NCLEX Review: NUR 245 Unit 5

The physician orders an ultrasound for a prenatal client prior to an amniocentesis. The nurse explains to the client that the purpose of the ultrasound is to: 1) Locate the placenta. 2) Measure the fetus's crown-rump length. 3) Determine the gestational sac volume. 4) Measure the fetus's biparietal diamet

1) The purpose of the ultrasound before an amniocentesis is to locate the placenta, fetus, and an adequate pocket of fluid. Determination of the gestational sac volume, measuring the crown-rump length, and measuring the biparietal diameter are aspects of assessing fetal well-being (biophysical profile, or BPP), and may or may not be done prior to the amniocentesis, depending on gestational age.

Your client in her fourth month of her pregnancy is suspected to have an incompetent cervix. Which diagnostic measures might the nurse expect to be ordered to confirm the diagnosis? (Select all that apply.) 1) Determining a history of second-trimester abortions 2) Serial pelvic examinations 3) Serial ultrasounds 4) Determining a history of drug abuse

1, 2, 3

A prenatal client at 30 weeks gestation is scheduled for a nonstress test (NST) and asks the nurse, "What is this test for?" The nurse correctly responds that the test is used to determine: (Select all that apply.) 1) Fetal well-being 2) Fetal lung maturity 3) Adequate fetal oxygenation 4) Accelerations of fetal heart rate

1, 3, 4 An NST documents fetal well-being by measuring fetal oxygenation and fetal heart rate accelerations, but not fetal lung maturity.

The nurse is teaching a prenatal client about chorionic villus sampling (CVS). The nurse correctly teaches the client that the risks associated with CVS include: (Select all that apply.) 1) Maternal hypertension 2) Rupture of membranes 3) Intrauterine infection 4) Spontaneous abortion

2. 3. 4.

A prenatal nurse is assessing a client at 34 weeks gestation who complains of watery vaginal discharge. What should be the nurse's initial action? 1) Test the urine for bacteria. 2) Prepare for a nonstress test. 3) Test the fluid with nitrazine paper. 4) Obtain vaginal cultures for STIs.

3) Testing the fluid with nitrazine paper would be the nurse's initial action, not preparing for a nonstress test or testing the urine for bacteria. Obtaining vaginal cultures for STIs is performed if further evaluation of the client is required.

A prenatal client in her second trimester is admitted to the maternity unit with painless, bright red vaginal bleeding. What test might the physician order? 1) Contraction stress test (CST) 2) Alpha-fetoprotein (AFP) 3) Amniocentesis 4) Ultrasound

4) An ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding. Alpha-fetoprotein (AFP) is a test used to screen for neural tube defects. A contraction stress test is ordered in the third trimester to evaluate the respiratory function of the placenta. Amniocentesis is a procedure used for genetic diagnosis or, in later pregnancy, for lung maturity studies.

A prenatal client at 30 weeks gestation is scheduled for an amniocentesis to determine fetal lung maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be: 1) 2:1 2) 3:1 3) 0.5:1 4) 1:1

4) After 35 wk, it's 2:1. Prior to 30, it's about 0.5:1. Around 30, it's 1:1.

A prenatal client at 16 weeks gestation presents to the clinic with unexplained, bright red bleeding, cramping, and backache for the past two days. A pelvic exam reveals a closed cervix. What type of abortion does this indicate? 1) Imminent 2) Incomplete 3) Missed 4) Threatened

4) A threatened abortion (miscarriage) has symptoms of vaginal bleeding and backache without cervical dilation. In an imminent abortion, the internal cervical os is dilated. Although the cervix is closed in a missed abortion, other symptoms would include a regression in breast changes and a brownish vaginal discharge. Diagnosis is made based on history, pelvic exam, and a negative pregnancy test. With an incomplete abortion, the embryo has passed out of the uterus, but the placenta remains, and the internal os is slightly dilated.

A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. What would be an appropriate nursing action to prepare this client for the procedure? 1) Encourage the client to take fluids. 2) Position the client in a left lateral tilt. 3) Administer Rh immune globulin to the client. 4) Cleanse the client's abdominal skin with alcohol.

2) An appropriate nursing action to prepare this client for amniocentesis would be to position the client in a left lateral tilt to prevent supine hypotension. The skin is cleansed with povidone-iodine (Betadine), not alcohol. Rh immune globulin is appropriate only for nonsensitized Rh-negative women after the procedure. Encouraging the client to take fluids is not appropriate prior to the procedure, because the client may become nauseous.

The nurse is caring for a laboring client with sickle cell anemia. Which therapy should the nurse anticipate the physician ordering? 1) Diuretics 2) Magnesium sulfate 3) Oxygen 4) Bronchodilators

3) Oxygen supplementation is an anticipated therapy for patients with sickle cell anemia, to reduce the risk of their red blood cells sickling in the presence of decreased oxygen. Diuretics, magnesium sulfate, and bronchodilators are not anticipated for patients with sickle cell anemia.

The nurse is providing prenatal care to an asymptomatic HIV-infected client. Which nursing intervention should take priority? 1) Assessing reflexes 2) Performing a vision test 3) Taking her temperature 4) Performing a hearing test

3) Taking her temperature to monitor for signs of fever is the nursing intervention that should take priority in an asymptomatic HIV-infected prenatal patient. The client should have a visual examination each trimester to detect complications. Performing a hearing test and assessing reflexes are not priority interventions

A prenatal client is receiving home care for severe hyperemesis gravidarum. If the client does not respond to standard treatment, the nurse will anticipate adding which of the following therapies on an outpatient basis? 1) Complex carbohydrates with limited liquids 2) Low-fat soft diet 3) IV fluids 4) Total parenteral nutrition

3) Intravenous fluids may be ordered on an outpatient basis. Total parenteral nutrition would be started only if the client is unresponsive to IV hydration. Low-fat soft diet and complex carbohydrates with limited liquids are progressive diets after the client is stabilized for hyperemesis gravidarum.

A client at 28 weeks gestation is admitted to the labor and birth unit. Which test might be used to assess the client's fetal status? 1) Amniocentesis 2) Contraction stress test (CST) 3) Ultrasound for physical structure 4) Biophysical profile (BPP)

4) Biophysical profile would be used to assess the client's fetal status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well-being. Contraction stress test is appropriate in the third trimester. Amniocentesis tests for lung maturity, not overall status.

The nurse is reviewing the lab tests of four prenatal clients. Which lab finding would support the diagnosis of hyperemesis gravidarum? 1) Hyperkalemia 2) Hypocalcemia 3) Hypercalcemia 4) Hypokalemia

4) Potassium loss (hypokalemia), not hyperkalemia, is characteristic of hyperemesis gravidarum. Neither hypercalcemia nor hypocalcemia (low calcium) is characteristic of hyperemesis gravidarum.

The client asks for information about ectopic pregnancy. The nurse correctly responds by saying ectopic pregnancy is caused by: (Select all that apply.) 1) Pelvic inflammatory disease (PID) 2) Presence of an IUD 3) Endometriosis 4) In utero exposure to diethylstilbestrol (DES)

1, 2, 3, 4 All of these can cause an ectopic pregnancy. Think female reproductive associated stuff. Also tubal surgery and previous ectopic pregnancies.

A client with Type I diabetes is admitted to the labor and birthing unit. What nursing action should the nurse perform first? 1) Obtain a CBC. 2) Assess blood sugar level. 3) Check urine for protein. 4) Obtain prenatal record.

2)

The nurse is counseling a prenatal client regarding the need to take folic acid supplements during pregnancy. The nurse also encourages the client to eat foods high in folic acid, such as: 1) Fruits and fruit juice. 2) Fresh green leafy vegetables and legumes. 3) Rice and pasta. 4) Eggs and yogurt.

2)

The nurse is completing a history for a new client in the prenatal clinic. The client states that she has had a successfully repaired ventricular septal defect with no further problems. The nurse anticipates what to order for this client? 1) cardiac consult 2) prophylactic antibiotics 3) strict bed rest with diuretics 4) home oxygen therapy

2) For a woman who has history of a congenital heart defect and is asymptomatic for that defect, antibiotic prophylaxis is recommended to prevent subacute bacterial endocarditis. A cardiac consult is not required unless there is remaining evidence of organic heart disease. Diuretics, strict bed rest, and anticoagulants are a few of the treatments often needed to support a woman with peripartum cardiomyopathy.

A client who has admitted to heavy alcohol use throughout her pregnancy just delivered a 6-pound baby. Which sign or symptom in the mother should the nurse anticipate in the 12-to-48-hour postpartum period? 1) Hypotension 2) Bradycardia 3) Seizures 4) Fever

3) As a result of alcohol dependence, the woman may have withdrawal seizures as early as 12 to 48 hours after she stops drinking. Hypertension and tachycardia are more likely to be experienced postpartum in the alcoholic mother. Fever is not expected.

The nurse is preparing a prenatal client for a transvaginal ultrasound. What nursing action should be included in the preparations? 1) Apply transmission gel over the client's abdomen. 2) Advise the client not to empty her bladder. 3) Encourage the client to drink 1.5 quarts of fluid. 4) Place client in lithotomy position.

4) After having the client void, assist her to a lithotomy position for a transvaginal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client's abdomen.

The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)? 1) A client with multiple gestation. 2) A client with an incompetent cervix. 3) A client with placenta previa. 4) A client with intrauterine growth retardation.

4) A contraction stress test (CST) is indicated for a client with intrauterine growth retardation (IUGR), because it will assess the respiratory function of the placenta, which may be adversely affected by the conditions causing IUGR. The contraction stress test is contraindicated for the client with multiple gestation, an incompetent cervix, or placenta previa.

A client in her third trimester has come to the clinic for her first prenatal visit. She asks the nurse whether ultrasound can determine the baby's age. What statement by the nurse would be the best response? 1) "The estimate of gestational age may vary by one to three weeks." 2) "The accuracy of ultrasound is the same in the first and third trimesters." 3) "The ultrasound measures gender, not age." 4) "A comprehensive ultrasound is needed for accuracy."

1) The ability to establish fetal age accurately by ultrasound is lost in the third trimester because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound can be used to approximate gestational age within one to three weeks' accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.

A postpartum client who admits to heavy alcohol use asks the nurse about breast-feeding her baby. The nurse correctly teaches this client that excessive alcohol consumption while breast-feeding may: 1) Decrease the maternal milk letdown reflex. 2) Cause mental retardation in the newborn. 3) Cause seizure disorders in the newborn. 4) Increase the maternal letdown reflex.

1) Excessive alcohol consumption while breast-feeding may decrease, not increase, the maternal milk ejection reflex. Fetuses exposed to heroin in utero may experience seizure disorders as newborns. Mental retardation in the newborn may result from alcohol exposure in utero, not through consumption of breast milk.

A prenatal client with diabetes asks the nurse about pregnancy-related complications for her baby from diabetes. For what is the baby at risk when the mother has diabetes? (Select all that apply.) 1) Respiratory distress syndrome 2) Sacral agenesis 3) Hyperactivity 4) Macrosomia

1, 2, 4

The nurse is caring for a laboring client with Type I diabetes. What signs and symptoms would the nurse assess if hypoglycemia was suspected? 1) Headache and anorexia 2) Diaphoresis and disorientation 3) Frequent urination and headache 4) Dry skin and blurred vision

2) Hypoglycemia manifests itself during labor in a Type I diabetic with diaphoresis and disorientation. There is usually hunger and decreased urination, with headache and clammy skin with blurred vision.

The nurse is teaching a client with diabetes about insulin requirements during pregnancy. Which statement is true regarding insulin requirements? 1) Insulin needs decrease late in the third trimester. 2) Insulin needs increase late in the first trimester. 3) Insulin needs increase early in the first trimester. 4) Insulin needs decrease early in the third trimester.

2) Insulin needs increase late in the first trimester and in the third trimester. Insulin needs decrease early in the first trimester.

A client at 30 weeks gestation is admitted to the maternity unit with vaginal bleeding. What should be the nurse's initial action? 1) Start an intravenous infusion drip. 2) Assess blood pressure and pulse. 3) Count and weigh peripads. 4) Observe for pallor, clammy skin, and perspiration.

2) The nurse's initial action for a client with vaginal bleeding at 30 weeks would be to assess blood pressure and pulse. Counting and weighing peripads, observing for pallor, clammy skin, and perspiration, and starting an intravenous infusion drip are all important actions for this client; they are just not the initial action.

A client presents to the physician's office with complaints of right-sided abdominal pain, dizziness, and vaginal bleeding. A pelvic exam determines the client to be 10 weeks gestation with adnexal tenderness. What diagnosis should the nurse suspect? 1) Appendicitis 2) Cholelithiasis 3) Ectopic pregnancy 4) Threatened abortion

3) A client with an ectopic pregnancy would present to the physician's office with complaints of one-sided abdominal pain, dizziness, and vaginal bleeding, and will have adnexal tenderness on exam. Clients with a threatened abortion would have complaints of unexplained bleeding, cramping, or backache. A pelvic exam would reveal a closed cervix. Clients with appendicitis would have complaints of lower right-sided tenderness, low-grade fever, nausea, and often vomiting. Clients with cholelithiasis would have complaints of epigastric distress, such as fullness, distention, with vague pain in the right upper quadrant of the abdomen. CLUES: RIGHT sided abdominal pain, dizziness, vaginal bleeding.

A client at 36 weeks gestation is admitted to the labor and birth unit. Her chief complaint is abdominal cramping with a sudden gush of clear fluid. What is the priority nursing diagnosis for this prenatal client? 1) Knowledge deficit related to unfamiliarity with loss of vaginal fluids. 2) Risk for ineffective coping related to unknown outcome of pregnancy. 3) Impaired physical mobility related to strict bed rest. 4) Risk for infection related to premature rupture of membranes.

4) The priority nursing diagnosis for this prenatal client is risk for infection related to premature rupture of membranes. Secondary diagnoses are risk for ineffective coping related to unknown outcome of pregnancy, knowledge deficit related to unfamiliarity with loss of vaginal fluids, and impaired physical mobility related to strict bed rest.

A client at 15 weeks gestation presents to the prenatal clinic with "prune juice"-like vaginal bleeding. Other assessment data include a hematocrit of 10 and complaints of severe nausea and vomiting. What diagnosis should the nurse suspect? 1) Abruptio placentae 2) Prolapsed cord 3) Placenta previa 4) Hydatidiform mole

4) A client with a hydatidiform mole at 15 weeks gestation presents at the prenatal clinic with "prune juice"-like vaginal bleeding, anemia, and complaints of severe nausea and vomiting. Placenta previa symptoms include painless bright red vaginal bleeding, usually in the third trimester of pregnancy. Prolapsed cord symptoms include a trickle of bright red vaginal blood and possibly a visible cord at the vaginal opening. Abruptio placentae symptoms include vaginal bleeding (bright red or dark red), abdominal pain, and uterine tenderness.