NCLEX Maternity Antepartum

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 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 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."

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

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 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.

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 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

A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information?

To avoid exercise because of the negative effects on insulin production

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

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

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 is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which?

Two umbilical arteries and one umbilical vein

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

Weight and height

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 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 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 separately

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

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

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

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

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 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.

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 urine

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

A licensed practical nurse (LPN) is assisting in the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop the contractions. The LPN checks to see that which is available on the unit as an antidote to magnesium sulfate?

Calcium gluconate

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

Cesarean section birth

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.

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 reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?

Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.

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 understands that the hormone responsible for the development of this sign is which?

Estrogen

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 understands that which hormone is responsible for the development of this sign?

Estrogen

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

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

Fresh spinach

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

Hypertension

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

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

The client will be able to identify measures to prevent infection.

The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?

The client will feel some pressure when the vaginal probe is moved.

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

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

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

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

Weight compared to last visit is a loss of 2.3 pounds

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."

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client would indicate that she understands her needs?

"I should avoid stressful situations."

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

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

A 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 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 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."

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 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 client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?

"The better control of your blood glucose means less effects; let's review your plan of care."

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 pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be appropriate?

"You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."

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.

1. Ballottement 2. Fetal movements felt by examiner

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.

1. Clear fluid 2. White flecks in the amniotic fluid 3. Presence of glucose and protein in the amniotic fluid

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.

1. Curtail exercise. 2. Measure your blood pressure daily. 3. Rest frequently by lying on your side. 4. Call the health care provider if you develop dizziness.

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.

1. Increases blood flow to the uterine vessels 2. Stimulates development of the breast ducts 3. Causes vascular changes in the mucous membranes of the nose and mouth

The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms would be noted in severe preeclampsia? Select all that apply.

1. Oliguria 2. Proteinuria 3+ 3. Blood pressure 168/116 mm Hg

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.

1. Pulse 2. Blood volume 3. Cardiac output 4. Red blood cell mass

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.

1. Vaginal bleeding 2. Excessive vomiting 3. No fetal heart activity 4. Larger than normal fetus size for gestational age 5. Elevated levels of human chorionic gonadotropin (HCG)

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 pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

16 and 20 weeks' gestation

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.

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 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

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 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

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.

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

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 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 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 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 angle.

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

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

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 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 client.

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 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 2. Hypertension 3. Increased pulse rate

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 assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would be least likely to assist in meeting her 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.

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