder of pregnancy? 1.Patellar reflex is 2+ 2.Chadwick's sign is positive 3.Ketone bodies in urine are negative 4.Weight compared to last visit is a loss of 2.3 pounds

Weight compared to last visit is a loss of 2.3 pounds

The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply. 1.Female organ of coitus 2.Discharge of menstrual flow 3.Allows for fetal passage during the process of birth 4.Assists in propelling the ovum through the fallopian tube 5.Produces sex hormones that assist in maintaining the pregnancy

1, 2, 3

The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the primary health care provider. Which warning signs should the nurse place on the list? Select all that apply. 1.Facial edema 2.Rapid weight gain 3.Visual disturbances 4.Generalized edema 5.Nausea on arising in the morning 6.The presence of irregular painless contractions

1, 2, 3, 4

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply. 1.Pulse 2.Blood volume 3.Cardiac output 4.Blood pressure 5.Red blood cell mass 6.White blood cell count

1, 2, 3, 5

A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply. 1.Edema 2.Polyuria 3.Proteinuria 4.Thrombocytopenia 5.Irregular, painless contractions

1, 3, 4

The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply. 1.Peanut butter 2.Fresh fruit salad 3.Whole grain bread 4.Omelet with cheese 5.Chocolate milkshake

1, 3, 4

The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply. 1.Curtail exercise. 2.Weigh yourself every week. 3.Measure your blood pressure daily. 4.Rest frequently by lying on your side. 5.Call the primary health care provider if you develop dizziness.

1, 3, 4, 5

The nurse is reading the primary health care provider's documentation regarding a pregnant client and notes that the primary health care provider has documented that the client has an android pelvic shape. Which descriptions apply to an android pelvis? Select all that apply. 1.Narrow wedge shape 2.Long, narrow oval shape 3.Favorable for a vaginal birth 4.Short, flattened, wide oval shape 5.Unfavorable for a vaginal birth 6.Rounded shape with a wide pelvic arch

1, 5

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 heart rate is noted? 1.80 beats per minute 2.100 beats per minute 3.150 beats per minute 4.180 beats per minute

150 beats per minute

The nurse is reviewing the health care record of a pregnant client at 24 weeks' gestation. The nurse should anticipate that the fundus should be located at which level? 1.16 cm to 18 cm 2.20 cm to 22 cm 3.22 cm to 26 cm 4.32 cm to 36 cm

22 cm to 26 cm

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply. 1."The preembryonic period is the period of time before conception." 2."The preembryonic period is the longest period of fetal development." 3."The preembryonic period is the first 2 weeks of fetal development following conception." 4."The preembryonic stage is the most critical time in the development of the organ systems and the main external features." 5."The preembryonic period is the fetal development period from the beginning of the third week through the eighth week after conception." 6."The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers."

3, 6

When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection? 1."Have you been sexually active during the pregnancy, and if so, with how many different partners?" 2."Have you experienced any high fevers or unusual rashes during the first 6 weeks of your pregnancy?" 3."Do you have any cats as house pets, and if so, do you ever come in contact with their soiled kitty litter?" 4."Have you been recently exposed to children with draining skin rashes or gastrointestinal symptoms?"

"Do you have any cats as house pets, and if so, do you ever come in contact with their soiled kitty litter?"

The nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which statement made by the client should the nurse question to receive more information? 1."I will drink at least 6 to 8 glasses of water each day." 2."I will take a nap each afternoon to help me feel more rested." 3."I have had mild vaginal spotting twice since my last prenatal visit." 4."I will continue to take the extra iron that was prescribed for me by the primary health care provider."

"I have had mild vaginal spotting twice since my last prenatal visit."

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client indicates that she understands her needs? 1."I should rest on my back." 2."My weight gain is not important." 3."I should avoid stressful situations." 4."There is no restriction on people who visit me."

"I should avoid stressful situations."

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 should the nurse make to help reduce the maternal fears that the newborn will be born with an infection? 1."Urinary infections during pregnancy are common. Your baby will be fine." 2."Your developing baby cannot acquire an infection from you during pregnancy." 3."You shouldn't worry about this because you received early prenatal care and are taking your prenatal vitamins." 4."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."

"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 client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic? 1."Tell me about your concerns." 2."Your husband called to say he's coming to be with you." 3."Many women have this problem with no further complications." 4."You have an excellent primary health care provider; if anyone can save your baby, she can."

"Tell me about your concerns."

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response best supports the client? 1."I wouldn't worry about your baby's health; complications from this condition are generally rare." 2."Your baby will likely need to spend a few days in the neonatal intensive care unit for observation following delivery." 3."Your baby will not have any problems if you follow all the advice the primary health care provider has given you during your pregnancy." 4."The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

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 statement by the nurse indicates an understanding of the problem? 1."You are afraid your husband will go to dinner without you." 2."You feel you are having difficulty fulfilling your role as a wife." 3."You are not physically able to go to dinner and should stay at home." 4."You should go to dinner. Others will understand if you don't feel well."

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

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply. 1.Small parts are located on the left side of the uterus. 2.Small parts are located on the right side of the uterus. 3.A round hard ballottable shape is located in the fundus. 4.A round hard ballottable shape is located just above the symphysis pubis. 5.A soft, irregular non-ballottable shape is located just above the symphysis pubis.

1, 2, 5

The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all that apply. 1.Preterm labor 2.Postterm labor 3.Maternal anemia 4.Oligohydramnios 5.Gestational diabetes

1, 3

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply. 1.Hegar's sign 2.Braxton Hicks 3.Goodell's sign 4.Chadwick's sign 5.McDonald's sign

1, 3, 5

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 which weeks of gestation? 1.6 and 8 weeks' gestation 2.8 and 10 weeks' gestation 3.10 and 12 weeks' gestation 4.16 and 20 weeks' gestation

16 and 20 weeks' gestation

The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply. 1.Rice 2.Liver 3.Beans 4.Cheese 5.Chicken

2, 3

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply. 1.Chadwick's sign relates to fundal height. 2.Chadwick's sign is a probable sign of pregnancy. 3.Chadwick's sign may be present as early as 6 weeks' gestation. 4.Chadwick's sign is a bluish discoloration of the vagina and cervix. 5.Chadwick's sign occurs when the pregnant client experiences fetal movement.

2, 3, 4

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses should the nurse make to the client? Select all that apply. 1."It maintains the uterine lining for implantation." 2."It prevents the involution of the corpus luteum." 3."It stimulates the breasts to prepare for lactation." 4.It stimulates metabolism of glucose and converts the glucose to fat." 5."It maintains the production of progesterone until the placenta is formed." 6."It stimulates uterine development to provide an environment for the fetus."

3, 6

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 statements by the student indicate an understanding of this hormone? Select all that apply. 1."It softens the muscles and joints of the pelvis." 2."It is the primary hormone of milk production." 3."It maintains the uterine lining for implantation." 4."It may play a role in the neural development of the fetus." 5."It increases during pregnancy to stimulate basal metabolic rate."

4, 5

A woman diagnosed previously with gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply. 1.Denial of visual problems 2.Braxton Hicks contractions 3.Negative protein on dipstick of urine 4.Blood pressure (BP) 165/120 mm Hg 5.Complaints of headache for the last 12 hours

4, 5

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client? 1.Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2.Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 3.A cesarean section will be necessary if vaginal lesions are present at the time of labor. 4.Daily administration of acyclovir is necessary during the first trimester of the pregnancy.

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

A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription should the nurse anticipate for the client? 1.A 3-hour glucose tolerance test 2.A sliding-scale regular insulin dose 3.Administration of an oral hypoglycemic agent 4.Administration of NPH insulin on a daily basis

A 3-hour glucose tolerance test

When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors should the nurse consider significant? 1.A client who is primigravida with mild preeclampsia 2.A client who is primigravida that delivered a 10-pound baby 3 hours ago 3.A client who is gravida VI that delivered 10 hours ago and has lost 450 mL of blood 4.A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago

A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago

The perinatal client is admitted to the obstetrical 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? 1.A low-calorie diet to ensure the absence of weight gain 2.A diet that is high in fluids and fiber to decrease constipation 3.A diet that is low in fluids and fiber to decrease blood volume 4.Unlimited sodium intake to increase the circulating blood volume

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

The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection? 1.A 33-year-old gravida III 2.An adolescent with multiple heterosexual contacts 3.A multigravida with a history of repeat cesarean deliveries 4.A 25-year-old client with a history of spontaneous abortions

An adolescent with multiple heterosexual contacts

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 should be noted at which time interval? 1.Between 4 and 8 weeks' gestation 2.Between 6 and 10 weeks' gestation 3.Between 10 and 14 weeks' gestation 4.Between 16 and 20 weeks' gestation

Between 16 and 20 weeks' gestation

A licensed practical nurse (LPN) is assisting in the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop the contractions. The LPN checks to see that which is available on the unit as an antidote to magnesium sulfate? 1.Vitamin K 2.Magnesium oxide 3.Calcium gluconate 4.Aluminum hydroxide

Calcium gluconate

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 reason? 1.A full bladder 2.Emotional instability 3.Insufficient iron intake 4.Compression of the vena cava

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 which about the ductus venosus? 1.Connects the pulmonary artery to the aorta 2.Is an opening between the right and left atria 3.Connects the umbilical vein to the inferior vena cava 4.Connects the umbilical artery to the inferior vena cava

Connects the umbilical vein to the inferior vena cava

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority? 1.Dehydration 2.Inability to perform activities 3.Verbalizing fear about delivery 4.Expressing concern about appearance

Dehydration

The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion? 1.Emphasizing the need to eliminate snack foods 2.Encouraging the need to avoid eating at local fast-food restaurants 3.Encouraging the adolescents to eat when hungry rather than three times a day 4.Describing the appropriate amount of weight gain required during the pregnancy

Describing the appropriate amount of weight gain required during the pregnancy

The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take? 1.Document the assessment. 2.Notify the primary health care provider. 3.Have another nurse check the fetal heart rate. 4.Compare the mother's pulse rate with the fetal heart rate.

Document the assessment

The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate? 1.Document the temperature. 2.Notify the primary health care provider. 3.Retake the temperature in 30 minutes. 4.Inform the client that the temperature is elevated and antibiotics may be required.

Document the temperature

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? 1.Dorsiflex the client's foot while flexing the knee. 2.Plantarflex the client's foot while flexing the knee. 3.Dorsiflex the client's foot while extending the knee. 4.Plantarflex the client's foot while extending the knee.

Dorsiflex the client's foot while extending the knee.

The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse should instruct the client to consume which best food item to ensure an adequate source of calcium in the diet? 1.Cheese 2.Spinach 3.Dried fruits 4.Orange juice

Dried fruit

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure? 1.Eliminate between-meal snacks. 2.Drink decaffeinated coffee and tea. 3.Lie down for 30 minutes after eating. 4.Substitute salt in cooking for other spices.

Drink decaffeinated coffee and tea.

A client who is 6 months pregnant is attending her first prenatal visit. On the first prenatal visit, the nurse notes that the client is gravida 4, para 0, abortion 3. The client is 5 feet, 6 inches tall, weighs 130 pounds, and is 25 years old. She states, "I get really tired after working all day and can't keep up with my housework." Which factor in the above data should lead the nurse to suspect gestational diabetes? 1.Fatigue 2.Obesity 3.Fetal demise 4.Maternal age

Fetal demise

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing? 1.Quickening 2.Braxton Hicks contractions 3.Consistent increase in fundal height 4.Fetal heart rate of 180 beats per minute

Fetal heart rate of 180 beats per minute

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching? 1.Milk 2.Potatoes 3.Cantaloupe 4.Fresh spinach

Fresh spinach

The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the primary health care provider? 1.Fundal height, 38 cm 2.Weight gain, 3 pounds 3.Blood pressure, 118/70 mm Hg 4.Fetal heart tones, 144 beats/minute

Fundal height, 38 cm

A woman is 24 weeks pregnant. She had a previous stillborn neonate at 38 weeks' gestation and a pregnancy that ended at 34 weeks with the birth of a stillborn girl. She states she has a 4-year-old son and an 8-year-old daughter who live with her at home and were both born at 38 weeks. What is her gravidity and parity, using the five-digit system (GTPAL)? 1.G (4) T (3) P (0) A (0) L (2) 2.G (4) T (1) P (2) A (0) L (2) 3.G (5) T (3) P (1) A (0) L (2) 4.G (5) T (0) P (4) A (0) L (2)

G (5) T (0) P (4) A (0) L (2)

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? 1.Gravida I, para I 2.Gravida II, para I 3.Gravida II, para II 4 .Gravida III, para II

Gravida II, para I

The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet? 1.Rice 2.Cheese 3.Chicken 4.Green, leafy vegetables

Green, leafy vegetables

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice? 1.Hematocrit 37% 2.Glucose 86 mg/dL 3.Hemoglobin 9.1 g/dL 4.White blood cell count 12,400/mm3

Hemoglobin 9.1 g/dL

The nurse is reviewing the laboratory results of a pregnant client and notes that the hemoglobin level is decreased. Physiological dilutional anemia is documented in the client's record by the primary health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation? 1.Poor intake of iron-rich foods 2.Decreased maternal hemoglobin formation 3.Decreased metabolism of iron during pregnancy 4.Increased blood volume of the mother during pregnancy

Increased blood volume of the mother during pregnancy

The nurse is collecting data on a pregnant woman who is diagnosed with human immunodeficiency virus (HIV) during the thirty-second gestational week. The nurse reviews the data and determines that which finding requires further follow-up? 1.Active fetal movement 2.Weight gain of 22 pounds 3.Slight lower extremity edema 4.Increased shortness of breath and bilateral rales

Increased shortness of breath and bilateral rales

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 nursing action should the nurse take? 1.Contact the primary health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Instruct the client that these are common and may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

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

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 (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date? 1.July 12, 2020 2.July 27, 2020 3.August 12, 2020 4.August 27, 2020

July 27, 2020

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client? 1.Laser therapy 2.Use of cytotoxic agents 3.Treatment with interferon 4.All treatment should be avoided.

Laser Therapy

The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use? 1.Ask about contractions at each visit. 2.Provide a simple pamphlet with multiple illustrations. 3.Palpate for uterine contractions at the same time as the client. 4.Attach the monitor to the client's abdomen and have her palpate at the same time.

Palpate for uterine contractions at the same time as the client.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed? 1.Rapid clotting times 2.Pain and swelling of the calf of one leg 3.Laboratory values that indicate increased platelets 4.Petechiae, oozing from injection sites, and hematuria

Petechiae, oozing from injection sites, and hematuria

The 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 take which action? 1.Have the client stand for the procedure. 2.Assist the client from a sitting to a right lateral position. 3.Place the client in a prone position with the head of the bed elevated. 4.Place the client in a supine position and place a wedge under the right hip.

Place the client in a supine position and place a wedge under the right hip.

A pregnant woman who is at 38 weeks' gestation 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, what does the nurse determine the client may be experiencing? 1.Placenta previa 2.Abruptio placentae 3.Rupture of the amniotic sac 4.The passage of the mucous plug

Placenta Previa

The nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client? 1.Potential for infection 2.Inability to tolerate activity 3.Inability to maintain adequate nutritional intake 4.Inability to perform hygiene measures independently

Potential for infection

The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy? 1.Iron supplements should be taken throughout pregnancy. 2.Calcium intake should be increased for the duration of the pregnancy. 3.Pregnancy greatly increases the risk of malnourishment for the mother. 4.The maternal diet significantly influences fetal growth and development.

Pregnancy greatly increases the risk of malnourishment for the mother.

The 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. According to the nurse, what is the purpose of progesterone? 1.Progesterone maintains the uterine lining for implantation. 2.Progesterone stimulates metabolism of glucose and converts the glucose to fat. 3.Progesterone prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 4.Progesterone stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

Progesterone maintains the uterine lining for implantation.

The nurse assists a pregnant client with cardiac disease in identifying 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 accomplish which tasks? 1.Help the mother prepare for labor and delivery. 2.Reduce excessive maternal stress and fatigue. 3.Avoid exposure to potential pathogens and resulting infections. 4.Prepare the 18-month-old child for maternal separation during hospitalization.

Reduce excessive maternal stress and fatigue.

A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid and rifampin. The nurse plans to implement which intervention? 1.Reviewing daily nutritional intake with the client 2.Reinforcing that infants are usually not susceptible to TB infection 3.Informing the client that follow-up care after delivery will not be needed 4.Encouraging the client to stop taking medications during the last trimester of pregnancy

Reviewing daily nutritional intake with the client

The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority? 1.Signs of fetal distress 2.Availability of support systems 3.Compliance with activity limitations 4.Client's understanding of her condition

Signs of fetal distress

A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise? 1.Swimming 2.Scuba diving 3.Low-weight gymnastics 4.Bicycling with the legs in the air

Swimming

A pregnant client is a gravida III, para 0, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband, knowing that which instruction will assist in promoting family adaptation? 1.Teaching the husband to administer and titrate tocolytic agents 2.Teaching the husband to instruct the wife how to perform Kegel exercises 3.Telling the husband that sexual intercourse has probably caused the preterm labor 4.Teaching the husband to perform passive range of motion and provide back rubs for his wife

Teaching the husband to perform passive range of motion and provide back rubs for his wife

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern? 1.Urinary output has increased. 2.There is no evidence of proteinuria. 3.The client complains of a headache and blurred vision. 4.The blood pressure reading has returned to the prenatal baseline.

The client complains of a headache and blurred vision.

The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client? 1.The client exhibits no signs of fetal distress. 2.The client expresses an understanding of her condition. 3.The client identifies and uses available support systems. 4.The client demonstrates compliance with activity limitations.

The client exhibits no signs of fetal distress.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching? 1.The client is wearing pantyhose. 2.The client is wearing nonslip shoes. 3.The client is wearing knee-high hose. 4.The client is wearing shoes with arch supports.

The client is wearing knee-high hose.

The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate? 1.The client will no longer have leg pain. 2.The client will verbalize a reduction of pain. 3.The client will report that an infection is likely to occur. 4.The client will be able to identify measures to prevent infection.

The client will be able to identify measures to prevent infection.

The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan? 1.Calcium is not important until the third trimester. 2.All mothers are at high risk for nutritional deficiencies. 3.Iron supplements are not necessary unless the mother has iron deficiency anemia. 4.The nutritional status of the mother significantly influences fetal growth and development.

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

A blood glucose screening measurement is going to be performed on a pregnant client. Which instructions should the nurse give to the client before this test? 1.Limit activity before the test. 2.Maintain your normal diet before the test. 3.There is no restriction for caffeine before the test. 4.A normal breakfast should be eaten before the test.

There is no restriction for caffeine before the test.

A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information? 1.Effects of diabetes on the pregnancy and fetus 2.Nutritional requirements for pregnancy and diabetic control 3.To avoid exercise because of the negative effects on insulin production 4.To be aware of any infections and report signs of infection immediately to the primary health care provider

To avoid exercise because of the negative effects on insulin production

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? 1.Week 5 2.Week 6 3.Week 7 4.Week 8

Week 5

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make? 1.The organ of copulation 2.Where the fetus develops 3.Where fertilization occurs 4.The organ that secretes estrogen and progesterone

Where fertilization occurs

A client who is pregnant will be treated by a dermatologist for acne. Which statement if made by the client indicates a need for further teaching? 1."I will continue to perform exfoliation treatments." 2."I will use my antibacterial soap at least one time daily." 3."I will apply topical erythromycin to my face as previously recommended." 4."I will continue to take the prescribed oral tetracycline hydrochloride on a daily basis."

"I will continue to take the prescribed oral tetracycline hydrochloride on a daily basis."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? 1."It is the fetal movement that is felt by the mother." 2."It is the compressibility of the lower uterine segment." 3."It is the irregular, painless contractions that occur throughout pregnancy." 4."It is the soft blowing sound that can be heard when the uterus is auscultated."

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

A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate? 1."Tell me what concerns you have." 2."Don't worry. Everything will be fine." 3."Why don't you want to have this test done?" 4."The primary health care provider has scheduled this test for a reason."

"Tell me what concerns you have."

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery? 1."A newborn cannot contract HIV during delivery." 2."There is no risk to the newborn of an HIV-infected mother during delivery." 3."Newborns who contract HIV during delivery will show immediate symptoms." 4."There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

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

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 is appropriate? 1."You should avoid all school-age children during pregnancy." 2."There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3."Be sure to tell the doctor on your next prenatal visit, but there is little risk in the second trimester." 4."You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."

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

A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a primary health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur at this time. Which statement is true? 1."You will only use insulin per sliding scale." 2."Your normal insulin dosage will have to be decreased." 3."Your NPH insulin dosage before supper will need to be increased." 4."You will not have to increase your normal insulin dosage at this time."

"Your normal insulin dosage will have to be decreased."

A client presents at her primary health care provider's office 10 weeks pregnant with her first pregnancy. Which are presumptive signs of pregnancy that the client might be expected to have? Select all that apply. 1.Fatigue 2.Breast changes 3.Chadwick's sign 4.Nausea and vomiting 5.Pigmentation changes of the face 6.A bluish discoloration of the vagina and cervix

1, 2, 4

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply. 1.Urinalysis 2.Rubella titer 3.Blood glucose 4.Complete blood count 5.Serum alpha-fetoprotein

1, 2, 4

The nurse is explaining physiological changes of pregnancy that are related to melanocyte-stimulating hormone (melanotropin). Which pregnancy changes are related to the effects of this hormone? Select all that apply. 1.Chloasma 2.Linea nigra 3.Hegar's sign 4.Darkening of areola 5.Positive pregnancy test

1, 2, 4

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply. 1.Shallow depth 2.Wide suprapubic arch 3.Deep, curved sacral area 4.Compatible with vaginal delivery 5.Flattened anteroposteriorly and wide transversel

1, 2, 4, 5

The nurse working in a prenatal clinic receives a telephone call from a client at 22 weeks of gestation. The client reports some vaginal discharge and has started to experience menstrual-like cramps and diarrhea. Which responses by the nurse indicate an understanding of the implications of the client's signs/symptoms? Select all that apply. 1."Lie on your left side for an hour and try to drink some fluids." 2."It is important that you urinate frequently to keep your bladder empty." 3."This is probably an emergency. Have someone drive you to a hospital now." 4."Palpate for contractions and call back if there are more than four contractions in the next hour." 5."Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"

1, 2, 4, 5

The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply. 1."Fertilization occurs in the outer third of the fallopian tube." 2."Only 1 sperm will penetrate the ovum to produce fertilization." 3."The pre-embryonic period is defined as the first 8 weeks of gestation." 4."Implantation occurs in the anterior or posterior fundal region of the uterus." 5."The ovary produces hormones to maintain the pregnancy before placental development."

1, 2, 4, 5

A 26-year-old woman comes to the clinic and asks for a pregnancy test because she thinks she might be pregnant. The nurse assesses for which presumptive signs of pregnancy? Select all that apply. 1.Breast tenderness 2.Early morning nausea 3.Positive urine pregnancy test 4.Fetal heartbeat heard by Doppler 5.No menstruation for the las

1, 2, 5

The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to potential problems specifically related to the twin pregnancy? Select all that apply. 1.Hypertension 2.Elevated blood glucose levels 3.Uterine size is large for gestational age 4.Six or more uterine contractions per hour 5.Mother is confirmed as blood type Rh negative

1, 4

A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply. 1.Clear fluid 2.Negative fern test 3.Foul odor of the amniotic fluid 4.White flecks in the amniotic fluid 5.Presence of glucose and protein in the amniotic fluid

1, 4, 5

A client who is in the second trimester of pregnancy develops melasma during pregnancy. Which statements made by the client indicates an understanding of this condition? Select all that apply. 1."Melasma may reoccur in a subsequent pregnancy. 2."My stretch marks will turn less noticeable after I have the baby." 3."This dark line down my abdomen will fade at the end of my pregnancy." 4."These brown, splotchy patches will most likely disappear after I deliver my baby." 5."The dark patches that are on my nose, cheeks and forehead will most likely darken until the baby is delivered."

1, 4, 5

The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms are noted in severe preeclampsia? Select all that apply. 1.Oliguria 2.Seizures 3.Contractions 4.Proteinuria 3+ 5.Muscle cramps 6.Blood pressure 168/116 mm Hg

1, 4, 6

The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply. 1.Low-birth-weight baby 2.Urinary tract infections 3.Increased chance of cesarean birth 4.Delayed lung maturation in the neonate 5.Pregnancy that lasts longer than 42 weeks

2, 3, 4

A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which should the nurse include in the instructions? Select all that apply. 1.Avoid milk. 2.Eat a low-fat diet. 3.Stop or decrease smoking. 4.Eat smaller, more frequent meals. 5.Consume adequate fluid between meals.

2, 3, 4, 5

The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply. 1.Hypotension 2.Vaginal bleeding 3.Excessive vomiting 4.No fetal heart activity 5.Larger than normal uterine size 6.Elevated levels of human chorionic gonadotropin (hCG)

2, 3, 4, 5, 6

The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to this group? Select all that apply. 1.A hemoglobin count that falls to 13 g/dL indicates anemia. 2.The number of red blood cells will be increased during pregnancy. 3.At term, the heart rate has increased by 15 to 20 beats per minute. 4.A reduction in coagulation factors protects against thrombus formation. 5.The white blood cell count will slowly decrease over the course of the pregnancy. 6.In a supine position, some degree of compression of the vena cava will occur.

2, 3, 6

The 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 response made by the student indicates an understanding of the function of this hormone? Select all that apply. 1."It is the primary hormone of milk production." 2."It maintains the uterine lining for implantation." 3."It softens the muscles and joints of the pelvis." 4."It relaxes all smooth muscle, including the uterus." 5."It increases during pregnancy to stimulate the basal metabolic rate."

2, 4

The primary health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply. 1.Vaginal mucosa thins. 2.Vaginal secretions increase. 3.Vaginal pH becomes more alkaline. 4.Bluish discoloration of the vagina. 5.Higher levels of glycogen in vaginal secretions.

2, 4, 5

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply. 1.Completely shutting off circulation to fetal lung tissue 2.Bypassing the fetal lungs to circulate oxygen rich blood 3.Using the fetal lungs and liver to promote gas exchange 4.Using the fetus's beating heart to pump blood in the circulatory system 5.Carrying more oxygen on fetal hemoglobin than maternal hemoglobin 6.Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

2, 4, 5, 6

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply. 1.Oval shaped 2.Heart shaped 3.Straight sidewalls 4.Convergent sidewalls 5.Wide suprapubic arch 6.Narrow interspinous diameter

2, 4, 6

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply. 1."Surfactant is manufactured by the fetal adrenal glands." 2."Surfactant is necessary to enhance clotting in the newborn." 3."Surfactant, which is needed for lung expansion, is present beginning at 28 weeks." 4."With decreased surfactant, more pressure must be generated to produce inspiration." 5."Surfactant lowers surface tension, reducing the pressure required to keep the alveoli expanded."

3, 4, 5

The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. Which assessment findings are most likely present at this time? Select all that apply. 1.Blood pressure peaks at 140/90. 2.The fundus is located at the umbilicus. 3.Fetal heart tones can be heard by Doppler. 4.Braxton Hicks contractions may be felt by the mother. 5.The fundus is located midway between the symphysis pubis and the umbilicus.

3, 4, 5

The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply. 1.Decreases salivation 2.Decreases skin pigmentation 3.Increases blood flow to the uterine vessels 4.Stimulates development of the breast ducts 5.Causes vascular changes in the mucous membranes of the nose and mouth

3, 4, 5

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 change that occurs with pregnancy? 1.A softening of the cervix 2.The presence of fetal movement 3.The presence of human chorionic gonadotropin in the urine 4.A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

A softening of the cervix

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor? 1.A urinary tract infection 2.A single-fetus pregnancy 3.A 26-year-old primigravida 4.A hemoglobin of 13.5 g/dL

A urinary tract infection

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? 1.Soft uterus 2.Abdominal pain 3.Nontender uterus 4.Painless vaginal bleeding

Abdominal pain

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed? 1.Repeating hepatitis screen 2.Retesting the mother in 1 week 3.Administration of antibiotics during pregnancy 4.Administration of immune globulin and vaccine in the infant soon after birth

Administration of immune globulin and vaccine in the infant soon after birth

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which should the nurse specifically monitor? 1.Apical heart rate 2.Degree of edema 3.Deep tendon reflexes 4.Presence of pitting peripheral edema

Deep tendon reflexes

The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client? 1.Expect the baby to move at least 35 times in 3 hours. 2.Lie on the stomach when preparing to count the fetal movement. 3.Schedule the counting periods in the morning when the fetal movement is highest. 4.Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours.

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

In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections? 1.Use specific closed-ended questions. 2.Omit this area of questions because they are highly personal. 3.Establish a therapeutic relationship between the nurse and pregnant client. 4.Apologize for the embarrassment that these questions may cause the client.

Establish a therapeutic relationship between the nurse and pregnant client

A client calls the primary 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 in the urine? 1.Estrogen 2.Progesterone 3.Follicle-stimulating hormone 4.Human chorionic gonadotropin (hCG)

Human chorionic gonadotropin (hCG)

During a prenatal visit of a client diagnosed with placenta previa, the primary health care provider defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk? 1.Initiating premature labor 2.Initiating severe hemorrhage 3.Causing rupture of the fetal membranes 4.Increasing the chance of uterine infection

Initiating severe hemorrhage

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 nursing action should be appropriate? 1.Contact the primary health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Instruct the client that these are common and may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

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

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? 1.Lie on the left side with the feet dorsiflexed. 2.Soak the feet in hot water after performing 10 pelvic tilt exercises. 3.Lie on the right side with the feet elevated on a pillow and a heating pad on the back. 4.Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

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

The nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as an effective teaching method? 1.Describe the process verbally in great detail. 2.Palpate for uterine contractions at the same time as the client. 3.Provide a pamphlet with both multiple pictures and drawings. 4.Place a monitor on the client's abdomen, and use it as a visual.

Palpate for uterine contractions at the same time as the client.

The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which? 1.Placing external fetal monitors so that each fetal heart rate is monitored separately 2.Placing the external fetal monitor over the fetus that is most anterior to the mother's abdomen 3.Placing the external fetal monitor over the fetus that is most posterior to the mother's abdomen 4.Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus

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

The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy? 1.She has a history of chronic hypertension. 2.She is 5 feet, 2 inches tall and weighs 175 pounds. 3.There is a family history of type 1 diabetes mellitus. 4.Her previous two babies were delivered by cesarean section.

She has a history of chronic hypertension.

The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects the client will indicate that which medication is prescribed? 1.Oral intake of 15 mg of warfarin daily 2.Subcutaneous administration of terbutaline 3.Intravenous infusion of heparin sodium 5000 units daily 4.Subcutaneous administration of heparin sodium 5000 units daily

Subcutaneous administration of heparin sodium 5000 units daily

Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care? 1.Tell the dental office staff that she is pregnant. 2.Avoid the use of local anesthetics during dental work. 3.Use toothpaste with baking soda to decrease plaque buildup. 4.Expect to lose at least one tooth because of calcium and phosphorus leaving the teeth to nourish the fetus.

Tell the dental office staff that she is pregnant.

A client in the prenatal clinic presents with a blood pressure reading of 140/90 mm Hg, which is an elevation from last month's reading of 114/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia? 1.Headaches 2.Generalized edema 3.Weight gain of 10 pounds 4.Trace amount of protein

Trace amount of protein

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic should be a part of the teaching plan for this class? 1.Use of over-the-counter medications 2.Fetotoxic substances in the workplace 3.Effects of secondary cigarette smoke on the fetus 4.Travel precautions and use of shoulder seat belts

Travel precautions and use of shoulder seat belts