NCLEX Antepartum

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

Breast changes

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

Deep tendon reflexes

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

Dehydration

The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse should instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?

Dried fruits

The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the health care provider?

Fundal height, 38 cm

The 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 take which action?

Place the client in a supine position and place a wedge under the right hip.

The nurse should prepare to give a prescribed oxytocic medication after delivery of which

Placenta

A pregnant woman who is at 38 weeks gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, what does the nurse determine the client may be experiencing?

Placenta previa

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

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

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

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?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right

A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?

Longest period of fetal development

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant and shares that which tests are expected to be conducted during the first trimester? Select all that apply

Urinalysis Rubella titer Complete blood count

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?

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

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?

Are where fertilization occurs

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time?

Explain the purpose of the nurse's actions and answer all questio

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

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?

Fresh spinach

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 was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?

July 27, 2017

The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complication is associated with a twin pregnancy?

Maternal anemia

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

The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy?

She has a history of chronic hypertension.

During the antenatal period of a client diagnosed with the human immunodeficiency virus (HIV), the nurse result of her rubella screening is positive. routinely and discusses the findings. Which is the primary purpose of this action?

To identify appropriate fetal development

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement?

"I am eating fresh fruits and vegetables for snacks and for dessert each day."

The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?

"I need to gain only 10 pounds so that my baby will be small like I am."

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?

A softening of the cervix

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which findings would place the client at risk for preterm labor?

A urinary tract infection

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation?

Acute anxiety and the need for support

The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond?

Administer oxygen via face mask to the mother.

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

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

A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the health care provider to prescribe?

Amniocentesis for fetal surfactant level

A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?

Avoid exposure to litter boxes used by cats.

The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal?

Avoid further stress on the maternal immune system.

The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.

Ballottement Fetal movements felt by examiner

The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food item?

Beans

The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?

Document the temperature.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

Drink decaffeinated coffee and tea.

The nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse determines that which hormone responsible for the development of this sign?

Estrogen

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

Hypertension

The clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs

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

The nurse assists a pregnant client with cardiac disease in identifying 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 accomplish which?

Reduce excessive maternal stress and fatigue.

The nurse is caring for a woman in the labor room. The health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?

Resting interval of 50 seconds

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock?

Restlessness and agitation

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn.

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

White blood cell count of 35,000 cells/mm3

The 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 which gestational week?

week 20

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?

28 cm

The nurse is collecting data from 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?

Gravida II, para I

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement 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 bor

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?

"I am so glad that I can breast-feed my baby after she has been vaccinated."

The nurse shares with a pregnant client that the result of her rubella screening is positive. Which 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 client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?

"You feel you are having difficulty fulfilling your role as a wife."

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

January 12

The nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. Which instructions should the nurse give the women with regard to performing the procedure?

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

A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?

Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?

The client complains of a headache and blurred vision.

The nurse is collecting data from a prenatal client. The nurse determines that which 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 nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results?

A negative test

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 should be noted at which time interval?

Between 16 and 20 weeks' gestation

The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking and the client tells the nurse that she has been taking the herb chamomile. The nurse refers to an herbal reference book and discovers which fact about chamomile?

Chamomile should not be used by pregnant women and persons with asthma.

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?

Change in uterine shape

A client who is 8 weeks pregnant calls the clinic and speaks to the nurse about complaints of nausea and vomiting every morning. Which action should the nurse suggest to promote relief?

Eat crackers before arising.

The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. The nurse should expect documentation that the fundus of the uterus is noted at which area?

Midway between the symphysis pubis and the umbilicus

The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?

The insulin needs will increase.

The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?

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

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?

he client will not develop an opportunistic infection during the remainder of pregnancy.

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 measure is appropriate to suggest to the client?

Wear a perineal pad to the play.

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

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors would the nurse consider significant?

A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago

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 should consult with the dietitian to ensure which dietary measure?

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

The 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 risk factor?

Maternal hypertension

The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?

Maternal hypertension

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply

Bypassing the fetal lungs to circulate oxygen rich blood Using the fetus's beating heart to pump blood in the circulatory system Carrying more oxygen on fetal hemoglobin than maternal hemoglobin Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone?

"It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."

A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation?

Adding 1 tablespoon of mineral oil to a bowl of cereal daily

The nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?

How to check for signs of hypoglycemia and the required treatment

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. Which position should the nurse place the client in?

In a sitting position

The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (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.

The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?

Newborn

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 reinforces teaching 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 which occurs?

Weight increases by more than 1 pound in a week.

The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breast-feed the infant after delivery. Which response by the nurse is appropriate?

"Breast-feeding is contraindicated."

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, which is the best response by the nurse?

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

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?"

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be appropriate?

"Do you plan to have any other children?"

The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further 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

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?

"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

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

The 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

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problems should the nurse expect to note on the plan of care?

Anxiety related to a slow progress of labor

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment would be part of the plan of care?

Any bleeding, such as in the gums, petechiae, and purpur

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions

During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which would the nurse check further?

Blood pressure changes and the presence of protein in the ur

Which history would place a maternity client at risk for uterine rupture?

Cesarean section birth

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 which should the nurse do first?

Check for signs of thrombophlebitis.

A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.

Clear fluid White flecks in the amniotic fluid Presence of glucose and protein in the amniotic fluid

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?

Compression of the vena cava

The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time?

Continue monitoring the client because the data reflect acceptable progress.

A client asks the nurse to describe how her baby is developing. The nurse bases the response on the knowledge that every organ system in the fetus is present by the end of which gestational week?

Eighth

In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

Establish a therapeutic relationship between the nurse and pregnant client.

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitude?

Excitement

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which client problem does the nurse identify as important at this time?

Fear about the safety of the fetus

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?

Fear of losing control

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 4, para 0, abortion 3. 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

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is which?

Flat and unfavorable for a vaginal birth

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 the GTPAL for this client as which?

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

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply.

Hegar's sign Goodell's sign McDonald's sign

The 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 substance abuse during this pregnancy

The nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which identified by the student indicates an understanding of this process?

In the fallopian tube

The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?

Increase in circulating volume

The 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 is collecting data on a pregnant woman who is human immunodeficiency virus (HIV) positive during the thirty-second gestational week. The nurse reviews the data and determines that which finding requires further follow-up?

Increased shortness of breath and bilateral rales

The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.

Increases blood flow to the uterine vessels Stimulates development of the breast ducts Causes vascular changes in the mucous membranes of the nose and mouth

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 nursing action should the nurse take?

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

A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?

Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.

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 area?

Just above the symphysis pubis

The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?

Nuts and green, leafy vegetables

The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use?

Palpate for uterine contractions at the same time as the c

The nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as an effective teaching method?

Palpate for uterine contractions at the same time as the c

The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that supports and protects the internal reproductive organs. The student correctly responds by identifying which structure?

Pelvis

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 which is observed?

Petechiae, oozing from injection sites, and hematuria

The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother.

At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action?

Prepare the client for a cesarean delivery.

The 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. According to the nurse, what is the purpose of progesterone?

Progesterone maintains the uterine lining for implantation.

The nurse is assigned to assist in caring for a client in labor. The nurse would determine that which sign/symptom would least likely indicate dystocia?

Progressive changes in the cervix

The nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that which hormone primarily stimulates the secretion of milk?

Prolactin

The nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that which hormone stimulates the secretion of milk?

Prolactin

The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.

Proteinuria Hypertension

The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time would be which action?

Provide emotional support.

The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?

Provide pain relief measures.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?

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

The clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs?

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

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

Pulse

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.

Pulse Blood volume Cardiac output Red blood cell mass

The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose?

Reduce the risk of injuring the bladder during the surgery.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse?

Respirations of 10 breaths per minute

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

The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?

Second

The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority

Signs of fetal distress

The 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 medication is prescribed?

Subcutaneous administration of heparin sodium 5000 units daily

The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?

Syphilis

A pregnant client is a gravida III, para 0, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband, knowing that which instruction will assist in promoting 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 should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

Tell the dental office staff that she is pregnant.

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

The client exhibits no signs of fetal distress.

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.

The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?

The feelings of guilt that is often associated with grief

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. The nurse understands that this characterizes which type of presentation?

The most common presentation

The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that which is a characteristic of this type of pelvis?

The most favorable for labor and birth

The nurse is providing information about health care to a pregnant client who is positive for human immunodeficiency virus (HIV). What is the primary reason to avoid alcohol and cigarettes during pregnancy and to get adequate rest?

To avoid further stress on the maternal immune system

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?

To regain her breathing pattern

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant and shares that which tests are expected to be conducted during the first trimester? Select all that apply.

Urinalysis Rubella titer Complete blood count

The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.

Urinary tract infections Increased chance of cesarean birth Delayed lung maturation in the neonate

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?

Uterine tenderness on palpation

The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply.

Vaginal bleeding Excessive vomiting No fetal heart activity Larger than normal fetus size for gestational age Elevated levels of human chorionic gonadotropin (HCG)

The health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.

Vaginal secretions increase. Bluish discoloration of the vagina. Higher levels of glycogen in vaginal secretions.

The 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 area, knowing that venous congestion is most commonly noted where?

Vulva

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is which?

Wedge-shaped and narrow and unfavorable for a vaginal birth

A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur. Which statement is true?

Your normal insulin dosage will have to be decreased."

The 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 responses by the nurse indicate a understanding of the implications of the client's symptoms? Select all that apply.

"Lie on your left side for an hour and try to drink some fluids." "It is important that you urinate frequently to keep your bladder empty." "Palpate for contractions and call back if there are more than four contractions in the next hour." "Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"

A client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic?

"Tell me about your concerns."

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

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

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds to the client, knowing that the gender of the fetus can be visually recognizable as early as which week?

12

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?

150 beats per minute

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

18

A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose level is elevated. Which prescription should the nurse anticipate for the mother?

A 3-hour glucose tolerance test

The nurse notes that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which is the explanation for this increase?

A normal finding

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 perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client would indicate the need for further teaching

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

A pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. Which nursing response would best support the client?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

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. How does the nurse describe the preembryonic period for the client?

"The preembryonic period is the first 2 weeks of fetal development following conception."

A woman at 20 weeks of gestation calls the health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"This is an emergency; you should come to the clinic within the hour."

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?

12 to 16

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. She also wants to know when she can hear the fetus's heartbeat with a fetoscope rather than a Doppler. During which time frame will the client both hear the heartbeat with a fetoscope and feel the fetus move?

16 and 20 weeks of gestation

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week?

28

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? Fill in the blank.

5

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 instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?

Assists in identifying infections that may need to be treated

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 which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava

The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take?

Document the assessment.

The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply

Curtail exercise. Measure your blood pressure daily. Rest frequently by lying on your side. Call the health care provider if you develop dizziness.

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?

Hemoglobin 9.1 g/dL

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 in the urine?

Human chorionic gonadotropin (hCG)

A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?

Inevitable

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 nursing action should be appropriate?

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

The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.

Peanut butter Whole grain bread Omelet with cheese

The 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. Which action should the nurse perform first?

Place a wedge pillow under the client's right side

The 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. Which action should the nurse perform first

Place a wedge pillow under the client's right side.

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

Swimming

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study would further support the presence of HIV?

T lymphocyte levels

The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action should the nurse take before the procedure to ensure fetal safety?

Test the ultrasound equipment to ensure proper functio

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching

The client is wearing knee-high hose.

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions would the nurse place on the list? Select all that apply

To note the color of blood on each perineal pad To watch for the evidence of the passage of tissue To note the quantity of blood on each perineal pad To count the number of perineal pads used on a daily basis

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which occurs?

Irregular, painless contractions

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

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

The 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 purpose of estrogen?

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

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data?

Weight and height

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

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

The 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 client statement indicates a need for further investigation?

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

The nurse employed in a health care provider's office is collecting information from a pregnant client. Which statement made by the client 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."

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?

he bladder must be full during the exam.

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse bases the response on what information?

he breast changes are a result of the secretion of estrogen and progesterone.

The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?

Describing the appropriate amount of weight gain required during the pregnancy

A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.

Edema Proteinuria Thrombocytopenia

The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description characterizes the purpose of estrogen?

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

The 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. Which warning signs would the nurse place on the list? Select all that apply.

Facial edema Rapid weight gain Visual disturbances Generalized edema

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

Laser therapy

The 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 taking which action?

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

The nurse is reviewing the health care record of a pregnant client at 16 weeks' gestation. The nurse should expect documentation that the fundus of the uterus is noted at which area?

Midway between the symphysis pubis and the umbilicus

The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (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.

Minimize the potential for developing infections.

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?

Minimizing the client's exposure to external stimuli

The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?

Monitoring fetal movement

The nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. Which terms apply to an android pelvis? Select all that apply.

Narrow wedge shape Unfavorable for a vaginal birth

A client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which treatment for acne should be avoided with this client?

Oral tetracycline hydrochloride

A client in the prenatal clinic presents with a blood pressure reading of 134/90 mm Hg, which is an elevation from last month's reading of 104/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?

Trace amount of protein

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic should be a part of the teaching plan for this class?

Travel precautions and use of shoulder seat belts

The 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

The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area?

Vulva