Exam 1: High Risk Antepartum NCLEX Questions

a

The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? a. weight loss b. 2+ proteinuria c. decrease in plasma proteins d. 3+ patellar reflexes

a b c e

A 39 year old, 16 week gravid woman has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences any of the following side effects (select all that apply) a. fever or chills b. lack of fetal movement c. abdominal pain d. rash or pruritis e. vaginal bleeding

c

A 14 year old woman is seeking obstetric care. Which of the following is an appropriate nursing care goal for this young woman? The young woman will: a. bring her partner to all prenatal visits b. terminate the pregnancy c. continue her education d. undergo prenatal chromosomal analysis

c

A 14 year old woman is seeking obstetric care. Which of the following vital signs must be monitored very carefully during this woman's pregnancy? a. heart rate b. respiratory rate c. blood pressure d. temperature

b

A 24 week gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? a. inquire whether or not the client has allergies b. take the woman's blood pressure c. assess the woman's fundal height d. ask the woman about stressors at work

d

A 25 year old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? a. cervical cerclage b. amniocentresis c. nonstress testing d. dilation and curettage

b

A client is being admitted to the labor suite with a diagnosis of eclampsia. The fetal heart rate tracing shows moderate variability with early decelerations. Which of the following actions by the nurse is appropriate at this time? a. tape a tongue blade to the head of the bed b. pad the side rails and head of the bed c. provide the client with needed stimulaton d. provide the client with grief counseling

d

A 26 week gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? a. low serum creatinine b. high serum protein c. bloody stools d. epigastric pain

b

A 29 week gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? a. fundal height of 32cm b. papilledema c. patellar reflex of +2 d. nystagmus

a

A 32 week gestation client states that she thinks she is leaking amniotic fluid. Which of the following tests could be performed to determine whether the membranes had ruptured? a. fern test b. biophysical profile c. amniocentesis d. kernig assessment

b

A client being seen in the ED has an admitting medical diagnosis of: third-trimester bleeding: rule out placenta previa. Each time a nurse passes by the client's room, the woman asks, "Please tell me, do you think the baby will be alright?" Which of the following is an appropriate nursing diagnosis for this client? a. hopelessness related to possible fetal loss b. anxiety related to inconclusive diagnosis c. situational low self-esteem related to blood loss d. potential for altered parenting related to inexperience

b

A client has been admitted with a diagnosis of hyperemesis gravidarum. Which of the following orders written by the primary health care provider is highest priority for the nurse to complete? a. obtain complete blood count b. start intravenous with multivitamins c. check admission weight d. obtain urine for urinalysis

c

A client with mild preeclampsia who has been advised to be on bed rest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give to the client? a. "bed rest will help you to conserve energy for your labor" b. "bed rest will help to relieve your nausea and anorexia" c. "reclining will increase the amount of oxygen that your baby gets" d. "the position change will prevent the placenta from separating"

a c d e

A client, 32 weeks gestation with placenta previa, is on total bed rest. The physician expects her to be hospitalized on best rest until her cesarean section, which is scheduled for 38 weeks gestation. To prevent complications, the nurse should do which of the following? (select all that apply) a. perform passive range of motion exercises b. restrict the fluid intake of the client c. decorate the room with pictures of family d. encourage the client to eat a high-fiber diet e. teach the client deep-breathing exercises

b

A client, G2 P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one sided pain is due to an ectopic pregnancy> a. "when did you have your pregnancy test done?" b. "when was the first day of your last menstrual period?" c. "did you have any complications with your first pregnancy?" d. "how old were you when you first got your period?"

b

A client, G8 P3406, 14 weeks gestation, is being seen in the prenatal clinic. During the nurse's prenatal teaching session, the nurse will emphasize that the woman should notify the obstetric office immediately if she notes which of the following? a. change in fetal movement b. signs and symptoms of labor c. swelling of feet and ankles d. appearance of spider veins

b

A gravid client is admitted with a diagnosis of third-trimester bleeding. It is priority for the nurse to assess for a change in which of the following vital signs? a. temperature b. pulse c. respirations d. blood pressure

a

A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following? a. grand mal seizure b. high platelet count c. explosive diarrhea d. fractured pelvis

c

The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? a. +1 b. +2 c. +3 d. +4

c

A gravid woman, who is 42 weeks gestation, had just had a 20 minute nonstress test. Which of the following results would the nurse interpret as a reactive test? a. moderate fetal heart baseline variability b. maternal heart rate accelerations to 140 bpm lasting atleast 20 seconds c. two fetal heart accelerations of 15 bpm lasting at least 15 seconds d. absence of maternal premature ventricular contractions

b

A lecithin:sphingomyelin (L/S) ratio has been ordered by a pregnant woman's obstetrician. Which of the following data will the nurse learn from this test? a. coagulability of maternal blood b. maturation of fetal lungs c. potential for fetal development of erythroblastosis fetalis d. potential for maternal development of gestational diabetes

d

A nurse is caring for a 25 year old client who has just had a spontaneous first trimester abortion. Which of the following comments by the nurse is appropriate? a. "you can try again very soon" b. "it is probably better this way" c. "at least you weren't very far along" d. "i'm here to talk if you like"

a b

A nurse is caring for four prenatal clients at the clinic. Which of the clients is high risk for placenta previa? (select all that apply) a. jogger with low body mass index b. primigravida who smokes 1 pack of cigarettes a day c. infertility client who is carrying in vitro triplets d. registered nurse who works 12 hour shifts e. police officer on foot patrol

c

A nurse is counseling a preeclamptic client about her diet. Which should the nurse encourage the woman to do? a. restrict sodium intake b. increase intake of fluids c. eat a well-balanced diet d. avoid simple sugars

a

A nurse remarks to a 38 week gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? a. altered glomerular filtration b. cardiac failure c. hepatic insufficiency d. altered splenic circulation

a

A nurse works in a clinic with a high adolescent pregnancy population. The nurse provides teaching to the young women to prevent which of the following high-risk complications of pregnancy? a. preterm birth b. gestational diabetes c. macrosomic babies d. polycythemia

c

A patient who is 24 weeks pregnant has been diagnosed with syphilis. She asks the nurse how the infection will affect the baby. The nurse's response should be based on which of the following? a. she is high risk for premature rupture of the membranes b. the baby will be born with congenital syphilis c. penicillin therapy will reduce the risk to the fetus d. the fetus will likely be born with a cardiac defect

a

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? a. assess deep tendon reflexes b. obtain complete blood count c. assess baseline weight d. obtain routine urinalysis

a

A type 1 diabetic gravida has developed polyhydramnios. The client should be taught to report which of the following? a. uterine contractions b. reduced urinary output c. marked fatigue d. puerperal rash

a

A type 1 diabetic is being seen for preconception counseling. The nurse should emphasize that during the first trimester the woman may experience which of the following? a. need for less insulin than she normally injects b. an increased risk for hyperglycemic episodes c. signs and symptoms of hydramnios d. a need to be hospitalized for fetal testing

c

A woman is recovering at the gynecologist's office following a late first-trimester spontaneous abortion. At this time, it is essential for the nurse to check which of the following? a. maternal rubella titer b. past obstetric history c. maternal blood type d. cervical patency

d

An insulin-dependent diabetic woman will require higher doses of insulin as which of the following pregnancy hormones increases in her body? a. estrogen b. progesterone c. human chorionic gonadotropin d. human placental lactogen

b

In analyzing the need for health teaching in a client, G5 P4004 with gestational diabetes, the nurse should ask which of the following questions? a. "how old were you at your first pregnancy?" b. "do you exercise regularly?" c. "is your partner diabetic?" d. "do you work outside the home?"

a

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18 week gravid client to call the office if she experiences which of the following? a. headache and decreased output b. puffy feet c. hemorrhoids and vaginal discharge d. backache

a

The laboratory reported the L/S ratio results from an amniocentresis as 1:1. How should the nurse interpret the result? a. the baby is premature b. the mother is high risk for hemorrhage c. the infant has kernicterus d. the mother is high risk for eclampsia

c

The nurse has assessed four primigravid clients in the prenatal clinic. Which of the women would the nurse refer to the nurse midwife for further assessment? a. 10 weeks gestation, complains of fatigue with nausea and vomitting b. 26 weeks gestation, complains of ankle edema and chloasma c. 32 weeks gestation, complains of epigastric pain and facial edema d. 37 weeks gestation, complains of bleeding gums and urinary frequency

d

The nurse is caring for a client who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following orders is the most important for the nurse to perform? a. take the client's temperature b. document the time of the client's last meal c. obtain urine for urinalysis and culture d. assess for complaint of dizziness or weakness

c

The nurse suspects that a client is third spacing fluid. Which of the following signs will provide the nurse with the best evidence of this fact? a. client's blood pressure b. client's appearance c. client's weight d. client's pulse rate

Coombs Test

This test is a screening tool for Rh incompatibility

d

Which finding should the nurse expect when assessing a client with placenta previa? a. severe occipital headache b. history of thyroid cancer c. previous premature delivery d. painless vaginal bleeding

a

Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? a. G1 P0000, age 44 with history of DM b. G2 P0101, age 27 with history of rheumatic fever c. G3 P1102, age 25 with history of scoliosis d. G3 P1011, age 20 with history of celiac disease

c

Which of the following findings should the nurse expect when assessing a client, 8 weeks gestation, with gestational trophoblastic disease (hydatidiform mole)? a. protracted pain b. variable fetal heart decelerations c. dark brown vaginal bleeding d. suicidal ideations

a

Which of the following long-term goals is appropriate for a client, 10 weeks gestation, who is diagnosed with gestational trophoblastic disease (hydatidiform mole)? a. client will be cancer free 1 year from diagnosis b. client will deliver her baby at full term without complications c. client will be pain free 3 months after diagnosis d. client will have normal hemoglobin and hematocrit at delivery

d

Which of the following nursing diagnoses would be most appropriate for a 15 year old woman who is in her first trimester of pregnancy? a. sleep pattern disturbance related to discomforts of pregnancy b. knowledge deficit related to care of infants c. anxiety related to fear of labor and delivery d. ineffective individual coping related to developmental level

d

Which of the following statements is appropriate for the nurse to say to a patient with a complete placenta previa? a. "during the first phase of labor you will do slow chest breathing" b. "you should ambulate in the halls at least two times a day" c. "the doctor will deliver you once you reach 25 weeks gestation" d. "it is important that you inform me if you become constipated"

c

Which of the following would indicate that a nipple stimulation test is creating the desired effects? a. the woman's inverted nipple become erect b. the woman's nipple and breast tissue hypertrophy c. the woman's uterus contracts 3 times in 10 minutes d. the woman's cervix dilates 2 centimeters in 3 hours

d

The nurse is providing health teaching to a group of women of childbearing age. One woman, who states that she is a smoker, asks about smoking's impact on the pregnancy. The nurse responds that which of the following fetal complications can develop if the mother smokes? a. genetic changes in the fetal reproductive system b. extensive central nervous system damage c. addiction to the nicotine inhaled from the cigarettes d. fetal intrauterine growth restriction

a

A pregnant diabetic has been diagnosed with hydramnios. Which of the following would explain this finding? a. excessive fetal urination b. recurring hypoglycemic episodes c. fetal sacral agenesis d. placental vascular damage

c e

A woman has just been admitted to the ED subsequent to a head on automobile accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which of the following complications of pregnancy? (select all that apply) a. placenta previa b. transverse fetal lie c. placental abruption d. severe preeclampsia e. preterm labor

a c d e

A 12 week gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. Which of the following signs/symptoms should the nurse assess this client for? (select all that apply) a. tachycardia b. referred shoulder pain c. headache d. fetal heart dysrhythmias e. hypertension

d

A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? a. severe anemia b. hypoprothrombinemia c. craniosynostosis d. intrauterine growth restriction

c

A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? a. strike the woman's patellar tendon b. palpate the woman's ankle c. dorsiflex the woman's foot d. position the woman's feet flat on the floor

b

A gravid client, 27 weeks gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? a. oral hypoglycemic agents b. diet control with exercise c. regular insulin injections d. inhaled insulin

c

A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis? a. dark brown rectal bleeding b. severe nausea and vomitting c. sharp unilateral pain d. marked hyperthermia