Saunders: Prenatal Period and Risk Conditions

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

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

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. A. Ballottement B. Chadwick's sign C. Uterine enlargement D. Braxton Hicks contractions E. Outline of fetus via radiography or ultrasound F. Fetal heart rate detected by a non-electronic device

A, B, C, D

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

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

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? A. Contact the provider B. Instruct the client to maintain bed rest for the remainder of pregnancy C. Tell the client that these are common and they may occur throughout the pregnancy D. Call the maternity unit and inform them that the client will be admitted in a pre-labor condition

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

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? A. Quickening B. Braxton Hicks contractions C. Consistent increase in fundal height D Fetal heart rate of 180 beats per minute

D Fetal heart rate of 180 beats per minute

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes. The nurse determines that the teaching has been effective when the client makes which statement? A. "I can eat more sweets now because I need more calories." B. "I need more fat in my diet so that the baby can gain enough weight." C. I need to eat a high-protein, low-carb diet now to control my blood glucose." D. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

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

The nurse is talking to a pregnant client with HIV regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? A. "You will need to bottle-feed your newborn." B. "You will need to feed your newborn by nasogastric tube feeding." C. "You will be able to breast feed for 6 months and then you will need to switch to bottle feeding." D. "You will be able to breast feed for 9 months and then will need to switch to bottle feeding."

A. "You will need to bottle-feed your newborn."

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? A. A softening of the cervix B. The presence of fetal movement C. The presence of human chorionic gonadotropin in the urine D. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

A. A softening of the cervix

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? A. The bladder must be full during the exam B. The bladder must be empty during the exam C. She should not eat or drink anything 4 to 6 hours before the exam D. She will be given Rh(D) immune globulin because she is Rh positive

A. The bladder must be full during the exam

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

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

A contraction stress test is scheduled for the client. The women asks the nurse about the test. Which response describes the most accurate description of the test? A. "Uterine contractions are stimulated by Leopold's maneuvers." B. "The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." C. "The internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." D. "Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions."

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

The nurse is collecting data from a pregnant client who is currently at 28 week's 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? A. 22 cm B. 26 cm C. 32 cm D. 40 cm

B. 26 cm

The perinatal client is admitted to the ob unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietician to ensure which dietary measure? A. A low calorie diet to ensure the absence of weight gain B. A diet that is high in fluids and fiber to decrease constipation C. A diet that is low in fluids and fiber to decrease blood volume D. Unlimited sodium intake to increase the circulating blood volume

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

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progress from preeclampsia to eclampsia, the nurse should take which action first? A. Administer oxygen by face mask B. Clear and maintain an open airway C. Check the blood pressure and the fetal hart rate tones D. Prepare the administration of IV magnesium sulfate

B. Clear and maintain an open airway

The nurse is collecting data form 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? A. Gravida I, Para I B. Gravida II, Para I C. Gravida II, Para II D. Gravida III, Para II

B. Gravida II, Para I

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 Nagele's rule, the nurse determines the estimated date of birth is which date? A. July 12, 2020 B. July 27, 2020 C. August 12, 2020 D. August 27, 2020

B. July 27, 2020

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? A. "I know I can never have another child." B. "I am glad I won't have to have those shots if I have another child." C. "I will have to have an injection once a month until the baby is born." D. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

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

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? A. 6 and 8 weeks' gestation B. 8 and 10 weeks' gestation C. 10 and 12 weeks' gestation D. 16 and 20 weeks' gestation

D. 16 and 20 weeks' gestation

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? A. A full bladder B. Emotional instability C. Insufficient iron intake D. Compression of the vena cava

D. Compression of the vena cava

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? A. Lie on the left side with the feet dorsiflexed B. Soak the feet in hot water after performing 10 pelvic tilt exercises C. Lie on the right side with the feet elevated on a pillow and a heating pad on the back D. Lie on the floor with the legs elevated onto a could or padded chair, with the hip and knees

D. Lie on the floor with the legs elevated onto a could or padded chair, with the hip and knees

The nurse caring for a client with abruption placenta is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed? A. Rapid clotting times B. Pain and swelling of the calf of one leg C. Lab values that indicate increased platelets D. Petechiae, oozing from injection sites, and hematuria

D. Petechiae, oozing from injection sites, and hematuria