Pregnancy and Reproduction

105. The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?

"The presenting part is at the true pelvis and is engaged."

53. The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on?

Accepting the pregnancy

67. The nursing instructor has completed a session on the induction of labor and how it is occurring more frequently. The instructor determines the session is successful when the students correctly choose which factor to be contributing to the increased induction rates?

Elective inductions by choice of both physician and client

51. A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet?

Fortified cereals

54. The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?

rubella

87. A 25-year-old client at 22 weeks gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and alert the RN or health care provider?

Initial BP 100/70 mm Hg: current BP 140/90 mm Hg

39. A client calls to cancel an appointment for the first prenatal visit after reporting a home pregnancy test is negative. Which instruction should the nurse prioritize?

Keep the appointment.

20. A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?

The client reports back pain, and the cervix is effacing and dilating.

3. A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?

amniocentesis

28. The primigravida client is surprised by the continued uterine contractions while holding her new baby. Which explanation by the nurse will best explain these contractions?

Seals off the blood vessels at the site of the placenta

25. The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine?

Slow respiration, less than 12 breaths per minute

2. The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?

positive home pregnancy test

10. A client at 19 weeks' gestation reports continued alcohol use 1 to 2 times each week to the nurse at her prenatal visit. Which suggestion should the nurse prioritize for this client?

Alcohol should not be consumed during pregnancy.

1. A woman dilated to 10 centimeters and feeling the urge to "have a bowel movement" is refusing to push and is screaming,. "t hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?

Pudendal block

23. A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?

Rest when possible with feet elevated at or above the heart.

52. A client at 40 weeks' gestation informs the nurse that she is tired of being pregnant. What is the best response from the nurse?

That is a very normal feeling, especially at this point in pregnancy."

103. The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?

meats

8. A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?

10 dipstick value of 2+ for protein

70. The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?

110 to 160 bpm

6. A client in the latent phase of the first stage of labor is noted to be uncomfortable with Intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action?

Ambulation ad lib

7. The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure?

Amniocentesis

90. A pregnant client in her second trimester reports feeling tired all the time. The nurse notes pale skin and low normal hemoglobin on assessment. Which recommendation should the nurse prioritize for this client?

An iron supplement

43. During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency?

Hair loss and hair that is easily removed from the scalp

29. The nurse is appraising the post birth laboratory results of a client and discovers the WBC is 22,000 cells/mcl The nurse predicts which action should be prioritized in response?

None, a normal variation due to labor

19. A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!' Which action should the nurse prioritize?

Quickly evaluate the perineum.

100. A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?

Reassuring; it is associated with normal acid-base balance.

106. The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?

Risk for injury: postpartum hemorrhage related to uterine atony

83. The client has been progressing well through the labor process and the health care provider prepares to deliver the infant and performs an episiotomy. The nurse predicts which situation is the reason for this procedure?

Shoulder dystocia

96. The nursing instructor is teaching a group of student nurses about the current use of episiotomies during the labor process. The instructor determines the session is successful when the students correctly choose which situation that may require the health care provider to perform an episiotomy?

Shoulder dystocia

59. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?

The patient has lost 10 pounds (4.5 kg) during the last month.

65. A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth?

The viral load

49. The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting?

Watch it and report if heavy increase in bleeding.

107. A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia instead of an epidural. Which medication will the nurse prepare to give the client first?

antacid

48. During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?

essential fatty acid

92. The nurse is teaching a pregnant client some nonpharmacologic ways to handle common situations encountered during pregnancy. The nurse determines the session is successful when the client correctly chooses which condition that can be minimized if she avoids drinking fluids with her meals?

heartburn

72. A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?

transvaginal ultrasound

57. The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder?

trichomoniasis

27. A client with limited prenatal care presents in labor and is requesting a VBAC. What is the nurse's response after verifying the client had a classical incision with the last cesarean delivery?

Based on your history, a vaginal delivery is not recommended, it might cause your uterus to rupture."

86. The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. What action should the nurse prioritize?

Check the chart for the last void,

55. The nurse is comforting and listening to a young couple who just suffered a miscarriage. When asked why this happened, which reason should the nurse share as a common cause?

Chromosomal abnormality

89. An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion but the cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action should the LPN prioritize?

Consult with the RN about offering the client a chance to speak with a psychiatrist.

109. The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxdety for the client?

Continuous labor support

35. A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?

Decrease activity and rest more often.

44. The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and Points: confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variablity with no late decelerations. Which action should the nurse prioritize?

Help the client regain control of her breathing technique.

45. The nurse is educating a patient with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply.

Hypertension Increased risk of spontaneous abortion Polyhydramnios

9. The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?

If I have changes in my vision, I will lie down and rest."

110. An infant is born to a mother with gestational diabetes. Which long-term maternal complication is associated with this diagnosis?

Increased risk of development of type 2 diabetes

91. A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxda. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending?

Palpate the area just above the symphysis pubis.

64. The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize?

Place an ice pack.

24. The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy?

Polyhydramnios

71. The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team, The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPNLVN members of the team?

Provide care under the supervision of an RN

108. A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?

Stop and walk every two hours.

101. The nurse is monitoring a client at 41 weeks' gestation receiving V oxytocin. Which action should the nurse prioritize if noticeable contractions are occurring every 2 minutes, lasting 60 to 90 seconds on the fetal monitor?

Stop the IV oxytocin infusion

32. At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment the client is dilated to 4 cm with contractions every 1 minute and increased signs of fetal distress. What action should the nurse prioritize after noting the time is now 1200 hrs?

Stop the oxytocin infusion.

62. The nurse is assessing a pregnant client in her third trimester who is reporting a first- time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?

The intestines are displaced by the growing fetus.

22. The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications.

111. During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations?

This measurement indicates that the patient is overweight and should follow a plan of djet and exercise to lose weight, mand should continue with current lifestyle.

30. The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper?

blue

34. The nurse is assessing a 37-year-old woman, pregnant with twins in her second trimester, and notes the following over the past 3 visits: blood pressure 128/88, 134/90, and 130/86. Which nutritional supplement should the nurse suggest the client take?

calcium

95. The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize?

hemorrhage/

13. The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize?

not to attempt another pregnancy for at least 3 months.

4. The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?

Darkened breast areolae

21. The LPNLVN is caring for a client who is scheduled for a cesarean delivery. The nurse points out to the client that during which stage of the process a different nurse will be the primary caregiver?

immediate postoperative

78. The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

inability to push

16. A nurse working at the local health district clinic assists numerous adolescents who become pregnant. Which factor will the nurse point out to each teen is crucial for a positive pregnancy outcome?

support network

38. The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. To the client with which condition will the nurse stress the importance of frequent office visits to monitor her progress?

A molar pregnancy

79. The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

Fear of pain during labor

33. The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?

Maintain a daily blood glucose log

61. The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?

Neglects to engage or provide care or show interest in infant.

94. A pregnant woman at 38 weeks' gestation is receiving care for preeclampsla and suddenly complains of sharp abdominal pain. Which action should the nurse prloritize If the nurse notes a firm, distended and painful abdomen and dark red vaginal bleeding?

Obtain a full set of vital signs.

42. The nursing instructor is leading a group discussion on the various types of delivery. The instructor determines the session is successful when the students correctly categorize forceps or vacuum-assisted delivery as what type?

Operative vaginal delivery

18. A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta

12. A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

Support the client's decision and call the obstetrician.

69. A primigravidia client at 38 weeks' gestation calls the clinic and reports, 'My baby is lower and it is more difficult to walk.' Which response should the nurse prioritize?

The baby has dropped into the pelvis, your body and baby are getting ready for labor in the next few weeks.

37. The nurse is caring for a client who has remained in stable condition at 37 weeks gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?

Vaginal bleeding and no pain

11. For the past 18 hours, the client has been progressing slowly in labor in spite of various attempts to encourage the labor. The health care provider decides a cesarean delivery is necessary to ensure the well-being of both the mother and fetus. The nurse should point out to the client that this is due to which situation?

dystocia

36. The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

engagement

47. The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

involution

82. The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and 'ready to see the baby.' The nurse interprets this to mean the client is in which stage or phase of labor?

latent phase

41. The client is asking the nurse about the various options for pain relief and requests more information about the intradermal water injection her sister had. When explaining the procedure, the nurse should point out these injections are given at which location?

lower back

84. The nurse is preparing a client for treatment to ripen her cervix in anticipation of labor When comparing the various options for the client, which one will the nurse point out provides an oral option?

misoprostol

26 A 24-year-old client presents in labor The nurse notes there is an order to administer RhoGAM after the birth of her infantWhen asked by the client the reason for this injection, which reason should the nurse point out?

prevent maternal D antibody formation

58. A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. The nurse notes on assessment cool, clammy skin, confusion, and vital signs: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize?

rule out shock

76. The nurse is caring for a pregnant client who has a class I heart disease. The nurse is prepared to intensify monitoring during which period of the pregnancy?

second trimester

17. A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?

Body secreting the excess fluids from pregnancy

56. A pregnant patient with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:

check her blood sugars frequently and adjust insulin accordingly.

46. A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?

chronic villus sampling

80. A pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records?

G3 TO P2 A1 L2

74. A 17-year-old primigravida at 37 weeks' gestation has been unable to maintain adequate control of her blood glucose throughout her pregnancy. The nurse should prioritize which action after the health care provider suspects the infant has macrosomia based on the recent ultrasound?

Prepare for assessment of fetal lung maturity.

15. The nurse is assessing a 35-year-old Hispanic woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dL, hemoglobin 13 g/dL, and hematorcrit 37%. Based on these results which instruction should the nurse prioritize?

Take daily iron supplements.

5. A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client?

With a pillow under her right hip

102. The nursing instructor has finished leading a general discussion with a group of nursing students exploring the labor and birthing process. The instructor determines the session is successful when the students correctly state which goal should be a priority?

Work with the labor client to plan pain management options.

98. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI of 31. How should the nurse instruct this patient?

You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

75. The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately?

relaxation

14. A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?

"I will let the doctor know so you can discuss your medications. In the meantime, 'il give you a list of folate-rich foods you can add to your diet."

31. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?

24 hour recall

66. The nursing instructor is preparing to illustrate the various changes between the nonpregnant and pregnant female body. The instructor should point out the blood volume in the pregnant woman can increase by what percentage?

40% to 45%d

93. A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?

Before reporting to the RN, determine the uterine contraction pattern.

77. The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role a mother by performing which actions of the first stage of adaptation?

Beginning attachment and preparation for family

104. A client has been admitted for induction of labor and is asking the nurse what happens next. The nurse should point out that the health care provider will conduct which evalution to determine what happens next?

Bishop score system

97. The health care provider has ordered a cesarean dellvery for an exhausted client who has been in labor for many hours with the fetus now showing increasing signs of distress. As the client and partner express disappointment in not having a natural birth (and anxiety in not knowing what will now happen), which response will the nurse prioritize?

Briefly describe what will be experienced, explain each procedure, and encourage the partner to participate.

60. The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4. three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry?

Clear liquids but no solid food

40. The nurse is monitoring a client who is in the second stage of labor, at 2+ station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

Encourage her through the contractions, explaining why she cannot receive any pain medication.

99. A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stablizing. The nurse notes on routine assessment the client sleeping, lying on her side and EFM showing gradually increasing baseline with late decelerations. Which action should the nurse prioritize?

Notify the primary care provider or RN STAT.

50. The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus?

The gloves they provide irritate my hands, so I don't use them."

85. The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage?

cervix

81. The nurse is assessing a new client who is being admitted for induction of labor. The client is very upset and keeps mentioning that she has an infection. The nurse interprets this to indicate the client most likely has which condition?

chorioamniotitis

73. A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?

ectopic pregnancy

68. The nurse is assessing a client with type I diabetes who has just been informed she is 8 weeks pregnant. The nurse should explain that her health care provider will probably refer her to which specialist to assist with this high-risk pregnancy?

perinatologist

88. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?

24 hour recall

63. The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right The nurse determines that this is most likely related to which situation?

bladder distension