NCLEX CH_14

1. A client in the prenatal clinic complains of nausea and vomiting. Which intervention should the nurse suggest? a. Eat dry crackers or toast before arising in the morning. b. Consume liquids with meals. c. Eat foods high in fiber. d. Brush teeth right after eating.

ANS: A 1. Eat dry crackers or toast before arising in the morning. Rationale: Eating dry crackers or toast before arising in the morning is a good intervention for a client complaining of prenatal nausea. Foods high in fiber help with constipation problems, not with nausea. Brushing teeth after meals can trigger vomiting. Consuming liquids with meals can cause over-distention of the stomach.

2. A second-trimester client in the prenatal clinic complains of ankle edema. Which intervention should the nurse suggest? a. Elevate legs when sitting. b. Stretching exercises before bedtime. c. Practice plantar flexion when standing. d. Wear ankle socks daily.

ANS: A 2. Elevate legs when sitting. Rationale: Elevating the legs when sitting will assist circulation and therefore reduce edema. Dorsiflexion and avoiding any restrictive bands around the ankles are appropriate to prevent ankle edema. Stretching exercises before bedtime help relieve leg cramps.

5. A pregnant client complains of severe heartburn. The nurse suggests which of the following relief measures for heartburn? a. Avoid fried and highly spiced foods. b. Lie down for half an hour after eating. c. Take a teaspoon of sodium bicarbonate in water after meals. d. Eat three well-spaced meals each day.

ANS: A 5. Avoid fried and highly spiced foods. Rationale: Remedies for heartburn include eating small and more frequent meals; avoiding fried and highly spiced foods; and remaining upright for at least an hour after meals. Use of low-sodium antacids also may be suggested. The use of sodium bicarbonate should be discouraged.

8. A nurse is teaching a group of prenatal clients about hazards in the workplace during pregnancy. The nurse correctly teaches that pregnant women who have jobs requiring long periods of standing have higher incidences of: a. Preterm birth. b. Placenta previa. c. Prolapsed cord. d. Abruptio placentae.

ANS: A 8. Preterm birth. Rationale: Preterm birth is an occupational hazard for women who work standing up for prolonged periods, as there is more uterine stimulation while standing than while sitting or lying down. Prolapsed cord, placenta previa, and abruptio placentae are not related to prolonged standing.

9. A nurse is teaching a group of prenatal clients about the importance of exercise during pregnancy. Which client would be the best candidate to continue with her exercise regime? a. A client with placenta previa. b. A client with a diagnosis of diabetes. c. A client with a diagnosis of pre-eclampsia. d. A client with an incompetent cervix and cerclage.

ANS: B 9. A client with a diagnosis of diabetes. Rationale: Exercise would be therapeutic in helping a client with a diagnosis of diabetes to control her glucose utilization. However, it would be contraindicated in a client with an incompetent cervix and cerclage, a client with a diagnosis of pre-eclampsia, or a client with placenta previa.

4. A prenatal client in the third trimester of pregnancy is diagnosed with varicosities in the vulva and perineum. Which self-care strategy should the nurse teach? a. Change shoes several times throughout the day. b. Elevate legs and feet while sitting or lying down. c. Elevate legs level with hips while sitting or lying down. d. Use supportive hose in the afternoon and evening.

ANS: B 4. Elevate legs level with hips while sitting or lying down. Rationale: The hips, as well as the feet and legs, must be elevated to promote venous drainage into the trunk. Supportive hose need to be applied in the morning, rather than starting in the afternoon or evening. Changing shoes might help with back pain but not with varicosities.

10. The pregnant woman who is over the age of 35 years has risks related to pregnancy outcome. Which statement about increased risk in this age group is true? a. Fetal death is significantly lower in women 35 years and older. b. Chronic health problems are less likely to occur in women 35 years and older. c. Amniocentesis is recommended for all women 35 years and older. d. The cesarean section rate is decreased in women 35 years of age or older.

ANS: C 10. Amniocentesis is recommended for all women 35 years and older. Rationale: Amniocentesis is recommended for all women over age 35 to provide early detection of chromosomal abnormalities, including Down syndrome. The cesarean section rate is increased, chronic medical conditions are more frequent, and the risk of fetal death is significantly higher for women over 35 years of age.

3. A prenatal client at 10 weeks' gestation is complaining of urinary frequency. Which self-care strategy should the nurse teach? a. Empty bladder every 4 hours. b. Decrease the amount of fluid intake. c. Empty the bladder when the urge is felt. d. Empty bladder every hour.

ANS: C 3. Empty the bladder when the urge is felt. Rationale: Fluid intake should be maintained at 2,000 mL, not decreased. The bladder should be emptied every 2 hours, not every hour (too frequent) or every 4 hours (not frequent enough). The bladder should be emptied when the urge is felt, not delayed.

7. A client at 38 weeks' gestation tells the nurse, "I had white liquid leaking out of my nipples while warm water was running over my breasts in the shower last night." The nurse explains that: a. "You have a galactoma, and will require a brain scan." b. "You will need to pump your breasts because your milk has come in early." c. "The liquid was colostrum, just removed with warm water." d. "I will need to culture the liquid because it might indicate mastitis."

ANS: C 7. "The liquid was colostrum, just removed with warm water." Rationale: Leakage of colostrum in the third trimester is expected. Leakage of colostrum is not a sign of mastitis, a galactoma, or early milk production.

6. The nurse is teaching a group of prenatal clients about care of the breasts during pregnancy. Which self-care measure might be effective for women with inverted nipples? a. A bra with wide straps. b. A bra with tucks that allow expansion for breast tissue. c. Breast shields. d. A bra that supports the nipple between shoulder and elbow.

ANS: C Rationale: Breast shields designed to correct inverted nipples are effective for some women, but others gain no benefit from them. A well-fitting supportive bra that: (1) has wide, non-stretch straps; (2) has tucks that allow for expansion of breast tissue; and (3) supports the nipple line between the elbow and shoulder will not remedy inverted nipples, but will provide excellent support.