Antepartum care

1. A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses? ■ 1. "I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy." ■ 2. "My boyfriend can buy Plan B from the pharmacy if he is over 18 years old." ■ 3. "The birth control works by preventing ovulation or fertilization of the egg." ■ 4. "I may feel nauseated and have breast tenderness or a headache after using the contraceptive."

1. 1. Plan B is a series of contraceptive pills similar in composition to birth control pills that have been used for the past 30 years. Plan B is the brand name for levonorgestrel 0.75 mg. Pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later. Males can purchase this contraceptive as long as they are over 18 years of age. Common side effects include nausea, breast tenderness, vertigo, and stomach pain. CN: Physiological adaptation; CL: Evaluate

10. A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning? ■ 1. Using a spermicide with the condom offers added protection against pregnancy. ■ 2. Natural skin condoms protect against sexually transmitted diseases. ■ 3. The typical failure rate for couples using condoms is about 25%. ■ 4. Condom users

10. 1. The typical failure rate of a condom is approximately 12% to 14%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy. Natural skin condoms do not offer the same protection against sexually transmitted diseases caused by viruses as latex condoms do. Unlike latex condoms, natural skin (membrane) condoms do not prevent the passage of viruses. Most condom users report decreased penile gland sensitivity. However, some users do report an increased sensitivity or allergic reaction (such as a rash) to latex, necessitating the use of another method of family planning or a switch to a natural skin condom. CN: Health promotion and maintenance; CL: Apply

100. A woman who has had asthma since she was a child and it is under control when the client takes her medication correctly and consistently is now pregnant for the first time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction? ■ 1. "I need to continue taking my asthma medication as prescribed." ■ 2. "It is my goal to prevent or limit asthma attacks." ■ 3. "During an asthma attack, oxygen needs continue to be high for mother and fetus." ■ 4. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

100. 4. Asthma medications and bronchodilators should be continued during pregnancy as prescribed before the pregnancy began. The medications do not cause harm to the mother or fetus. Regular use of asthma medication will usually prevent asthma attacks. Prevention and limitation of an asthma attack is the goal of care for a client who is or is not pregnant and is the appropriate care strategy. During an asthma attack, oxygen needs continue as with any pregnant client but the airways are edematous, decreasing perfusion. Asthma exacerbations during pregnancy may occur as a result of infrequent use of medication rather than as a result of the pregnancy. CN: Pharmacological and parenteral therapies; CL: Evaluate

101. A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client? ■ 1. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. ■ 2. Refer the client to her health care provider for evaluation and treatment of the pain. ■ 3. Discuss nutritional strategies to decrease the possibility of heartburn. ■ 4. Support the client's use of acetaminophen (Tylenol) to relieve pain.

101. 2. The nurse seeing this client should refer her to a health care provider for further evaluation of the pain. This referral would allow a more defi nitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the infl uence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Tylenol is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems. CN: Management of care; CL: Synthesize

102. A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? ■ 1. Abruptio placentae. ■ 2. Placenta previa. ■ 3. Disseminated intravascular coagulation. ■ 4. Threatened abortion

102. 3. A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," fi rm consistency of the abdomen (abruption) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no complaints of cramping or vaginal bleeding. CN: Management of care; CL: Analyze

103. A 40-year-old client at 8 weeks' gestation has a 3-year-old child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling as genetic screening methods for the expected baby. The nurse is confident that the teaching has been understood when the client states which of the following? ■ 1. "Each test identifies a different part of the infant's genetic makeup." ■ 2. "Chorionic villus sampling can be performed earlier in pregnancy." ■ 3. "The test results take the same length of time to be completed." ■ 4. "Amniocentesis is a more dangerous procedure for the fetus."

103. 2. Chorionic villus sampling (CVS) can be performed from approximately 8 to 12 weeks' gestation, while amniocentesis cannot be performed until between 11 weeks' gestation and the end of the pregnancy. Eleven weeks' gestation is the earliest possible time within the pregnancy to obtain a suffi cient amount of amniotic fl uid to sample. Because CVS take a piece of membrane surrounding the infant, this procedure can be completed earlier in the pregnancy. Amniocentesis and chorionic villus sampling identify the genetic makeup of the fetus in its entirety, rather than a portion of it. Laboratory analysis of chorionic villus sampling takes less time to complete. Both procedures place the fetus at risk and postprocedure teaching asks the client to report the same complicating events (bleeding, cramping, fever, and fluid leakage from the vagina). CN: Management of care; CL: Evaluate

104. After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which of the following? ■ 1. Denial of the pregnancy. ■ 2. Low-birth-weight infant. ■ 3. Cephalopelvic disproportion. ■ 4. Congenital anomalies.

104. 4. Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents are at greater risk for denial of the pregnancy, lack of prenatal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional defi cits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies. CN: Health promotion and maintenance; CL: Evaluate

105. A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which of the following feelings? ■ 1. Ambivalence. ■ 2. Anxiety. ■ 3. Fear. ■ 4. Guilt.

105. 4. With a spontaneous abortion, many clients and their partners feel an acute sense of loss. Their grieving commonly includes feelings of guilt, which may be expressed as wondering whether the woman could have done something to prevent the loss. Anger, sadness, and disappointment are also common emotions after a pregnancy loss. Ambivalence, anxiety, and fear are not common emotions after a spontaneous abortion. CN: Psychosocial adaptation; CL: Analysis

106. When providing care to the client who has undergone a dilatation and curettage (D&C) after a spontaneous abortion, the nurse administers hydroxyzine (Vistaril) as ordered. Which of the following is an expected outcome? ■ 1. Absence of nausea. ■ 2. Minimized pain. ■ 3. Decreased uterine cramping. ■ 4. Improved uterine contractility

106. 1. Hydroxyzine (Vistaril) has a tranquilizing effect and also decreases nausea and vomiting. It does not decrease fl uid retention, reduce pain, decrease uterine cramping, or promote uterine contractility. One of the adverse effects of the medication is sleepiness. Ibuprofen may decrease pain from uterine cramping. Oxytocin may be used to increase uterine contractility. CN: Pharmacological and parenteral therapies; CL: Evaluate

107. On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client crying. Which of the following comments by the nurse would be most appropriate? ■ 1. "Are you having a great deal of uterine pain?" ■ 2. "Commonly spontaneous abortion means a defective embryo." ■ 3. "I'm truly sorry you lost your baby." ■ 4. "You should try to get pregnant again as soon as possible."

107. 3. The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I'm truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappropriate because this is a "yes-no" question and doesn't allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus's demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should get pregnant again as soon as possible is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus. CN: Psychosocial adaptation; CL: Apply

108. Rho(D) immune globulin (RhoGAM) is ordered for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following? ■ 1. Development of a future Rh-positive fetus. ■ 2. An antibody response to Rh-negative blood. ■ 3. A future pregnancy resulting in abortion. ■ 4. Development of Rh-positive antibodies.

108. 4. Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rhnegative mothers do not develop sensitivities if the fetus is also Rh negative. CN: Pharmacological and parenteral therapies; CL: Apply

109. A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which of the following instructions would be helpful? ■ 1. Perform slow contraction and relaxation of the feet and ankles twice daily. ■ 2. Take frequent rest periods with the legs elevated above the hips. ■ 3. Avoid support hose that reach above the leg varicosities. ■ 4. Take a leave of absence from your job to avoid prolonged standing.

109. 2. The client with leg varicosities should take frequent rest periods with the legs elevated above the hips to promote venous circulation. The client should avoid constrictive clothing, but support hose that reach above the varicosities may help alleviate the pain. Contracting and relaxing the feet and ankles twice daily is not helpful because it does not promote circulation. Taking a leave of absence from work may not be possible because of economic reasons. The client should try to rest with her legs elevated or walk around for a few minutes every 2 hours while on the job. CN: Reduction of risk potential; CL: Synthesis

11. Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning? ■ 1. Douching with an acidic solution after intercourse is recommended. ■ 2. Diaphragms should not be used if the client develops acute cervicitis. ■ 3. The diaphragm should be washed in a weak solution of bleach and water. ■ 4. The diaphragm should be le

11. 2. The teaching plan should include a caution that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with increased incidence of urinary tract infections. Douching after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermicidal jelly or cream should be used if intercourse is repeated during this period. CN: Reduction of risk potential; CL: Create

110. A multigravid client at 36 weeks' gestation has been diagnosed with condylomata acuminata. Which of the following should the nurse include when teaching the client about the disorder and current therapies? ■ 1. Cryotherapy may be used to remove the warts. ■ 2. Podophyllin solution may be used to decrease the size of the warts. ■ 3. A 25% trichloroacetic acid solution can eradicate the disorder. ■ 4. Condylomata acuminata has been associated with ovarian cancer.

110. 1. Cryotherapy, electrocautery, or laser therapy may be used to remove the genital warts. Podophyllin solution should not be used to decrease their size while the client is pregnant, because fetal malformations may result. A 25% trichloroacetic acid solution can decrease the size of the warts, but because this disease is caused by a virus, the disorder may recur. Condylomata acuminata has been associated with cervical cancer, and the client should have semiannual or annual Pap smears to detect cervical dysplasia. CN: Pharmacological and parenteral therapies; CL: Create

111. A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flulike symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a physician because the nurse suspects which of the following sexually transmitted diseases? ■ 1. Gonorrhea. ■ 2. Chlamydia trachomatis infection. ■ 3. Syphilis. ■ 4. Herpes genitalis.

111. 4. The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. C. trachomatis infection in women is commonly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre. CN: Physiological adaptation; CL: Apply

112. While caring for a 24-year-old primigravid client scheduled for emergency surgery because of a probable ectopic pregnancy, the nurse should: ■ 1. Prepare to witness an informed consent for surgery. ■ 2. Assess the client for massive external bleeding. ■ 3. Explain that the fallopian tube can be salvaged. ■ 4. Monitor the client for uterine contractions.

112. 1. The client may need surgery to remove a ruptured fallopian tube where the pregnancy has occurred, and the nurse is usually responsible for witnessing the signature on the informed consent. Typically, if bleeding is occurring, it is internal and there is only scant vaginal bleeding with no discoloration. The nurse cannot determine whether the fallopian tube can be salvaged; this can be accomplished only during surgery. If the tube has ruptured, it must be removed. If the tube has not ruptured, a linear salpingostomy may be done to salvage the tube for future pregnancies. With an ectopic pregnancy, although the client is experiencing abdominal pain, she is not having uterine contractions. CN: Physiological adaptation; CL: Synthesize

113. A 30-year-old G 4, P 3 client at 30 weeks' gestation is admitted to the hospital for evaluation. The client has experienced two neonatal deaths because of hemolytic disease of the newborn. An amniocentesis is to be performed to evaluate bilirubin density. The nurse should obtain a specimen container that is which of the following? ■ 1. Dark. ■ 2. Clear. ■ 3. Green. ■ 4. Amber.

113. 1. The optical density of the amniotic fl uid is evaluated for bilirubin level with a spectrophotometer. The higher the optical density, the more bilirubin is present in the fl uid, indicating that fetal red blood cells are being destroyed. From these fi ndings, the severity of the disease can be estimated. Because light destroys bilirubin, specimens should be kept in a dark container until the analysis is complete. A clear, green, or amber container would allow light to enter, thus destroying bilirubin. CN: Reduction of risk potential; CL: Apply

114. The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrants prompt notification of the health care provider and a further plan of care? ■ 1. Primigravida who reports fetal movement 6 times in 2 hours. ■ 2. Multigravida who had a positive oxytocin challenge test. ■ 3. Primigravida whose infant has a biophysical profile of 9. ■ 4. Multigravida whose infant has a reactive nonstress test.

114. 2. Late decelerations during an oxytocin challenge test indicate that the infant is not receiving enough oxygen during contractions and is exhibiting signs of utero-placental insuffi ciency. This client would need further medical intervention. Fetal movement 6 times in 2 hours is adequate in a healthy fetus and a biophysical profi le of 9 indicates that the risk of fetal asphyxia is rare. A reactive nonstress test informs the health care provider that the fetus has 2 fetal heart rate accelerations of 15 beats per minute above baseline and lasting for 15 seconds within a 20-minute period, which is a reassuring result and an indication of fetal well-being. CN: Management of care; CL: Evaluate

115. A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: ■ 1. "Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers." ■ 2. "Eating foods with moderate amounts of folic acid helps regulate blood glucose levels." ■ 3. "Folic acid consumption helps with the absorption of iron during pregnancy." ■ 4. "Folic acid is needed to promote blood clotting and collagen formation in the newborn."

115. 1. Folic acid supplementation is recommended to prevent neural tube defects and anemia in pregnancy. Defi ciencies increase the risk of hemorrhage during delivery as well as infection. The recommended dose prior to pregnancy is 400 mcg/ day; while breast-feeding and during pregnancy, the recommended dosage is 500 to 600 mcg/day. Blood glucose levels are not regulated by the intake of folic acid. Vitamin C potentiates the absorption of iron and is also associated with blood clotting or collagen formation. CN: Reduction of risk potential; CL: Apply

117. The health care provider at a prenatal clinic has ordered multivitamins for a woman who is 3 months' pregnant. The client calls the nurse to report that she has gone to the pharmacy to fi ll her prescription but is unable to buy it as it costs too much. The nurse should refer the client to: ■ 1. The charge nurse. ■ 2. The hospital finance office. ■ 3. Her hospital social worker. ■ 4. Her insurance company.

117. 3. The social worker is available to assist the client in fi nding services within the community to meet client needs. This individual is able to provide the names of pharmacies within the community that offer generic substitutes or others that utilize the client's insurance plan. The charge nurse of the unit would be able to refer the client to the social worker. The hospital finance office does not handle this type of situation and would refer the client back to the unit. The client's insurance company deals with payments for health care and would refer the client back to the local setting. CN: Management of care; CL: Apply

12. After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching? ■ 1. "I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case." ■ 2. "If I get pregnant, I will have to be refi tted for another diaphragm after the delivery." ■ 3. "Before inserting the diaphragm I should coat the rim with contraceptive jelly." ■ 4. "If I gain or lose 20 lb, I can still use the same diaphragm."

12. 4. The client would need additional instructions when she says that she can still use the same diaphragm if she gains or loses 20 lb. Gaining or losing more than 15 lb can change the pelvic and vaginal contours to such a degree that the diaphragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case. The client should be refitted for another diaphragm after pregnancy and delivery of a newborn because weight changes and physiologic changes of pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm. The client should use a spermicidal jelly or cream before inserting the diaphragm. CN: Reduction of risk potential; CL: Evaluate

13. A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the incidence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods? Select all that apply. ■ 1. Leafy green vegetables. ■ 2. Strawberries. ■ 3. Beans. ■ 4. Milk. ■ 5. Sunfl ower seeds. ■ 6. Lentils.

13. 1,2,3,5,6. The pregnancy requirement for folic acid is 600 micrograms/day. Major sources of folic acid include leafy green vegetables, strawberries and oranges, beans, particularly black and kidney beans, sunflower seeds, and lentils. Milk and fats contain no folic acid. CN: Health promotion and maintenance; CL: Apply

14. A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan? ■ 1. "Another method of contraception is needed until the sperm count is 0." ■ 2. "Vasectomy is easily reversed if children are desired in the future." ■ 3. "Vasectomy is contraindicated in males with prior history of cardiac disease." ■ 4. "Vasectomy requires only a yearly follow-up once the procedure is completed."

14. 1. Another method of contraception is needed until all sperm has been cleared from the body. The number of ejaculates for this to occur varies with the individual and laboratory analysis is required to determine when that has been accomplished. Vasectomy is considered a permanent sterilization procedure and requires microsurgery for anastomosis of the vas deferens to be completed. Studies have shown that there is no connection between cardiac disease in males and vasectomy. There is no need for follow-up once verification there is no sperm in the system. CN: Physiological adaptation; CL: Create

15. A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching? ■ 1. "My fallopian tubes will be tied off through a small abdominal incision." ■ 2. "Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%." ■ 3. "After this procedure, I must abstain from intercourse for at least 3 weeks." ■ 4. "Both of my ovaries will be removed during the tubal ligation procedure."

15. 1. Tubal ligation, a female sterilization procedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy). Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the client may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries. CN: Health promotion and maintenance; CL: Evaluate

16. A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following? ■ 1. Check the cervical mucus to see if it is thick and sparse. ■ 2. Take her temperature at the same time every morning before getting out of bed. ■ 3. Document ovulation when her temperature decreases at least 1° F. ■ 4. Avoid coitus for 10 days after a slight rise in temperature.

16. 2. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5° F. At the time of ovulation, the temperature rises 0.4° to 0.8° F because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy. CN: Health promotion and maintenance; CL: Apply

17. A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit? ■ 1. Choose an appropriate infertility treatment method. ■ 2. Acknowledge that only 50% of infertile couples achieve a pregnancy. ■ 3. Discuss alternative methods of having a family, such as adoption. ■ 4. Describe each of the potential causes and possible treatment modalities.

17. 4. By the end of the fi rst visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be diffi cult, painful, or risky. The fi rst visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for defi nitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insuffi cient data are available to suggest that a specifi c treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility. CN: Health promotion and maintenance; CL: Analyze

18. A client is scheduled to have in vitro fertilization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure? ■ 1. "IVF requires supplemental estrogen to enhance the implantation process." ■ 2. "The pregnancy rate with IVF is higher than that with gamete intrafallopian transfer." ■ 3. "IVF involves bypassing the blocked or absent fallopian tubes." ■ 4. "Both ova and sperm are instilled into the open end of a fallopian tube."

18. 3. The client's understanding of the procedure is demonstrated by the statement describing IVF as a technique that involves bypassing the blocked or absent fallopian tubes. The physician removes the ova by laparoscope- or ultrasound-guided transvaginal retrieval and mixes them with prepared sperm from the woman's partner or a donor. Two days later, up to four embryos are returned to the uterus to increase the likelihood of a successful pregnancy. Supplemental progesterone, not estrogen, is given to enhance the implantation process. Gamete intrafallopian transfer (GIFT) and tubal embryo transfer have a higher pregnancy rate than IVF. However, these procedures cannot be used for clients who have blocked or absent fallopian tubes because the fertilized ova are placed into the fallopian tubes, subsequently entering the uterus naturally for implantation. In IVF, fertilization of the ova by the sperm occurs outside the client's body. In GIFT, both ova and sperm are implanted into the fallopian tubes and allowed to fertilize within the woman's body. CN: Reduction of risk potential; CL: Evaluate

19. A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal delivery. Which of the following responses would be most helpful? ■ 1. "Today's modern technology has resulted in a low maternal mortality rate." ■ 2. "Don't concern yourself with things that happened in the past." ■ 3. "In the United States, mothers seldom die in childbirth." ■ 4. "What is it that concerns you about pregnancy, labor, and delivery?"

19. 4. The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Asking the client about these concerns would be most helpful to determine the client's knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconceptions. Although the maternal mortality rate is low in the United States, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring the client's need for a discussion about complications of pregnancy may further increase the client's anxiety. CN: Health promotion and maintenance; CL: Apply

2. An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options? ■ 1. Satisfaction with prior methods. ■ 2. Preference of sexual partner. ■ 3. Breast- or bottle-feeding plan. ■ 4. History of clotting disease.

2. 3. Birth control plans are infl uenced primarily by whether the mother is breast- or bottle-feeding her infant. The maternal milk supply must be well established prior to the initiation of most hormonal birth control methods. Low dose oral contraceptives would be the exception. Use of estrogen/progesterone based pills and progesterone only pills are commonly initiated from 4 to 6 weeks postpartum because the milk supply is well established by this time. Prior experiences with birth control methods have an impact on the method chosen as does the preferences of the client's partner; however, they are not the most influential factors. A history of blood clots or thrombophlebitis is the second most important factor as several methods will be eliminated because of their potential to place the client at risk for clotting disorders. CN: Pharmacological and parenteral therapies; CL: Analysis

20. A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan? ■ 1. About midway through the menstrual cycle, cervical mucus is thick and sticky. ■ 2. During ovulation, the cervix remains dry without any mucus production. ■ 3. As ovulation approaches, cervical mucus is abundant and clear. ■ 4. Cervical mucus disappears immediately after ovulation, resuming with menses.

20. 3. As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (plus or minus 2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present. CN: Health promotion and maintenance; CL: Create

21. When instructing a client about the proper use of condoms for pregnancy prevention, which of the following instructions would be included to ensure maximum effectiveness? ■ 1. Place the condom over the erect penis before coitus. ■ 2. Withdraw the condom after coitus when the penis is fl accid. ■ 3. Ensure that the condom is pulled tightly over the penis before coitus. ■ 4. Obtain a prescription for a condom with nonoxynol 9.

21. 1. To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples fi nd condom use objectionable because foreplay may have to be interrupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes fl accid. Otherwise sperm may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescription for a condom with nonoxynol 9 because these are sold over the counter. CN: Reduction of risk potential; CL: Apply

22. A multigravid client will be using medroxyprogesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? ■ 1. "This method of family planning requires monthly injections." ■ 2. "I should have my first injection during my menstrual cycle." ■ 3. "One possible adverse effect is absence of a menstrual period." ■ 4. "This drug will be given by subcutaneous injections."

22. 3. With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are common adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramuscular injections every 3 months. The first injection should occur within 5 days after menses. CN: Reduction of risk potential; CL: Evaluate

23. Which of the following instructions should the nurse include in the teaching plan for a 30-yearold multiparous client who will be using an intrauterine device (IUD) for family planning? ■ 1. Amenorrhea is a common adverse effect of IUDs. ■ 2. The client needs to use additional protection for conception. ■ 3. IUDs are more costly than other forms of contraception. ■ 4. Severe cramping may occur when the IUD is inserted.

23. 4. Severe cramping and pain may occur as the device is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses, because it is unlikely that she is pregnant at that time. Common adverse effects of IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea. Uterine infection or ectopic pregnancy may occur. The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are less costly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use. CN: Reduction of risk potential; CL: Apply

24. After counseling a 35-year-old client about breast self-examination and mammography, the nurse determines that the client has understood the instructions when the client states which of the following? ■ 1. "I should have a mammogram every year once I'm 40." ■ 2. "I should schedule a mammography examination during my menstrual period." ■ 3. "Mammography screening is inexpensive." ■ 4. "Mammography is an extremely painful procedure."

24. 1. The American Cancer Society recommends an annual mammography screening examination for all women after the age of 40. Some high-risk women may begin annual screening at an earlier age. Some women have never had a mammogram because of fear or misconceptions. Mammography should be scheduled after the client's menses to reduce complaints of breast tenderness. Mammography screening is considered expensive, especially by low-income women. Although some discomfort is common because the breast is placed between two plates during the screening process, the procedure should not be considered extremely painful. CN: Health promotion and maintenance; CL: Evaluate

25. After instructing a 40-year-old woman about osteoporosis after menopause, the nurse determines that the client needs further instruction when the client states which of the following? ■ 1. "One cup of yogurt is the equivalent of one glass of milk." ■ 2. "Women who do not eat dairy products should consider calcium supplements." ■ 3. "African American women are at the greatest risk for osteoporosis." ■ 4. "Estrogen therapy at menopause can reduce the risk of osteoporosis."

25. 3. Small-boned, fair-skinned women of northern European descent are at the greatest risk for osteoporosis, not African American women. One cup of yogurt or 1.5 oz of hard cheese is the equivalent of one glass of milk. Women who do not eat dairy products, such as women who are lactose intolerant, should consider using calcium supplements. Inadequate lifetime intake of calcium is a major risk factor for osteoporosis. Estrogen therapy, or some of the newer medications that are not estrogen based, can greatly reduce the incidence of osteoporosis. CN: Reduction of risk potential; CL: Evaluate

26. When developing a teaching plan for an 18 year old client who asks about treatments for sexually transmitted diseases, the nurse should explain that? ■ 1. Acyclovir (Zovirax) can be used to cure herpes genitalis. ■ 2. Chlamydia trachomatis infections are usually treated with penicillin. ■ 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections. ■ 4. Metronidazole (Flagyl) is used to treat condylomata acuminata.

26. 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections and is commonly combined with doxycycline hyclate (Vibramycin). Both the client and her partner should be treated if gonorrhea is present. Acyclovir (Zovirax) can be used to treat herpes genitalis; however, the drug does not cure the disease. Chlamydia trachomatis infections are usually treated with antibiotics such as doxycycline or azithromycin (Zithromax). Metronidazole (Flagyl) is used to treat trichomoniasis vaginalis, not condylomata acuminata (genital warts). CN: Pharmacological and parenteral therapies; CL: Create

37. After instructing a female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states that which of the following hormones is evaluated by this test? ■ 1. Prolactin. ■ 2. Follicle-stimulating hormone. ■ 3. Luteinizing hormone. ■ 4. Human chorionic gonadotropin (hCG).

37. 4. The hormone analyzed in most pregnancy tests is hCG. In the pregnant woman, trace amounts of hCG appear in the serum as early as 24 to 48 hours after implantation owing to the trophoblast production of this hormone. Prolactin, folliclestimulating hormone, and luteinizing hormone are not used to detect pregnancy. Prolactin is the hormone secreted by the pituitary gland to prepare the breasts for lactation. Follicle-stimulating hormone is involved in follicle maturation during the menstrual cycle. Luteinizing hormone is responsible for stimulating ovulation. CN: Reduction of risk potential; CL: Evaluate

27. A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. After discussing the various causes of male infertility, the nurse determines that the male partner needs further instruction when he states which of the following as a cause? ■ 1. Seminal fluid with an alkaline pH. ■ 2. Frequent exposure to heat sources. ■ 3. Abnormal hormonal stimulation. ■ 4. Immunologic factors.

27. 1. The client needs further instruction when he says that one cause of male infertility is decreased sperm count due to seminal fl uid that has an alkaline pH. A slightly alkaline pH is necessary to protect the sperm from the acidic secretions of the vagina and is a normal fi nding. An alkaline pH is not associated with decreased sperm count. However, seminal fl uid that is abnormal in amount, consistency, or chemical composition suggests obstruction, infl ammation, or infection, which can decrease sperm production. The typical number of sperm produced during ejaculation is 400 million. Frequent exposure to heat sources, such as saunas and hot tubs, can decrease sperm production, as can abnormal hormonal stimulation. Immunologic factors produced by the man against his own sperm (autoantibodies) or by the woman can cause the sperm to clump or be unable to penetrate the ovum, thus contributing to infertility. CN: Health promotion and maintenance; CL: Evaluate

29. A primagravid client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? ■ 1. "I need to call if I start to leak fluid from my vagina." ■ 2. "If I start bleeding, I will need to call back." ■ 3. "If my baby does not move, I need to call my health care provider." ■ 4. "If I start running a fever, I should let the office know."

29. 3. At 16 weeks' gestation, a primipara will not feel the baby moving. Quickening occurs between 18 and 20 weeks' gestation for a primipara and between 16 and 18 weeks' gestation for a multipara. Leaking fluid from the vagina should not occur until labor begins and may indicate a rupture of the membranes. Bleeding and a fever are complications that warrant further evaluation and should be reported at any time during the pregnancy. CN: Health promotion and maintenance; CL: Evaluate

3. After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self examination, which of the following client statements indicates that the teaching has been successful? ■ 1. "I should perform breast self-examination on the day my menstrual flow begins." ■ 2. "It's important that I perform breast self examination on the same day each month." ■ 3. "If I notice that one of my breasts is much smaller than the other, I shouldn't worry." ■ 4. "If there is discharge from my nipples, I should call my health care provider."

3. 4. The nurse determines that the client has understood the instructions when the client says that she will notify her physician if she notices discharge or bleeding because this may be symptomatic of underlying disease. Ideally, breast self-examination should be performed about 1 week after the onset of menses because hormonal infl uences on breast tissue are at a low ebb at this time. The client should perform breast self-examination on the same day each month only if she has stopped menstruating (as with menopause). The client's breasts should mirror each other. If one breast is significantly larger than the other, or if there is "pitting" of breast tissue, a tumor may be present. CN: Reduction of risk potential; CL: Evaluate

30. During a visit to the prenatal clinic, a pregnant client at 32 weeks' gestation complains of heartburn. The client needs further instruction when she says she must do what? ■ 1. Avoid highly seasoned foods. ■ 2. Avoid laying down right after eating. ■ 3. Eat small, frequent meals. ■ 4. Consume liquids only between meals.

30. 4. Consuming most liquids between meals rather than at the same time as eating is an excellent strategy to deter nausea and vomiting in pregnancy but does not relieve heartburn. During the third trimester, progesterone causes relaxation of the sphincter and the pressure of the fetus against the stomach increases the potential of heartburn. Avoiding highly seasoned foods, remaining in an upright position after eating, and eating small, frequent meals are strategies to prevent heartburn. CN: Physiological adaptation; CL: Evaluate

38. Using Nägele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of delivery would be which of the following? ■ 1. January 13. ■ 2. January 17. ■ 3. February 13. ■ 4. February 17.

38. 4. When using Nägele's rule to determine the estimated date of delivery, the nurse would count back 3 calendar months from the fi rst day of the last menstrual period and add 7 days. This means the client's estimated date of delivery is February 17. CN: Health promotion and maintenance; CL: Apply

31. The nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? ■ 1. "I will need to take iron supplements now." ■ 2. "I may have anemia because my family is of Asian descent." ■ 3. "I am considered anemic if my hemoglobin is below 11 g/dL." ■ 4. "The workload on my heart is increased when there is not enough oxygen in my system."

31. 2. Iron defi ciency anemia is caused by insuffi cient iron stores in the body, poor iron content in the diet of the pregnant woman, or both. Other thalassemias and sickle cell anemia, rather than iron defi ciency anemia, can be associated with ethnicity but occur primarily in clients of African American or Mediterranean origin. Because red blood cells increase by about 50% during pregnancy, many clients will need to take supplemental iron to avoid iron defi ciency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dL. In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells. CN: Reduction of risk potential; CL: Evaluate

32. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which of the following information about changes the client can anticipate in the first trimester? ■ 1. Differentiating the self from the fetus. ■ 2. Enjoying the role of nurturer. ■ 3. Preparing for the reality of parenthood. ■ 4. Experiencing ambivalence about pregnancy.

32. 4. Many women in their fi rst trimester feel ambivalent about being pregnant because of the signifi cant life changes that occur for most women who have a child. Ambivalence can be expressed as a list of positive and negative consequences of having a child, consideration of fi nancial and social implications, and possible career changes. During the second trimester, the infant becomes a separate individual to the mother. The mother will begin to enjoy the role of nurturer postpartum. During the third trimester, the mother begins to prepare for parenthood and all of the tasks that parenthood includes. CN: Health promotion and maintenance; CL: Apply

33. An antenatal primagravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which of the following? ■ 1. Preterm labor. ■ 2. Twin-to-twin transfusion. ■ 3. Anemia. ■ 4. Group B Streptococcus.

33. 4. Group B Streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation. The normal uterus is only able to distend to a certain point and when that point is reached, labor may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestation. The donor twin may become growth restricted and can have oligohydramnios while the recipient twin may become polycythemic with polyhydramnios and develop heart failure. Anemia is a common problem with multiple gestation clients. The mother is commonly unable to consume enough protein, calcium, and iron to supply her needs and those of the fetuses. A maternal hemoglobin level below 11 g/dL is considered anemic. CN: Physiological adaptation; CL: Evaluate

34. A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy? ■ 1. Positive. ■ 2. Probable. ■ 3. Presumptive. ■ 4. Diagnostic.

34. 2. The plan of care should refl ect that this woman is experiencing probable signs of pregnancy. She may be pregnant but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease processes as well as pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound confi rmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word "diagnostic" is not used to describe the condition of pregnancy. CN: Physiological adaptation; CL: Analyze

35. An antenatal client receives education concerning medications that are safe to use during pregnancy. The nurse evaluates the client's understanding of the instructions and determines that she needs further information when she states which of the following? ■ 1. "If I am constipated, Milk of Magnesia is okay but mineral oil is not." ■ 2. "If I have heartburn, it is safe to use Tums, Rolaids, Mylanta, and Maalox." ■ 3. "I can take Tylenol if I have a headache." ■ 4. "If I need to have a bowel movement, Ex-Lax is preferred."

35. 4. Ex-Lax is considered too abrasive to use during pregnancy. In most instances, a Fleet enema will be given before Ex-Lax. Medications for constipation that are considered safe during pregnancy include compounds that produce bulk, such as Metamucil and Citrucel. Colace, Dulcolax, and Milk of Magnesia can also be used. Mineral oil prevents the absorption of vitamins and minerals within the GI tract. The strategies for heartburn are considered safe and Tylenol may be used as an over-the-counter analgesic. CN: Pharmacological and parenteral therapies; CL: Evaluate

36. When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay pregnancy test, the nurse should tell the client which of the following about this test? ■ 1. It has a high degree of accuracy within 1 week after ovulation. ■ 2. It is identical in nature to an over-the-counter home pregnancy test. ■ 3. A positive result is considered a presumptive sign of pregnancy. ■ 4. A urine sample is needed to obtain quicker results.

36. 1. The radioimmunoassay pregnancy test, which uses an antiserum with specifi city for the b-subunit of human chorionic gonadotrophin (hCG) in blood plasma, is highly accurate within 1 week after ovulation. The test is performed in a laboratory. Over-the-counter or home pregnancy tests are performed on urine and use the hemagglutination inhibition method. Radioimmunoassay tests usually use blood serum. A positive pregnancy test is considered a probable sign of pregnancy. Certain conditions other than pregnancy, such as choriocarcinoma, can cause increased hCG levels. CN: Reduction of risk potential; CL: Apply

39. After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is produced by the placenta? ■ 1. Estrogen. ■ 2. Progesterone. ■ 3. Human chorionic gonadotropin (hCG). ■ 4. Testosterone

39. 4. The placenta does not produce testosterone. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. The hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi. CN: Health promotion and maintenance; CL: Evaluate

4. Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Defi cient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client? ■ 1. The ovum survives for 96 hours after ovulation, making conception possible during this time. ■ 2. The basal body temperature falls at least 0.2° F after ovulation has occurred. ■ 3. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. ■ 4. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.

4. 3. For a client with a menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body temperature rises 0.5° to 1.0° F when ovulation occurs. Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious. CN: Health promotion and maintenance; CL: Create

41. A primiparous client at 10 weeks' gestation questions the nurse about the need for an ultrasound. She states "I don't have health insurance and I can't afford it. I feel fi ne, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply. ■ 1. "We must view the gross anatomy of the fetus." ■ 2. "We need to determine gestational age." ■ 3. "We want to view the heart beating to determine that the fetus is viable." ■ 4. "We must determine fetal position." ■ 5. "We must determine that there is a sufficient nutrient supply for the fetus."

40. 4,3,2,1. While initially continuing to attempt to fi nd the fetal heart beat, the nurse can ask the client if the baby has been moving. This will give a quick idea of status. The next step would be to obtain different equipment and attempt to fi nd the fetal heart beat again. A simple statement of fact that the nurse cannot fi nd the heartbeat and is taking steps to rule out equipment error is appropriate. Calling the health care provider would be the last step after it is determined that the baby does not have a heartbeat. CN: Reduction of risk potential; CL: Synthesize

42. A 20-year-old married client with a positive pregnancy test states, "Is it really true? I can't believe I'm going to have a baby!" Which of the following responses by the nurse would be most appropriate at this time? ■ 1. "Would you like some booklets on the pregnancy experience?" ■ 2. "Yes it is true. How does that make you feel?" ■ 3. "You should be delighted that you are pregnant." ■ 4. "Weren't you and your husband trying to have a baby?"

42. 2. This client is expressing a feeling of surprise about having a baby. Therefore, the nurse's best response would be to confi rm the pregnancy, which is something that the client already suspects, and then ascertain how the client is feeling now that the suspicion is confi rmed. Studies have shown that a common reaction to pregnancy is summarized as ambivalence or "someday, but not now." Such feelings are normal and are experienced by many women early in pregnancy. Offering a pamphlet on pregnancy does not respond to the client's feelings. Telling the client that she should be delighted ignores, rather than addresses, the client's feelings. Also, doing so imposes the nurse's opinion on the client. Ambivalence is a common reaction to pregnancy. Telling the client that she should be delighted may lead to feelings of guilt. Asking the client if she and her husband were trying to have a baby is a "yes-no" question and is not helpful. In addition, it ignores the client's underlying feelings. CN: Psychosocial adaptation; CL: Synthesize

43. A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, I'm not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which of the following? ■ 1. Fear of pregnancy outcome. ■ 2. Rejection of the pregnancy. ■ 3. Normal ambivalence. ■ 4. Inability to care for the newborn.

43. 3. Women normally experience ambivalence when pregnancy is confi rmed, even if the pregnancy was planned. Although the client's culture may play a role in openly accepting the pregnancy, most new mothers who have been ambivalent initially accept the reality by the end of the fi rst trimester. Ambivalence also may be expressed throughout the pregnancy; this is believed to be related to the amount of physical discomfort. The nurse should become concerned and perhaps contact a social worker if the client expresses ambivalence in the third trimester. The client's statement reflects ambivalence, not fear. There is no evidence to suggest or imply that the client is rejecting the fetus. The client's statement reflects ambivalence about the pregnancy, not her ability to care for the newborn. CN: Psychosocial adaptation; CL: Analyze

44. A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these findings as suggesting that the client's husband is experiencing which of the following? ■ 1. Ptyalism. ■ 2. Mittelschmerz. ■ 3. Couvade syndrome. ■ 4. Pica.

44. 3. Couvade syndrome refers to the situation in which the expectant father experiences some of the discomforts of pregnancy along with the pregnant woman as a means of identifying with the pregnancy. Ptyalism is the term for excessive salivation. Mittelschmerz is the lower abdominal discomfort felt by some women during ovulation. Pica refers to an oral craving for substances such as clay or starch that some pregnant clients experience. CN: Psychosocial adaptation; CL: Analyze

45. A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which of the following would be the nurse's best response? ■ 1. "The effects of alcohol on a fetus during pregnancy are unknown." ■ 2. "You should limit your consumption to beer and wine." ■ 3. "You should abstain from drinking alcoholic beverages." ■ 4. "You may have 1 drink or 2 oz of alcohol per day."

45. 3. Maternal alcohol use may result in fetal alcohol syndrome, marked by mild to moderate mental retardation, physical growth retardation, central nervous system disorders, and feeding diffi culties. Because there is no defi nitive answer as to how much alcohol can be safely consumed by a pregnant woman, it is recommended that pregnant clients be taught to abstain from drinking alcohol during pregnancy. Smoking and other medications also may affect the fetus. CN: Reduction of risk potential; CL: Apply

59. When performing Leopold's maneuvers, which of the following would the nurse ask the client to do to ensure optimal comfort and accuracy? ■ 1. Breathe deeply for 1 minute. ■ 2. Empty her bladder. ■ 3. Drink a full glass of water. ■ 4. Lie on her left side.

59. 2. Leopold's maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold's maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly. CN: Health promotion and maintenance; CL: Apply

46. Examination of a primigravid client complaining of increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which of the following? ■ 1. A decrease in vaginal glycogen stores. ■ 2. Development of a sexually transmitted disease. ■ 3. Prevention of expulsion of the cervical mucus plug. ■ 4. Control of the growth of pathologic bacteria.

46. 4. An increase in clear, highly acidic vaginal secretions is a normal fi nding during pregnancy that aids in controlling the growth of pathologic bacteria. Vaginal secretions increase because of the infl uence of estrogen secretion and increased vaginal and cervical vascularity. The highly acidic nature of the vaginal secretions is caused by the action of Lactobacillus acidophilus, which increases the lactic acid content of the secretions. The increased acidity helps to make the vagina resistant to bacterial growth. During pregnancy, estrogen secretion fosters a glycogen-rich environment. Unfortunately, this glycogen-rich, acidic environment fosters the development of yeast (Candida albicans) infections, manifested by itching, burning, and a cheese-like vaginal discharge. If the client had a sexually transmitted disease, most likely she would complain of additional symptoms, such as lesions in the genital area or changes in color, consistency, or odor of the vaginal secretions. An increase in vaginal secretions does not help prevent expulsion of the mucus plug. The mucus plug is held in place by the cervix until the cervix becomes ripe. CN: Health promotion and maintenance; CL: Analyze

47. When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points? ■ 1. Halfway between the client's symphysis pubis and umbilicus. ■ 2. At about the level of the client's umbilicus. ■ 3. Between the client's umbilicus and xiphoid process. ■ 4. Near the client's xiphoid process and compressing the diaphragm.

47. 2. Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older. CN: Health promotion and maintenance; CL: Apply

49. After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which of the following? ■ 1. "A total weight gain of approximately 20 lb (9 kg) is recommended." ■ 2. "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." ■ 3. "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." ■ 4. "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

49. 4. The National Academy of Sciences Institute of Medicine recommends that women gain between 25 and 35 lb during pregnancy. These guidelines were developed to decrease the risk of intrauterine growth retardation. It is believed that the pattern of weight gain is as important as the total amount of weight gained. Underweight women and women carrying twins should have a greater weight gain. Typically, women should gain 3.5 lb during the fi rst trimester and then 1 lb/week during the remainder of the pregnancy (24 weeks) for a total of about 27 to 28 lb. A weight gain of only 6.6 lb in the second and third trimesters is not considered normal because the client should be gaining about 1 lb/week, or 12 lb during the second and third trimesters. Gaining 12 lb during each trimester would total 36 lb, which is slightly more than the recommended weight gain. In addition, nausea and vomiting during the fi rst trimester can contribute to a lack of appetite and smaller weight gain during this trimester. CN: Health promotion and maintenance; CL: Evaluate

5. Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate? ■ 1. Take a mild analgesic if needed for menstrual pain. ■ 2. Avoid cold foods if menstrual pain persists. ■ 3. Stop exercise while menstruating. ■ 4. Avoid sexual intercourse while menstruating.

5. 1. The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or "cramps" are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases abdominal tone. Avoiding cold foods will not decrease dysmenorrhea. Sexual intercourse is not prohibited during menstruation, but the male partner should wear a condom to prevent exposure to blood. CN: Health promotion and maintenance; CL: Apply

50. When developing a teaching plan for a client who is 8 weeks pregnant, which of the following foods would the nurse suggest to meet the client's need for increased folic acid? ■ 1. Spinach. ■ 2. Bananas. ■ 3. Seafood. ■ 4. Yogurt.

50. 1. Green, leafy vegetables, such as asparagus, spinach, brussel sprouts, and broccoli, are rich sources of folic acid. The pregnant woman needs to eat foods high in folic acid to prevent folic acid deficits, which may result in neural tube defects in the newborn. A well-balanced diet must include whole grains, dairy products, and fresh fruits; however, bananas are rich in potassium, seafood is rich in iodine, and yogurt is rich in calcium, not folic acid. CN: Reduction of risk potential; CL: Apply

51. The nurse instructs a primigravid client about the importance of sufficient vitamin A in her diet. The nurse knows that the instructions have been effective when the client indicates that she should include which of the following in her diet? ■ 1. Buttermilk and cheese. ■ 2. Strawberries and cantaloupe. ■ 3. Egg yolks and squash. ■ 4. Oranges and tomatoes.

51. 3. Egg yolks and squash and other yellow vegetables are rich sources of vitamin A. Pregnant women should avoid megadoses of vitamin A because fetal malformations may occur. Buttermilk and cheese are good sources of calcium. Strawberries, cantaloupe, citrus fruits (such as oranges), and tomatoes are good sources of vitamin C, not vitamin A. CN: Basic care and comfort; CL: Evaluate

52. The nurse is discussing dietary concerns with pregnant teens. Which of the following choices are convenient for teens yet nutritious for both the mother and fetus? Select all that apply. ■ 1. Milkshake or yogurt with fresh fruit or granola bar. ■ 2. Chicken nuggets with tater tots. ■ 3. Cheese pizza with spinach and mushroom topping. ■ 4. Peanut butter with crackers and a juice drink. ■ 5. Buttery light popcorn with diet cola. ■ 6. Cheeseburger with tomato, lettuce, pickle, ketchup, and baked potato.

52. 1, 3, 4. Dairy products, fresh fruit, vegetables, and foods high in protein (like cheese and peanut butter) are excellent choices. Fried foods, such as chicken nuggets and tater tots, and foods such as cheeseburgers and buttered popcorn are high in fat; carbonated drinks such as diet colas, and foods such as pickles and ketchup contain large amounts of sodium. These foods can lead to an increase in ankle edema and promote weight gain from empty calories. CN: Health promotion and maintenance; CL: Apply

53. An antenatal client is discussing her anemia with the nurse in the prenatal clinic. After a discussion about sources of iron to be incorporated into her daily meals, the nurse knows the client needs further instruction when she responds with which of the following? ■ 1. "I can meet two goals when I drink milk, lots of iron and meeting my calcium needs at the same time." ■ 2. "Drinking coffee, tea, and sodas decrease the absorption of iron." ■ 3. "I can increase the absorption of iron by drinking orange juice when I eat." ■ 4. Cream of wheat and molasses are excellent sources of iron."

53. 1. Milk contains a large amount of calcium but contains no iron. Coffee, tea, and caffeinated soft drinks inhibit the absorption of iron. The vitamin C found in orange juice enhances the absorption of iron. Cream of wheat (1 cup/10 mg iron) and molasses (1 tbsp/3.0 mg iron) are considered excellent sources of iron as they contain the indicated amounts of iron. CN: Physiological adaptation; CL: Evaluate

54. The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which of the following? ■ 1. Prevention of demineralization of the mother's bones. ■ 2. Synthesis of proteins, nucleic acids, and fats. ■ 3. Amino acid metabolism. ■ 4. Synthesis of neural pathways in the fetus.

54. 2. Magnesium aids in the synthesis of protein, nucleic acids, proteins, and fats. It is important for cell growth and neuromuscular function. Magnesium also activates the enzymes for metabolism of protein and energy. Calcium prevents demineralization of the mother's bones. Vitamin B6 is important for amino acid metabolism. Folic acid assists in the development of neural pathways in the fetus. CN: Basic care and comfort; CL: Apply

55. When caring for a primigravid client at 9 weeks' gestation who immigrated to the United States from Vietnam 1 year ago, the nurse would assess the client's diet for a deficiency of which of the following? ■ 1. Calcium. ■ 2. Vitamin E. ■ 3. Vitamin C. ■ 4. Iodine.

55. 1. The diet for Vietnamese Americans typically consists of small portions of meat and ample amounts of rice. Fresh milk may not have been readily available in Vietnam, and many Asian clients are lactose intolerant. Therefore, the nurse would need to assess the client's diet for deficiencies of calcium and possibly iron. Traditionally, Southeast Asian diets have an abundance of dark green leafy vegetables, such as mustard greens and bok choy, which contain adequate amounts of vitamin E and vitamin C. Seafood, which contains iodine, is usually adequate in the diets of Southeast Asian women. CN: Reduction of risk potential; CL: Analyze

56. Which of the following statements by a primigravid client scheduled for chorionic villi sampling indicates effective teaching about the procedure? ■ 1. "A fiberoptic fetoscope will be inserted through a small incision into my uterus." ■ 2. "I can't have anything to eat or drink after midnight on the day of the procedure." ■ 3. "The procedure involves the insertion of a thin catheter into my uterus." ■ 4. "I need to drink 32 to 40 oz of fluid 1 to 2 hours before the procedure."

56. 3. Chorionic villi sampling, which can be performed between 8 and 10 weeks' gestation, involves the insertion of a thin catheter into the vagina and uterus to obtain a sample of the chorionic cells. It is a useful diagnostic test to determine trisomy 13, translocations, fragile X syndrome, and trisomy 18. Fetoscopy is performed with a small fi - beroptic fetoscope inserted through a small incision into the client's uterus to inspect the fetus for gross abnormalities. There are no food or fl uid restrictions necessary before chorionic villi sampling. Ideally, the client should empty the bladder before this procedure. A full bladder would be needed if the client were scheduled to have an ultrasound examination. CN: Reduction of risk potential; CL: Evaluate

57. A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. The nurse interprets this as which of the following? ■ 1. The possibility that the client is carrying twins. ■ 2. Unusual because most multiparous clients do not experience quickening until 30 weeks' gestation. ■ 3. Evidence that the client's estimated date of delivery is probably off by a few weeks. ■ 4. Normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation.

57. 4. Although most multiparous women experience quickening at about 17½ weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect. Detecting movement early does not suggest a twin pregnancy. If the multiparous client does not experience quickening by 20 weeks' gestation, further investigation is warranted, because the fetus may have died, the client has a hydatidiform mole, or the pregnancy dating is incorrect. There is no evidence that the client's expected date of delivery is erroneous. CN: Health promotion and maintenance; CL: Analyze

58. Which diagnostic test would be the most important to have for a primigravid client in the second trimester of her pregnancy? ■ 1. Culdocentesis to detect abnormalities. ■ 2. Chorionic villus sampling. ■ 3. Ultrasound testing. ■ 4. α-fetoprotein (AFP) testing.

58. 4. AFP testing is usually performed between the 15th and 18th weeks of gestation. Abnormally high levels found in maternal serum may be indicative of neural tube defects such as anencephaly and spina bifi da. Low levels may indicate trisomy 21 (Down syndrome). Culdocentesis is used to confi rm a tubal pregnancy. Chorionic villus sampling is done as early as 10 weeks' gestation to detect anomalies. Ultrasound testing may be done in the first trimester to determine fetal viability and in the third trimester to determine pelvic adequacy and fetal or placental position. CN: Reduction of risk potential; CL: Apply

6. After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective? ■ 1. "Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy." ■ 2. "I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle." ■ 3. "Sperm from a healthy male usually remain viable in the female reproductive tract for 96 hours." ■ 4. "After an ovum is fertilized by a sperm, the ovum then contains 21 pairs of chromosomes."

6. 1. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexually active. Many people believe that the time interval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmitted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the woman is most likely to conceive. Using a 28-day cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibility that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes. After fertilization, the conceptus contains 46 chromosomes unless there is a chromosomal abnormality. CN: Health promotion and maintenance; CL: Evaluate

62. Which of the following statements by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?" ■ 1. "This usually disappears after delivery." ■ 2. "It is a sign of skin melanoma." ■ 3. "The discoloration is due to dilated capillaries." ■ 4. "It will fade if you use a prescribed cream."

62. 1. Discoloration on the face that commonly appears during pregnancy, called chloasma (mask of pregnancy), usually fades postpartum and is of no clinical signifi cance. The client who is bothered by her appearance may be able to decrease its prominence with ordinary makeup. Chloasma is not a sign of skin melanoma. It is not caused by dilated capillaries. Rather, it results from increased secretion of melanocyte-stimulating hormones caused by estrogen and progesterone secretion. No treatment is necessary for this condition. CN: Health promotion and maintenance; CL: Apply

63. A 36-year-old primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. The nurse should assess the client's fundal height to: ■ 1. Determine the level of uterine activity. ■ 2. Identify the need for increased weight gain. ■ 3. Assess the location of the placenta. ■ 4. Estimate the fetal gestational age.

63. 4. Assessment of fundal height is a gross estimate of gestational age. By 20 weeks' gestation, the height of the fundus should be at the level of the umbilicus, after which it should increase 1 cm for each week of gestation until approximately 36 weeks' gestation. Fundal height that is signifi - cantly different from that implied by the estimated gestational age warrants further evaluation (e.g., ultrasound examination), because it possibly indicates multiple pregnancy or fetal growth retardation. Fundal height estimation will not determine uterine activity or a need for increased weight gain. Ultrasound examination, not fundal height estimation, will locate the placenta. CN: Health promotion and maintenance; CL: Apply

64. After the nurse reviews the physician's explanation of amniocentesis with a multigravid client, which of the following indicates that the client understands a serious risk of the procedure.? ■ 1. Premature rupture of the membranes. ■ 2. Possible premature labor. ■ 3. Fetal limb malformations. ■ 4. Fetal organ malformations

64. 2. One of the primary risks of amniocentesis is stimulation of the uterus and subsequent preterm labor. Other risks include hemorrhage from penetration of the placenta, infection of the amniotic fl uid, and puncture of the fetus. There is little risk for rupture of the membranes, fetal limb malformations, or fetal organ malformations, if a practitioner skilled in using ultrasound performs the procedure. Fetal limb malformations have been associated with percutaneous umbilical blood sampling. CN: Reduction of risk potential; CL: Evaluate

65. A primigravid client at 28 weeks' gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hundred miles away. Which of the following recommendations by the nurse would be best? ■ 1. "Try to avoid traveling anywhere in the car during your third trimester." ■ 2. "Limit the time you spend in the car to a maximum of 4 to 5 hours." ■ 3. "Taking the trip is okay if you stop every 1 to 2 hours and walk." ■ 4. "Avoid wearing your seat belt in the car to prevent injury to the fetus."

65. 3. The client traveling by automobile should be advised to take intermittent breaks of 10 to 15 minutes, including walking, every 1 to 2 hours to stimulate the circulation, which becomes sluggish during long periods of sitting. Automobile travel is not contraindicated during pregnancy unless the client develops complications. There is no set maximum number of hours allowed. The pregnant client should always wear a seat belt when traveling by automobile. The client should be aware of the nearest health care facility in the city to which she is traveling. CN: Reduction of risk potential; CL: Apply

67. Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks' gestation who is complaining of leg cramps? ■ 1. Change positions frequently throughout the day. ■ 2. Alternately flex and extend the legs. ■ 3. Straighten the knee and flex the toes toward the chin. ■ 4. Lie prone in bed with the legs elevated.

67. 3. Leg cramps are thought to result from excessive amounts of phosphorus absorbed from milk products. Straightening the knee and fl exing the toes toward the chin is an effective measure to relieve leg cramps. Also, decreasing milk intake and supplementing with calcium lactate may help to reduce the cramping. Keeping the legs warm and elevating them are good preventive measures. Changing positions frequently aids venous return but is not helpful in relieving leg cramps. Alternately fl exing and extending the legs will not help to relieve the leg cramp. Lying prone in the bed is a difficult position for a client at 37 weeks' gestation to achieve and maintain because of the increase in abdominal size and therefore is not considered helpful. CN: Basic care and comfort; CL: Synthesize

68. Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn? ■ 1. Eat smaller and more frequent meals during the day. ■ 2. Take a pinch of baking soda with water before meals. ■ 3. Decrease fluid intake to four glasses daily. ■ 4. Drink several cups of regular tea throughout the day.

68. 1. Eating smaller and more frequent meals may help prevent heartburn because acid production is decreased and stomach displacement is reduced. Heartburn can occur at any time during pregnancy. Contributing factors include stress, tension, worry, fatigue, caffeine, and smoking. Certain spicy foods (e.g., tacos) may trigger heartburn in the pregnant client. The client should be advised to avoid sodium bicarbonate antacids (e.g., Alka- Seltzer), baking soda, Bicitra or sodium citrate, and fatty foods, which are high in sodium and can contribute to fluid retention. Increasing, not decreasing, fluid intake may help to relieve heartburn by diluting gastric juices. Caffeinated products such as coffee or tea can stimulate acid formation in the stomach, further contributing to heartburn. CN: Basic care and comfort; CL: Synthesize

7. A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which of the following would the nurse include in the teaching plan? ■ 1. This method has a 50% failure rate during the fi rst year of use. ■ 2. Couples must abstain from coitus for 5 days after the menses. ■ 3. Cervical mucus is carefully monitored for changes. ■ 4. The male partner uses condoms for signifi cant effectiveness.

7. 3. The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning. CN: Health promotion and maintenance; CL: Create

70. When performing Leopold's maneuvers on a primigravid client at 22 weeks' gestation, the nurse performs the first maneuver to do which of the following? ■ 1. Locate the fetal back and spine. ■ 2. Determine what is in the fundus. ■ 3. Determine whether the fetal head is at the pelvic inlet. ■ 4. Identify the degree of fetal descent and flexion.

70. 2. In the fi rst maneuver, which is done with the nurse facing the client's head, both hands are used to palpate and determine which fetal body part (e.g., the head or buttocks) is in the fundus. This first maneuver helps to determine the presenting part of the fetus. In the second maneuver, also done with the nurse facing the client's head, the palms of both hands are used to palpate the sides of the uterus and determine the location of the fetal back and spine. In the third maneuver, one hand gently grasps the lower portion of the abdomen just above the symphysis pubis to determine whether the fetal head is at the pelvic inlet. The fourth maneuver, done with the nurse facing the client's feet, determines the degree of fetal descent and fl exion into the pelvis. CN: Health promotion and maintenance; CL: Apply

71. A primigravid adolescent client at approximately 15 weeks' gestation who is visiting the prenatal clinic with her mother is to undergo alphafetoprotein (AFP) screening. When developing the teaching plan for this client, the nurse should include which of the following? ■ 1. Ultrasonography usually accompanies AFP testing. ■ 2. Results are usually very accurate until 20 weeks' gestation. ■ 3. A clean-catch midstream urine specimen is needed. ■ 4. Increased levels of AFP are associated with neural tube defects.

71. 4. Increased AFP levels are associated with neural tube defects, such as spina bifi da, anencephaly, and encephalocele. Ultrasonography is used to confi rm a neural tube defect only when AFP levels are increased. Because AFP levels are usually highest at 15 to 18 weeks' gestation, this is the optimum time for testing. Performing the test after this time leads to inaccurate results. The client's blood, not urine, is used for the sample. CN: Reduction of risk potential; CL: Create

72. Which of the following statements best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client? ■ 1. Pregnant adolescents are at high risk for pregnancy-induced hypertension. ■ 2. Gestational diabetes during pregnancy commonly develops in adolescents. ■ 3. Adolescents need additional instruction related to common discomforts. ■ 4. The father of the baby is rarely involved in the pregnancy.

72. 1. Prenatal care is commonly the most critical factor infl uencing pregnancy outcome. This is especially true for adolescents, because the most signifi cant medical complication in pregnant adolescents is pregnancy-induced hypertension. Continued prenatal care helps to allow for early detection and prompt intervention should the complication arise. Other risks for adolescents include low-birth-weight infant, preterm labor, iron-defi - ciency anemia, and cephalopelvic disproportion. Gestational diabetes can occur with any pregnancy regardless of the age of the mother. Generally, all fi rst-time mothers need instruction related to discomforts. Adolescent mothers have better nutrition when they attend group classes and are subject to peer pressure. No evidence demonstrates that most adolescents lack support systems. Fathers may abandon mothers at any time during the pregnancy; other fathers, regardless of age, are supportive throughout the pregnancy. CN: Health promotion and maintenance; CL: Apply

73. Which of the following would be included in the teaching plan about pregnancy-related breast changes for a primigravid client? ■ 1. Growth of the milk ducts is greatest during the first 8 weeks of gestation. ■ 2. Enlargement of the breasts indicates adequate levels of progesterone. ■ 3. Colostrum is usually secreted by about the 16th week of gestation. ■ 4. Darkening of the areola occurs during the last month of pregnancy.

73. 3. Colostrum is usually secreted by about the 16th week of gestation in preparation for breast-feeding. Growth of the milk ducts is greatest in the last trimester, not in the first 8 weeks of gestation. Enlargement of the breasts is usually caused by estrogen, not progesterone. Darkening of the areola can occur as early as the sixth week of gestation. CN: Health promotion and maintenance; CL: Create

74. A primigravid client at 32 weeks' gestation is enrolled in a breast-feeding class. Which of the following statements indicate that the client understands the breast-feeding education? Select all that apply. ■ 1. "My milk supply will be adequate since I have increased a whole bra size during pregnancy." ■ 2. "I can hold my baby several different ways during feedings." ■ 3. "If my infant latches on properly, I won't develop mastitis." ■ 4. "If I breast-feed, my uterus will return to prepregnancy size more quickly." ■ 5. "Breast milk can be expressed and stored at room temperature since it is natural." ■ 6. "I need to feed my baby when I see feeding cues and not wait until she is crying."

74. 2, 4, 6. Understanding of breast-feeding education is demonstrated by statements involving knowledge of the several positions available for comfortable breast-feeding, oxytocin release from the pituitary leading to a let-down refl ex and uterine contractions for involution, and feeding cues helpful in successful breast-feeding (because waiting until the infant is hungry and crying is stressful). Breast size does not ensure successful breast-feeding. Mastitis is an infectious process and is not influenced by latching on. Breast milk needs to be stored in the refrigerator or freezer to decrease the risk of bacterial growth. CN: Basic care and comfort; CL: Evaluate

75. When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? ■ 1. The temperature decreases slightly early in pregnancy. ■ 2. Cardiac output increases by 25% to 50% during pregnancy. ■ 3. The circulating fibrinogen level decreases as much as 50% during pregnancy. ■ 4. The anterior pituitary gland secretes oxytocin late in pregnancy.

75. 2. During pregnancy, the circulatory system undergoes tremendous changes. Cardiac output increases by 25% to 50%, and circulatory blood volume increases by about 30%. The client may experience transient hypotension and dizziness with sudden position changes. Early in pregnancy there is a slight increase in the temperature, and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fi brinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported, because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Braxton Hicks contractions or early labor symptoms. CN: Health promotion and maintenance; CL: Create

76. When teaching a primigravid client at 24 weeks' gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include? ■ 1. A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. ■ 2. A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography. ■ 3. Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks' gestation. ■ 4. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample.

76. 1. The fetal biophysical profi le includes fetal breathing movements, fetal body movements, tone, amniotic fl uid volume, and fetal heart rate reactivity. A reactive nonstress test is a sign of fetal well-being and does not require further evaluation. A nonreactive nonstress test requires further evaluation. A contraction stress test or oxytocin challenge test should be performed only on women who are at risk for fetal distress during labor. The contraction stress test is rarely performed before 28 weeks' gestation because of the possibility of initiating labor. Percutaneous umbilical cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood sample. CN: Reduction of risk potential; CL: Apply

77. When teaching a primigravid client how to do Kegel exercises, the nurse explains that the expected outcome of these exercises is to: ■ 1. Prevent vulvar edema. ■ 2. Alleviate lower back discomfort. ■ 3. Strengthen the perineal muscles. ■ 4. Strengthen the abdominal muscles

77. 3. The purpose of Kegel exercises is to strengthen the perineal muscles in preparation for the labor process. These movements strengthen the pubococcygeal muscle, which surrounds the urinary meatus and vagina. No evidence is available to support the idea that these exercises prevent vulvar edema, alleviate lower back discomfort, or strengthen the abdominal muscles. CN: Basic care and comfort; CL: Apply

78. During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks' gestation and is now in her third trimester states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." The nurse should tell the mother: ■ 1. "Dreams like the ones that you describe are very unusual. Please tell me more about them." ■ 2. "Commonly when a mother has these dreams, she is trying to cope with becoming a parent." ■ 3. "Dreams about the baby late in pregnancy usually mean that labor is about to begin soon." ■ 4. "It's not uncommon to have dreams about the baby, particularly in the third trimester."

78. 4. During the third trimester, it is not uncommon for clients to have dreams or fantasies about the baby. Sometimes the dreams are about infants who are malformed or, in this example, covered with hair. There is no evidence to suggest that the client is trying to cope with becoming a parent. Having dreams about the baby does not mean that labor will begin soon. CN: Psychosocial adaptation; CL: Synthesize

79. A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the following suggestions would be most helpful? ■ 1. Practice relaxation techniques before bedtime. ■ 2. Drink a cup of hot chocolate before bedtime. ■ 3. Drink a small glass of wine with dinner. ■ 4. Exercise for 30 minutes just before bedtime.

79. 1. Insomnia in the later part of pregnancy is not uncommon because the client has diffi culty getting into a position of comfort. This is further compounded by frequent nocturia. The best suggestion would be to advise the client to practice relaxation techniques before bedtime. The client should avoid caffeine products such as chocolate and coffee before going to bed because caffeine is a stimulant. Alcohol consumption, regardless of the type or amount, should be avoided. Exercise is advised during the day, but it should be avoided before bedtime because exercise can stimulate the client and decrease the client's ability to fall asleep. CN: Basic care and comfort; CL: Apply

8. Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? ■ 1. Anemia. ■ 2. Hypertension. ■ 3. Dysmenorrhea. ■ 4. Acne vulgaris.

8. 2. Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-defi ciency anemia, dysmenorrhea, and acne are not contraindications for the use of oral contraceptives. Irondefi ciency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual fl ow and thus decrease the amount of iron lost through menses, thereby providing a benefi cial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives commonly improves facial acne. CN: Reduction of risk potential; CL: Analyze

80. Which of the following client statements indicates a need for additional teaching about selfcare during pregnancy? ■ 1. "I should use nonskid pads when I take a shower or bath." ■ 2. "I should avoid using soap on my nipples to prevent drying." ■ 3. "I should sit in a hot tub for 20 minutes to relax after working." ■ 4. "I should avoid douching even if my vaginal secretions increase."

80. 3. The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the fi rst trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk of infection. CN: Health promotion and maintenance; CL: Evaluate

81. To obtain the obstetric conjugate measurement, the nurse would do which of the following? ■ 1. Add 1.5 cm to the transverse diameter. ■ 2. First measure the angle of the pubic arch. ■ 3. Subtract 1.5 to 2 cm from the diagonal conjugate. ■ 4. Measure the diameter of the pelvic inlet.

81. 3. The obstetric conjugate can be estimated by subtracting 1.5 to 2 cm from the diagonal conjugate, which can be measured during a pelvic examination. Transverse diameters of the pelvic inlet are not measured and the pubic arch has no relevance to the obstetrical conjugate. CN: Health promotion and maintenance; CL: Apply

82. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. ■ 1. Differentiating the fetus from the self. ■ 2. Ambivalence concerning pregnancy. ■ 3. Experimenting with mothering roles. ■ 4. Realignment of roles and tasks. ■ 5. Trying various caregiver roles. ■ 6. Concern about labor and delivery.

82. 3, 4, 5, 6. During the third trimester of pregnancy, the woman experiments with maternal and caregiver roles and may make plans for changes in employment, managing household tasks, and/ or childcare. The woman is also concerned about safety and passage through labor and delivery.. Other psychological tasks include preparation of the nursery, being tired of the pregnancy, and being introspective. A woman will begin to see herself as someone different from the fetus in the second trimester. Additionally, the mother may fantasize about the infant during the second trimester and be concerned about her changing body image. She may experience ambivalence about pregnancy in the first trimester. CN: Psychosocial adaptation; CL: Create

83. A new antenatal G 6, P 4, Ab 1 client attends her first prenatal visit with her husband. The nurse is assessing this couple's psychological response to their pregnancy. Which of the following requires the most immediate follow up? ■ 1. The couple are concerned with financial changes this pregnancy causes. ■ 2. The couple expresses ambivalence about the current pregnancy. ■ 3. The father of the baby states that the pregnancy has changed the mother's focus. ■ 4. The father of the baby is irritated that the mother is not like she was before pregnancy.

83. 4. Pregnancy creates changes in the mother and father. Being considerate, accepting changes, and being supportive of the current situation are considered acceptable responses by the father, rather than feeling irritation about these changes. Expressing concern with the fi nancial changes pregnancy and an expanded family include is normal. The fi rst trimester involves the client and family feeling ambivalent about pregnancy and moving toward acceptance of the changes associated with pregnancy. Maternal acceptance of the pregnancy and a subsequent change in her focus are normal occurrences. CN: Health promotion and maintenance; CL: Analyze

84. When preparing a prenatal class about endocrine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? ■ 1. Human placental lactogen maintains the corpus luteum. ■ 2. Progesterone is responsible for hyperpigmentation and vascular skin changes. ■ 3. Estrogen relaxes smooth muscle in the respiratory tract. ■ 4. The thyroid enlarges with an increase in basal metabolic rate.

84. 4. Thyroid enlargement and increased basal body metabolism are common occurrences during pregnancy. Human placental lactogen enhances milk production. Estrogen is responsible for hyperpigmentation and vascular skin changes. Progesterone relaxes smooth muscle in the respiratory tract. CN: Health promotion and maintenance; CL: Create

85. When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? ■ 1. External genitalia. ■ 2. Myelinization of nerves. ■ 3. Brown fat stores. ■ 4. Air ducts and alveoli.

85. 1. Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of fetal development. Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approximately 21 to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks. CN: Health promotion and maintenance; CL: Apply

86. A primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? ■ 1. Monozygotic twins result from fertilization of two ova by different sperm. ■ 2. Monozygotic twins occur by chance regardless of race or heredity. ■ 3. Dizygotic twins are usually of the same sex. ■ 4. Dizygotic twins occur more often in primigravid than in multigravid clients.

86. 2. Monozygotic twinning is independent of race, age, parity, or heredity. Monozygotic twins result from the fertilization of one ovum by two different sperm. Dizygotic twinning occurs with the fertilization of more than one ovum during conception. Dizygotic twins may be of the same sex or different sexes. Dizygotic twinning is correlated with increased parity, becoming pregnant within 1 month after stopping oral contraception, and infertility treatments. A primigravid client is less likely to conceive dizygotic twins. CN: Health promotion and maintenance; CL: Apply

88. A primigravid client in a Preparation for Parenting class asks how much blood is lost during an uncomplicated delivery. The nurse should tell the woman: ■ 1. "The maximum blood loss considered within normal limits is 500 mL." ■ 2. "The minimum blood loss considered within normal limits is 1,000 mL." ■ 3. "Blood loss during a delivery is rarely estimated unless there is a hemorrhage." ■ 4. "It would be very unusual if you lost more than 100 mL of blood during the delivery."

88. 1. In a normal delivery and for the fi rst 24 hours postpartum, a total blood loss not exceeding 500 mL is considered normal. Blood loss during delivery is almost always estimated because it provides a valuable indicator for possible hemorrhage. A blood loss of 1,000 mL is considered hemorrhage. CN: Health promotion and maintenance; CL: Apply

89. Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? ■ 1. "The amniotic fluid helps to dilate the cervix once labor begins." ■ 2. "Fetal nutrients are provided by the amniotic fluid." ■ 3. "Amniotic fluid provides a cushion against impact of the maternal abdomen." ■ 4. "The fetus is kept at a stable temperature by the amniotic fluid and sac."

89. 2. Although the amniotic fl uid promotes normal prenatal development by allowing symmetric development, it does not provide the fetus with nutrients. Rather, nutrients are provided by the placenta. The amniotic fl uid does help dilate the cervix once labor begins by pressure and gravity forces. The amniotic fl uid helps to protect the fetus from injury by cushioning against impact of the maternal abdomen and allows room and buoyancy for fetal movement. The amniotic fluid and sac keep the fetus at a stable temperature by maintaining a neutral thermal environment. CN: Health promotion and maintenance; CL: Evaluate

9. After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which of the following as an adverse effect? ■ 1. Weight gain. ■ 2. Nausea. ■ 3. Headache. ■ 4. Ovarian cancer.

9. 4. The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovarian and endometrial cancer are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is thrombophlebiti. CN: Pharmacological and parenteral therapies; CL: Evaluate

90. During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which of the following exercises suggested by the nurse would be most helpful? ■ 1. Pelvic rocking. ■ 2. Deep breathing. ■ 3. Tailor sitting. ■ 4. Squatting.

90. 1. Pelvic rocking helps to relieve backache during pregnancy and early labor by making the spine more flexible. Deep breathing exercises assist with relaxation and pain relief during labor. Tailor sitting and squatting help stretch the perineal muscles in preparation for labor. CN: Health promotion and maintenance; CL: Analyze

91. A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. ■ 1. Walk in the hospital room. ■ 2. Use slow chest breathing. ■ 3. Request pain medication on a regular basis. ■ 4. Lightly massage her abdomen. ■ 5. Sip ice water.

91. 1, 2, 4. Pain during the fi rst stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching of the lower uterine segment, dilatation of the cervix and perineum, and pressure on adjacent structures. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles. Slow chest breathing is appropriate during the fi rst stage of labor to promote increased oxygenation as well as relaxation. The woman or her coach can lightly massage the abdomen (effl eurage) while using slow chest breathing. Chest breathing and massaging increase oxygenation and relaxation of uterine muscles. Pain medication is not used during the fi rst stage of labor because most medications will slow labor; anesthesia may be considered during the second stage of labor. Sipping ice water, while helpful for maintaining hydration, will not be useful as a pain management strategy. CN: Health promotion and maintenance; CL: Synthesize

92. During a Preparation for Parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" The nurse should tell the participant which of the following about true labor contractions? ■ 1. "Walking around helps to decrease true contractions." ■ 2. "True labor contractions may disappear with ambulation, rest, or sleep." ■ 3. "The duration and frequency of true labor contractions remain the same." ■ 4. "True labor contractions are felt first in the lower back, then the abdomen."

92. 4. With true labor, the contractions are felt fi rst in the lower back and then the abdomen. They gradually increase in frequency and duration and do not disappear with ambulation, rest, or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase true contractions. False labor contractions disappear with ambulation, rest, or sleep. False labor contractions commonly remain the same in duration and frequency. Clients who are experiencing false labor may have pain, even though the contractions are not very effective. CN: Health promotion and maintenance; CL: Apply

93. After instructing participants in a childbirth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which of the following? ■ 1. Biofeedback. ■ 2. Effleurage. ■ 3. Guided imagery. ■ 4. Pelvic tilt exercises

93. 4. Pelvic tilt exercises are useful to alleviate backache during pregnancy and labor but are not useful for the pain from contractions. Biofeedback (a conscious effort to control the response to pain), effl eurage (light uterine massage), and guided imagery (focusing on a pleasant scene) are appropriate pain relief techniques to practice before labor begins. Various breathing exercises also can help to alleviate the discomfort from contraction pain. CN: Health promotion and maintenance; CL: Evaluate

94. After a Preparation for Parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse's best action is to advise the client to do which of the following? ■ 1. Use an over-the-counter cream for yeast infections. ■ 2. Schedule an appointment at the clinic for an examination. ■ 3. Administer a vinegar douche under low pressure. ■ 4. Prepare for preterm labor and delivery.

94. 2. Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge with local itching is associated with infection (e.g., Trichomonas vaginalis). The client's symptoms must be further assessed by a health professional because the client needs treatment for this condition. T. vaginalis infection is commonly treated with metronidazole (Flagyl). However, this drug is not used in the fi rst trimester. In the fi rst trimester, the typical treatment is topical clotrimazole. Although a yeast infection is associated with vaginal itching, the vaginal discharge is cheese-like. Furthermore, because the client may have a serious vaginal infection, over-the-counter medications are not advised until the client has been evaluated. Douching is not recommended during pregnancy because it would predispose the client to an ascending infection. The client is not exhibiting signs and symptoms of preterm labor, such as contractions or leaking fl uid. And although the client's complaints are suggestive of a T. vaginalis infection, which can lead to preterm labor and premature rupture of the membranes, further evaluation is needed to confirm the cause of the infection. CN: Health promotion and maintenance; CL: Synthesize

95. The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan? ■ 1. Decreased plasma volume. ■ 2. Increased risk for urinary tract infections. ■ 3. Increased peripheral vascular resistance. ■ 4. Increased hemoglobin levels.

95. 2. During pregnancy, urinary tract infections are more common because of urinary stasis. Clients need instructions about increasing fl uid volume intake. Plasma volume increases during pregnancy. The increase in plasma volume is more pronounced and occurs earlier than the increase in red blood cell mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable blood pressure. Hemoglobin levels decrease during pregnancy even though there is an increase in blood volume. CN: Health promotion and maintenance; CL: Apply

96. The nurse is obtaining information to support the need for improved prenatal care services in the community. Which of the following information is most important to include? ■ 1. The maternal mortality rate. ■ 2. The infant mortality rate. ■ 3. The perinatal mortality rate. ■ 4. The neonatal mortality rate.

96. 1. The maternal mortality rate is defi ned as the number of maternal deaths related to childbearing divided by the number of live births. Maternal mortality in the United States has been increasing in part due to inadequate prenatal care and the increasing number of cesarean sections. Infant mortality rate is defi ned as the number of deaths of infants younger than 12 months of age per 1,000 live births. The perinatal mortality rate includes all stillborn infants with a gestational age of 28 weeks or more plus all neonatal deaths before 7 days of age per 1,000 of this population. The neonatal mortality rate is the number of deaths of infants younger than 28 days of age per 1,000 live births. CN: Health promotion and maintenance; CL: Analysis

97. A multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following? ■ 1. Placental blood. ■ 2. Amniotic fluid. ■ 3. Fetal blood. ■ 4. Maternal blood.

97. 4. For the Rh-negative client who may be pregnant with an Rh-positive fetus, an indirect Coombs test measures antibodies in the maternal blood. Titers should be performed monthly during the first and second trimesters and biweekly during the third trimester and the week before the due date. CN: Health promotion and maintenance; CL: Apply

98. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification? ■ 1. Class I. ■ 2. Class II. ■ 3. Class III. ■ 4. Class IV

98. 2. According to the New York Heart Association Cardiac Disease classifi cation, this client would fi t under Class II because she is symptomatic with increased activity (dyspnea with exertion). The New York Heart Association Cardiac Disease Classifi cation identifi es Class II clients as having cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits. CN: Management of care; CL: Analyze

99. A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include? Select all that apply. ■ 1. Hepatitis B immune globulin at birth. ■ 2. Series of three hepatitis B vaccinations per recommended schedule. ■ 3. Hepatitis B screening when born. ■ 4. Isolation of infant during hospitalization. ■ 5. Universal precautions for mother and infant. ■ 6. Contraindication for breast-feeding because the mother is HBsAg positive.

99. 1, 2, 5. The test result indicates that the mother has an active hepatitis infection and is a carrier. Hepatitis B immune globulin at birth provides the infant with passive immunity against hepatitis B and serves as a prophylactic treatment. Additionally, the infant will be started on the vaccine series of three injections. The infant should not be screened or isolated because the infant is already hepatitis B positive. As with all clients, universal precautions should be used and are sufficient to prevent transmission of the virus. Women who are positive for hepatitis B surface antigen are able to breast-feed. CN: Management of care; CL: Create

48. A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of Hemophilia A in her family. The nurse informs the client that she will need to wait until she is 15 weeks gestation for the amniocentesis. Which of the following provides the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? ■ 1. Fetal development needs to be complete before testing. ■ 2. The volume of amniotic fluid needed for testing will be available by 15 weeks. ■ 3. Cells indicating Hemophilia A are not produced until 15 weeks' gestation. ■ 4. Fetal anomalies are associated with amniocentesis prior to 15 weeks' gestation.

these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older. CN: Health promotion and maintenance; CL: Apply