OB 202 weeks 3 NCLEX questions

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information would the nurse provide to the client?

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

The nurse is interviewing a 16-year-old client during the initial prenatal clinic visit. The client is beginning week 18 of their first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?

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

The nurse is providing instructions to a pregnant 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?

"I need to drink adequate fluids and increase my intake of high-fiber foods."

The nurse is caring for a pregnant client who has herpes genitalis. The nurse provides instructions to the client about treatment modalities that may be necessary for this condition. Which statement made by the client indicates an understanding of these treatment measures?

"It may be necessary to have a cesarean section for delivery."

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 tube for 3 days, what is the nurse's best response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if the client makes which statement?

"My contractions will last longer and be more intense."

A pregnant client who is anemic expresses concern about the infant's condition after 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 client in the first trimester calls the nurse at a health care clinic and reports noticing a thin, colorless vaginal drainage. The nurse would make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence."

A nulliparous client asks the nurse when fetal movements will be felt. The nurse responds by telling the client that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

18 weeks

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

A fetal heart rate of 90 beats/minute

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor would the nurse ask the client about to determine this risk?

Presence of cats in the home

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

A private room two doors away from the nurses' station

The nurse is assessing a client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings would the nurse expect to note if abruptio placentae is present?

Abdominal pain Firm uterus by palpation

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction would the nurse provide?

An informed consent needs to be signed before the procedure.

A client with chloasma is extremely stressed about the change in facial appearance. Which integumentary change observed by the nurse is consistent with this problem?

Blotchy brown macules across the cheeks and forehead

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

Continue to monitor the client.

A client who is 8 weeks' pregnant calls the prenatal clinic and tells nurse about experiencing nausea and vomiting every morning. The nurse would suggest which measure that will best promote relief of the signs and symptoms?

Eating dry crackers before arising

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)?

Fetal heart rate of 180 beats per minute

Which assessment following an amniotomy would be conducted first?

Fetal heart rate pattern

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia?

Proteinuria Hypertension

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

Provide pain relief measures.

The nurse is assessing a client who is at 28 weeks' gestation and is complaining of pelvic pain. The client is diagnosed with symphysis pubis dysfunction. The nurse explains that this condition occurs in response to hormones inducing joint instability and widening in the pelvis to accommodate childbirth. The nurse would explain to the client that which hormones increase joint laxity?

Relaxin Progesterone

List in order of priority the actions the nurse would take when a client in labor is experiencing eclampsia?

Remain with the client. Ensure that the client's airway is open, turn the client to the side, and provide 8 to 10 L/min of oxygen. Monitor fetal heart rate patterns. Administer medications to control seizure. Insert an oral airway after the seizure ends and suction the client's mouth. Document the occurrence, client's response, and outcome.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse would place the client in which position?

Supine position with a wedge under the right hip

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise would the nurse instruct the client to engage in?

Swimming

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How would the nurse interpret this finding?

The client is measuring normal for gestational age.

A pregnant client is diagnosed with tuberculosis. Which instruction would the nurse provide to the client regarding therapeutic management of tuberculosis?

The newborn will be tested at birth and may be started on preventive therapy.

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction would the nurse provide to the client?

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

The nurse is providing education to a client with pregestational diabetes who is at 8 weeks' gestation and the client's partner. The nurse describes measures to take during a hypoglycemic episode. The client's partner asks the nurse how to respond if the client is hypoglycemic and becomes unconscious. The nurse would tell the client and partner that which is the most appropriate action?

Administer intramuscular glucagon.

A client arrives at the clinic for the first prenatal assessment. The client tells the nurse that the first day of the last normal menstrual period was October 19, 2023. Using Näegele's rule, which expected date of delivery would the nurse plan to document in the client's chart?

July 26, 2024

The goal for a client with partial premature separation of the placenta is: "The client will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved?

Moderate variability present

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal?

Pale straw in color, with flecks of vernix

On assessment of the fetal heart rate (FHR) of a laboring client, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations?

Periodic, early decelerations that indicate fetal head compression

The nurse is assessing a client who is 12 weeks pregnant when the client expresses worry about contracting COVID-19. The client asks the nurse about adverse outcomes related to COVID-19 during pregnancy. How would the nurse respond?

Pregnant people are more likely to become severely ill if infected with COVID-19.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a loss of variability. What is the initial nursing action?

Turn the client on the side and administer oxygen by face mask at 8 to 10 L/min.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding would the nurse expect to note if this condition is present?

Uterine tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that that "my water broke" before coming to the hospital. What is the appropriate nursing action?

Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse would provide the client with which information?

Glucose crosses the placenta

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

"I need to lie on my back to perform the procedure."

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, would alert the nurse to a potential psychosocial problem?

"I want to gain only 10 pounds because I want to have a small, petite baby."

The nurse is discussing home care instructions with a client at 32 weeks' gestation diagnosed with vulvar varicose veins. Which statement made by the client indicates a need for further teaching?

"I will avoid lying on my left side in bed."

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem?

"I will eat fresh fruits and vegetables for snacks and for dessert each day."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nurse is providing instructions to a client who is at 26 weeks' gestation and is scheduled for a 3-hour glucose tolerance test due to a positive 1-hour glucose tolerance test result. Which client statement would indicate to the nurse that there is a need for further teaching?

"I would follow a low-carbohydrate diet for at least 3 days prior to the test."

The nurse is reviewing the medical record of a client scheduled for a weekly prenatal appointment. The nurse notes that the client has been diagnosed with mild preeclampsia. Which interventions would the nurse include in planning nursing care for this client?

Assess blood pressure. Check the urine for protein. Assess deep tendon reflexes. Teach the importance of keeping track of a daily weight.

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast/chest tenderness. Which instruction would the nurse provide?

Wash the breasts/chest with warm water and keep them dry.