NCLEX Antepartum, Maternity Medications, Reproductive System, Obstetrical Assessment, Prenatal Period, and Risk Conditions Related to Pregnancy Questions
The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. "I should avoid between meal snacks" 2. "I should lie down for an hour after eating" 3. "I should use spices for cooking rather than salt" 4. "I should avoid eating foods that produce gas and fatty foods"
4. "I should avoid eating foods that produce gas and fatty foods"
The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and expects which finding? 1. 22 cm 2. 30 cm 3. 36 cm 4. 40 cm
2. 30 cm During the second and third trimesters, fundal height in centimeters approximately equals the fetuses age in weeks.
Methylergonovine is prescribed for a women to treat postpartum hemorrhage. Before administration, what is the priority nursing assessment? 1. Uterine tone 2. BP 3. Amount of lochia 4. Deep tendon reflexes
2. BP
The nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. SQ 4. IM
2. Intratracheal
The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan? 1. "One artery carries oxygenated blood from the placenta to the fetus" 2. "Two arteries carry oxygenated blood from the placenta to the fetus" 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta" 4. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta"
3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta"
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Early decelerations of the fetal heart rate
3. Uterine hyperstimulation
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tubes for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survivial" 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone" 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus" 4. "It promotes the fertilized ovum's exposure to lutenizing hormone and follicle-stimulating hormone"
3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus"
The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instruction? 1. "I should wear panty hose" 2. "I should wear support hose" 3. "I should wear flat nonslip shoes that have good support" 4. "I should wear knee high hose, but I should not leave them on longer than 8 hours"
4. "I should wear knee high hose, but I should not leave them on longer than 8 hours" Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing impedes venous return from the lower legs and places the client at risk for developing varicosities.
A pregnant client reports to a health care clinic complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Myobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1. Therapeutic abortion is required 2. She will have to stay at home until the treatment is completed 3. Medication will not be started until after delivery 4. Isoniazid plus rifampin will be required for 9 months
4. Isoniazid plus rifampin will be required for 9 months
The nurse evaluates the ability of a hepatitis-B positive mother to provide safe bottle-feeding to her newborn. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding 2. The mother holds the newborn properly during feeding and burping 3. The mother tests the temperature of the formula before initiating feeding 4. The mother washes and dries her hands before and after self care of the perineum and asks for a pair of gloves before feeding
4. The mother washes and dries her hands before and after self care of the perineum and asks for a pair of gloves before feeding
The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which statement indicates a need for further teaching? 1. "I will flush the eyes after instilling the ointment" 2. "I will clean the newborn's eyes before instilling the ointment" 3. "I need to administer the ointment within 1 hour after delivery" 4. "I will instill eye ointment into each of the newborn's conjuctival sacs"
1. "I will flush the eyes after instilling the ointment" Eye prophylaxis protects the newborn against gonorrhea and chlamydia.
The nurse is assessing a pregnant client with type 1 DM about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy" 2. "My insulin dose will likely need to be increased during the second and third trimesters" 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy" 4. "My insulin needs should return to normal within 7-10 days after birth if I am bottle feeding"
1. "I will need to increase my insulin dosage during the first 3 months of pregnancy" Insulin needs decrease in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin.
The clinic is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting HIV? 1. A client has a history of IV drug use 2. A client who has a significant other who is heterosexual 3. A client who has a history of STI's 4. A client who has had one sexual partner for the past 10 years
1. A client has a history of IV drug use
A pregnant client tells the clinic nurse that she want to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks gestation because of which factor? 1. The appearance of external genitalia 2. The beginning of the differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent
1. The appearance of external genitalia
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on a diabetic diet" 2. "I should perform glucose monitoring at home" 3. "I should avoid exercise because of the negative effect on insulin production" 4. "I should be aware of any infections and report signs of infections immediately to my HCP"
3. "I should avoid exercise because of the negative effect on insulin production"
The nurse in a maternity unit is reviewing the client's records. Which client would the nurse identify as being the most risk for developing DIC? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10 lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood
3. A gravida II who has just been diagnosed with dead fetus syndrome Dead fetus syndrome, severe preeclampsia, and hemorrhage (500 mL is not considered hemorrhage) are considered a risk factors for DIC.
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure 2. Hospitalization is necessary for 24 hours after the procedure 3. An informed consent needs to be signed before the procedure 4. A fever is expected after the procedure because of the trauma to the abdomen
3. An informed consent needs to be signed before the procedure An informed consent needs to be obtained before the procedure. After the procedure the client is instructed to rest, but may resume light activity after the cramping subsides.
A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava
3. Connects the umbilical vein to the inferior vena cava The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.
Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 1. It cushions and protects the baby 2. It maintains the temperature of the baby 3. It is the way the baby gets food and oxygen 4. It prevents all antibodies and viruses from passing to the baby
3. It is the way the baby gets food and oxygen
The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? 1. "I should avoid straining during bowel movements" 2. "I can gently replace the hemorrhoids into the rectum" 3. "I can apply ice packs to the hemorrhoids to reduce the swelling" 4. "I should apply heat packs to the hemorrhoids to help them shrink"
4. "I should apply heat packs to the hemorrhoids to help them shrink" Measures to provide relief from hemorrhoids include avoiding constipation and straining during bowel movements, applying ice packs, gently replacing hemorrhoids into the rectum, using stool softeners, ointments, or sprays as prescribed, and assuming certain positions to relieve pressure.
The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy" 2. "I should lower my blood volume by limiting my fluids" 3. "I should maintain a low calorie diet to prevent any weight gain" 4. "I should drink adequate fluids an increase my intake of high fiber foods"
4. "I should drink adequate fluids an increase my intake of high fiber foods" The valsalva maneuver should be avoided in a client with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system.
The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instructions should the nurse provide for the client? 1. Total abstinence from sexual intercourse is necessary during the entire pregnancy 2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present 3. Daily administration of acyclovir is necessary during the entire pregnancy 4. A C-section will be necessary if vaginal lesions are present at the time of labor
4. A C-section will be necessary if vaginal lesions are present at the time of labor
RhoGAM is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh+ blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility
4. Being affected by Rh incompatibility
The nurse is performing an assessment on a pregnant client with severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura
4. Evidence of bleeding, such as in the gums, petechiae, and purpura Severe preeclampsia can trigger DIC because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported immediately.
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The healthcare provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document the findings? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for cesarean delivery
1. A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds duration in a 10 minute period.
The nurse instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all the apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and fetus
1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function
The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group" 2. "We never want to try to have a baby again" 3. "We are going to try and adopt a child immediately" 4. "We are okay and we are going to try and have another baby immediately"
1. "We want to attend a support group"
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their initial period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven" 3. "Don't worry, there is nothing you could have done to prevent this" 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience"
1. "What can I do for you?"
The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultasonography
1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix), Chadwick's sign (violet coloration of the cervix, vagina, and vulva), ballottement (rebounding of the fetus against the examiner's fingers), Braxton Hicks contractions, and positive pregnancy test.
The HCP is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 1. Auscultate for fetal heart sounds 2. Assess the cervix for compressibility 3. Palpate the abdomen for fetal movement 4. Initiate a gentle upward tap on the cervix
4. Initiate a gentle upward tap on the cervix Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound.
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical record? 1. Hypotension 2. Hypothyroidism 3. DM 4. Peripheral vascular disease
4. Peripheral vascular disease Methylergonovine is an ergot alkaloid, which are contraindicated in client with significant CVD, peripheral vascular disease, hypertension, preeclampsia, or eclampsia.
The nurse is providing instructions to a pregnant client with HIV regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle feed your newborn" 2. "You will need to feed your newborn by NG tube feeding" 3. "You will be able to breastfeed for 6-months and then you will need to switch to bottle feeding" 4. "You will be able to breastfeed for 9 months and then will need to switch to bottle feeding"
1. "You will need to bottle feed your newborn"
The 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. This finding is most closely associated with which characteristic? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of HCG in the urine 4. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus
1. A softening of the cervix
The nurse is describing cardiovascular system changes the occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? 1. Increase in pulse rate 2. Increase in BP 3. Frequent bowel elimination 4. Decrease in red blood cell production
1. Increase in pulse rate Between 14-20 weeks gestation the pulse rate increases about 10-15 bpm, which then persists to term.
An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory distress occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Meperidine hydrochloride
1. Naloxone
A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps? 1. "Bend your foot toward your body while flexing the knee when the cramps occur" 2. "Bend your foot toward your body while extending the knee when the cramps occur" 3. "Point your foot away from your body while flexing the knee when the cramps occur" 4. "Point your foot away from your body while extending the knee when the cramps occur"
2. "Bend your foot toward your body while extending the knee when the cramps occur"
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 most appropriate? 1. "Has either of you ever had surgery" 2. "Do you plan to have any other children" 3. "Do either of you have DM" 4. "Do either of you have problems with high blood pressure"
2. "Do you plan to have any other children"
A 55-year-old male client confides in the nurse that he in concerned about his sexual function. What is the nurses best response? 1. "How often do you have sexual relations" 2. "Please share with me more about your concerns" 3. "You are still young and have nothing to be concerned about" 4. "You should not have a decline in testosterone until you are in your 80's"
2. "Please share with me more about your concerns"
The nurse should include which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pelvic arch" 2. "Your type of pelvis is most favorable for labor and birth" 3. "Your type of pelvis is a wide pelvis, but has a short diameter" 4. "You will need a C-section because this type of pelvis is not favorable for vaginal birth"
2. "Your type of pelvis is most favorable for labor and birth" An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.
A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone (Celestone) 3. RhoGAM 4. Dinoprostone (Cervidil vaginal insert)
2. Betamethasone (Celestone) Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered between 28-32 weeks if labor can be inhibited for 48 hours.
A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? 1. Hematocrit 38% 2. Glucose 86 mg/dL 3. Hemoglobin 9.1 g/dL 4. White blood cell count 12,400 cells/mm
3. Hemoglobin 9.1 g/dL Pica often leads to iron deficiency anemia, resulting in a decreased hemoglobin level. The lab results in options 1, 2, and 4 are normal for the pregnant client.
A home care nurse is monitoring a pregnant with gestational HTN who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic sign of preeclampsia? Select all that apply. 1. Proteinuria 2. HTN 3. Low-grade fever 4. Generalized edema 5. Increased pulse 6. Increased respirations
1. Proteinuria 2. HTN 4. Generalized edema
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all the apply. 1. Breast-feeding needs to be stopped for 3 months 2. Pregnancy needs to be avoided for 1-3 months 3. The vaccine is administered by the SQ route 4. Exposure to immunosuppressed individuals needs to be avoided 5. A hypersensitivity reaction can occur if the client has an egg allergy 6. The area of the injection needs to be covered with sterile gauze for one week
2. Pregnancy needs to be avoided for 1-3 months 3. The vaccine is administered by the SQ route 4. Exposure to immunosuppressed individuals needs to be avoided 5. A hypersensitivity reaction can occur if the client has an egg allergy
The nurse is monitoring a client in preterm labor who is receiving IV magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all the apply. 1. Flushing 2. HTN 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes
1. Flushing 4. Depressed respirations 5. Extreme muscle weakness Adverse effects of magnesium sulfate include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.
The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test is reactive. How should the nurse document the finding? 1. Normal 2. Abnormal 3. The need for further evaluation 4. That findings were difficult to interpret
1. Normal A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within the normal range (120-160 bpm) with good long term variability. In addition, two or more fetal heart rate accelerations of at least 15 bpm must occur, each with a duration of at least 15 seconds, in a 20 minute interval.
A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell the client that which exercise is safest? 1. Swimming 2. Scuba diving 3. Low-impact gymnastics 4. Bicycling with the legs in the air
1. Swimming Non weight bearing exercises are preferable to weight bearing exercises.
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding the management of care. Which statement made by the client indicates a need for further teaching? 1. "I will watch for the evidence of the passage of tissue" 2. "I will maintain strict bed rest throughout the remainder of the pregnancy" 3. "I will count the number of perineal pads used on a daily basis and not the amount and color of the blood on the pad" 4. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding"
2. "I will maintain strict bed rest throughout the remainder of the pregnancy"
The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document? 1. G3T2P0A0L1 2. G2T1P0A0L1 3. G1T1P1A0L1 4. G2T0P0A0L1
2. G2T1P0A0L1
The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 1. Avoid wearing a bra 2. Wash the breasts with warm water and keep them dry 3. Wear tight-fitting blouses or dresses to provide support 4. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.
2. Wash the breasts with warm water and keep them dry
The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up? 1. Quickening 2. Braxton Hicks contractions 3. Fetal heart rate of 180 bpm 4. Consistent increased fundal height
3. Fetal heart rate of 180 bpm
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding which nursing action is most appropriate? 1. Contact the health care provider 2. Instruct the client to maintain bed rest for the remainder of the pregnancy 3. Inform the client that these contractions are common and may occur throughout the pregnancy 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition
3. Inform the client that these contractions are common and may occur throughout the pregnancy
The nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the fetal heart rate is 174 bpm. On the basis of this finding, what is the priority nursing assessment? 1. Document the findings 2. Check the mother's heart rate 3. Notify the HCP 4. Tell the client that the fetal heart rate is normal
3. Notify the HCP
The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1. "I will record the number of movements or kicks" 2. "I need to lie flat on my back to perform the procedure" 3. "If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours" 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks"
2. "I need to lie flat on my back to perform the procedure" The client should sit or lie quietly on her side to perform the kick counts.
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2014 2. July 26, 2015 3. August 12, 2015 4. August 26, 2015
2. July 26, 2015
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately" 2. "The vaginal discharge may be bothersome, but it is a normal occurrence" 3. "Report to the emergency department at the maternity center immediately" 4. "Use tampons if the discharge is bothersome, but be sure to change the tampon every 2 hours"
2. "The vaginal discharge may be bothersome, but it is a normal occurrence" Leukorrhea begins during the first trimester. The client should not wear tampons because of the risk for infection, the client should wear panty liners and change them frequently.
A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 2. 8 and 10 3. 10 and 12 4. 14 and 18
4. 14 and 18
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted? 1. Proteinuria +3 2. Respirations of 10 breaths per minute 3. Presence of deep tendon reflexes 4. Serum magnesium level of 6 mEq/L
2. Respirations of 10 breaths per minute Signs of magnesium toxicity relate to the CNS depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and sudden decline in FHR, maternal heart rate, and blood pressure.
The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider? 1. Urinary output has decreased 2. Dependent edema has resolved 3. BP is at the prenatal baseline 4. The client complains of a headache and blurred vision
4. The client complains of a headache and blurred vision
A health care provider has prescribed transvaginal ultrasonography for the client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 1. "The procedure takes about 2 hours" 2. "It will be necessary to drink 1-2 quarts of water before the examination" 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel" 4. "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture"
3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel" Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in the lithotomy position and a probe, encased in a disposable cover and coated with gel is inserted into the vagina. The procedure takes about 10-15 minutes.
