Antepartum NCLEX 5th edition

A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. The nurse analyzes this data as indicative of:

A normal finding

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following informative statements will the nurse provide to the client?

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

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, the nurse determines that the best response would be which of the following?

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

A nurse is instructing 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?

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

A nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for more teaching regarding possible complications of preeclampsia?

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

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?

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

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 statement by the student indicates an understanding of this hormone?

"It increases during pregnancy to stimulate basal metabolic rate."

A nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at gestational week:

20

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. The nurse interprets these findings as indicating:

A negative test

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?

5

A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which should the nurse anticipate to be prescribed for the mother?

A 3-hour glucose tolerance test

The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following?

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

A nurse is collecting data from a prenatal client. The nurse determines that which of the following places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

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

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign, and the nurse determines that this sign is indicative of:

A softening of the cervix

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:

A softening of the cervix

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?

Abdominal pain

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes:

Are where fertilization occurs

A nursing student is asked to identify the location of the isthmus of the uterus. The student correctly states that the isthmus is the:

Area between the corpus of the uterus and the cervix

A perinatal client is at risk for toxoplasmosis. The nurse should teach the client which of the following to prevent exposure to this disease?

Avoid exposure to litter boxes used by cats

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign(s) of pregnancy that the nurse should recognize? Select all that apply.

Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions

A client presents at her health care provider's office 10 weeks pregnant with her first pregnancy. Which of the following is a presumptive sign of pregnancy that the client might be expected to have?

Breast changes

A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client?

Client exhibits no signs of fetal distress

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:

Compression of the vena cava

A client age 23 develops melasma during pregnancy. The nurse notes that the client has started wearing very heavy makeup. The client tells the nurse that she is fearful that her mate will reject her, and that she has decreased her social engagements drastically because of this change. The nurse determines that the client is experiencing which problem?

Concern about her appearance

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 that it:

Connects the umbilical vein to the inferior vena cava

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?

Consume dry crackers before getting out of bed.

A nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, the nurse should specifically monitor which of the following?

Deep tendon reflexes

A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which of the following problems should receive highest priority?

Dehydration

A client who is 8 weeks pregnant calls the clinic and speaks to the nurse about complaints of nausea and vomiting every morning. To promote relief, the nurse suggests:

Eating crackers before arising

The nurse is collecting data during the admission assessment of 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 would document which gravida and para status on this client?

Gravida II, para I

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 of the following problems do the data best support?

High risk for infection

A 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:

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

A nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record would support this diagnosis?

Maternal hypertension

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?

The client is blaming herself

A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?

The client will be able to identify measures to prevent infection

A nurse is preparing to instruct a pregnant client about nutrition. The nurse plans to include which of the following in this client's teaching plan?

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

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?

To avoid exercise because of the negative effects on insulin production

A 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:

Turn the client on her left side

A 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 finding would support potential further maternal compromise?

Vaginal spotting twice since the last prenatal visit

A 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 of the following areas, knowing that venous congestion is most commonly noted here?

Vulva

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?

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

A 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 statement by the client indicates an immediate need for further investigation?

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

A nurse employed in a health care provider's office is collecting information from a pregnant client. Which of the following statements made by the client likely indicates the need for psychological referral?

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

A nurse provides instructions to a client with mild preeclampsia on home care. The nurse evaluates that the teaching has been effective when the client states:

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

When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?

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

Abdominal ultrasonography is prescribed for a woman who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement to the woman?

"You will be positioned on your back and turned slightly to one side with your head elevated."

A 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?

History of substances abuse during this pregnancy

A pregnant client asks a 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:

16 and 20 weeks of gestation

A client calls the 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 of the following in the urine?

Human chorionic gonadotropin (hCG)

A nurse is collecting data on a client who is pregnant with twins. Which of the following signs would alert the nurse to a potential problem specifically related to the twin pregnancy?

Hypertension

A client diagnosed with severe preeclampsia is on magnesium sulfate by continuous intravenous infusion. Which finding suggests to the nurse that the next dose of this medication should be held?

Absence of deep tendon reflexes

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which of the following areas?

Midway between the symphysis pubis and the umbilicus

When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?

Expression of hope for a positive outcome

A 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 health care provider. Choose the warning signs that the nurse places on the list. Select all that apply.

Facial edema Rapid weight gain Visual disturbances Generalized edema

A nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse tells the client that she will:

Feel some pressure when the vaginal probe is moved

A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid (INH) and rifampin (Rifadin). The nurse plans to implement which intervention?

Reviewing daily nutritional intake with the client

A nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which of the following nursing interventions would be least likely to assist in meeting her emotional needs?

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

A nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which of the following would the nurse check first?

Pulse

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, the nurse should first:

Check for signs of thrombophlebitis

A nurse is monitoring a client at risk for placental abruption. Which of the following is indicative of this complication?

Fetal distress

A nurse assists a pregnant client with cardiac disease to identify 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:

Reduce excessive maternal stress and fatigue

During an initial prenatal visit, the nurse notes that the client's hemoglobin level is indicative of iron deficiency anemia. Which additional client data would also support this finding?

Reports of fatigue

A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to:

Strengthen the pelvic floor in preparation for delivery

A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed?

Subcutaneous administration of heparin sodium 5000 units daily

A pregnant client asks a nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following?

Swimming

A pregnant client is a gravida III, para 0, abortus II. She is placed on bedrest at home because of preterm labor. The nurse provides information to the husband, knowing that which of the following will assist to promote family adaptation?

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

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?

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

Which finding in the prenatal client supports the medical diagnosis of placental abruption?

Tender, rigid abdomen

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which of the following statements by the client would identify the need for further teaching regarding the hemorrhoids?

"Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born."

A perinatal client with a history of heart disease has been instructed on care at home. Which of the following statements if made by the client would indicate the need for further instructions?

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

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?

"Tell me what concerns you have."

A nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:

In a sitting position

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which of the following does the nurse anticipate to be prescribed?

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

A pregnant woman visiting a health care clinic for the first prenatal visit hears the health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the preembryonic period is the:

First 2 weeks of fetal development following conception

During the antenatal period of a client diagnosed with the human immunodeficiency virus (HIV), the nurse weighs and plots the weight gain pattern routinely and discusses the findings. The primary purpose of this action is to:

Identify appropriate fetal development

A nurse is collecting data from a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:

In a sitting position

A 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 health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation?

Increased blood volume of the mother during pregnancy

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes:

Petechiae, oozing from injection sites, and hematuria

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 of the following is appropriate to suggest to the client?

Wear a perineal pad to the play

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding would indicate a serious nutritional disorder of pregnancy?

Weight compared to last visit is a loss of 2.3 pounds

A nurse shares with a pregnant client that the results of her rubella screening is positive. What 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?

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

A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?

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

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, what would be the estimated date of delivery (EDD)?

January 12

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which of the following treatments would the nurse consider to be safe for this maternity client?

Laser therapy

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 of the following nursing actions would be appropriate?

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

A 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. The nurse tells the woman that the purpose of progesterone is to:

Maintain the uterine lining for implantation

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 IV, para 0, aborta III. 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 would lead the nurse to suspect gestational diabetes?

Fetal demise

A nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) HIV to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?

Minimize the potential for developing infections

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 statement by the student indicates an understanding of this hormone?

Palpate for uterine contractions at the same time as the client

A nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. The student describes the procedure correctly if the student states to:

Place a rolled blanket under the right abdominal flank and hip area

A 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. What is the first nursing action?

Place a wedge pillow under the client's right side

A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:

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

A nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?

Potential for infection

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta:

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

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 teaches the client about the signs that need to be reported to the health care provider (HCP) and tells the client to call the HCP if:

Weight increases by more than 1 pound in a week

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning?

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

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process?

"Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."

A 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 response by the nurse indicates a lack of understanding of the implications of the client's symptoms?

"This is probably an emergency. have someone drive you to a hospital now."

A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

An adolescent with multiple heterosexual contacts