Antepartum NCLEX

A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?

Abdominal pain

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem do the data best support?

High risk for infection

The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking, and the client tells the nurse that she has been taking the herb chamomile. Which statement made by the client demonstrates correct information about this herbal intervention?

"Chamomile should not be used while I am pregnant and because I have asthma."

The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?

Nuts and green, leafy vegetables

A blood glucose screening measurement is going to be performed on a pregnant client. Which instructions should the nurse give to the client before this test?

There is no restriction for caffeine before the test.

A client who is in the second trimester of pregnancy develops melasma during pregnancy. Which statements made by the client indicates an understanding of this condition? Select all that apply.

1."Melasma may reoccur in a subsequent pregnancy. 4."These brown, splotchy patches will most likely disappear after I deliver my baby." 5."The dark patches that are on my nose, cheeks and forehead will most likely darken until the baby is delivered."

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply.

1.Urinalysis 2.Rubella titer 4.Complete blood count

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement should the nurse provide to the client?

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

A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply.

1.Avoid greasy foods. 2.Eat 5 to 6 small meals each day. 3.Do not drink fluids with meals.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed?

Petechiae, oozing from injection sites, and hematuria

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

The nurse is reading the primary health care provider's documentation regarding a pregnant client and notes that the primary health care provider has documented that the client has an android pelvic shape. Which descriptions apply to an android pelvis? Select all that apply.

1.Narrow wedge shape 5.Unfavorable for a vaginal birth

A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which should the nurse include in the instructions? Select all that apply.

2.Eat a low-fat diet. 3.Stop or decrease smoking. 4.Eat smaller, more frequent meals. 5.Consume adequate fluid between meals.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses should the nurse make to the client? Select all that apply.

3."It stimulates the breasts to prepare for lactation." 6."It stimulates uterine development to provide an environment for the fetus."

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions should the nurse place on the list? Select all that apply.

1.To note the color of blood on each perineal pad 2.To watch for the evidence of the passage of tissue 3.To note the quantity of blood on each perineal pad 4.To count the number of perineal pads used on a daily basis

The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?

second

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results?

A negative test

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements should be noted at which time interval?

Between 16 and 20 weeks' gestation

The nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record supports this risk factor?

Maternal hypertension

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason?

Compression of the vena cava

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action?

Massaging the abdomen during contractions using both hands in a circular motion

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?

Midway between the symphysis pubis and the umbilicus

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?

Minimizing the client's exposure to external stimuli

The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action should the nurse perform first?

Place a wedge pillow under the client's right side.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava

The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the primary health care provider. Which warning signs should the nurse place on the list? Select all that apply.

1.Facial edema 2.Rapid weight gain 3.Visual disturbances 4.Generalized edema

The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.

3,Fetal heart tones 6.Fetal movements felt by examiner

The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence?

Cause hemorrhage

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority?

Dehydration

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position should the nurse place the client?

In a sitting position

The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?

Syphilis

A pregnant client is a gravida III, para 0, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband, knowing that which instruction will assist in promoting family adaptation?

Teaching the husband to perform passive range of motion and provide back rubs for his wife

The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?

The insulin needs will increase.

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic should be a part of the teaching plan for this class?

Travel precautions and use of shoulder seat belts

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?

Violet bluish color of vaginal mucosa and cervix

The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first?

pulse

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

week 5

The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?

Maternal hypertension

A 26-year-old woman comes to the clinic and asks for a pregnancy test because she thinks she might be pregnant. The nurse assesses for which presumptive signs of pregnancy? Select all that apply.

1.Breast tenderness 2.Early morning nausea 5.No menstruation for the last 8 weeks

The nurse is reviewing the health care record of a pregnant client at 24 weeks' gestation. The nurse should anticipate that the fundus should be located at which level?

22 cm to 26 cm

The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to potential problems specifically related to the twin pregnancy? Select all that apply.

1.Hypertension 4.Six or more uterine contractions per hour

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

1.Oliguria 4.Proteinuria 3+ 6.Blood pressure 168/116 mm Hg

The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.

1.Peanut butter 3.Whole grain bread 4.Omelet with cheese

The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all that apply.

1.Preterm labor 3.Maternal anemia

The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply.

1.Curtail exercise. 3.Measure your blood pressure daily. 4.Rest frequently by lying on your side. 5.Call the primary health care provider if you develop dizziness.

The nurse is explaining physiological changes of pregnancy that are related to melanocyte-stimulating hormone (melanotropin). Which pregnancy changes are related to the effects of this hormone? Select all that apply.

1.Chloasma 2.Linea nigra 4.Darkening of areola

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.

1.Pulse 2.Blood volume 3.Cardiac output 5.Red blood cell mass

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.

1.Round shape 4.Diagonal conjugate measures 12.5 cm to 13 cm 5.Blunt, somewhat widely separated ischial spines

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply.

2.Chadwick's sign is a probable sign of pregnancy. 3.Chadwick's sign may be present as early as 6 weeks' gestation. 4.Chadwick's sign is a bluish discoloration of the vagina and cervix.

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply.

2.Heart shaped 4.Convergent sidewalls 6.narrow interspinous diameter

The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.

2.Urinary tract infections 3.Increased chance of cesarean birth 4.Delayed lung maturation in the neonate

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statements by the student indicate an understanding of this hormone? Select all that apply.

4."It may play a role in the neural development of the fetus." 5."It increases during pregnancy to stimulate basal metabolic rate."

When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors should the nurse consider significant?

A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment should be part of the plan of care?

Any bleeding, such as in the gums, petechiae, and purpura

A pregnant client is seen in the health care clinic with reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion?

Consume dry crackers before getting out of bed.

The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?

Describing the appropriate amount of weight gain required during the pregnancy

When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?

Expression of hope for a positive outcome

The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the primary health care provider?

Fundal height, 38 cm

The nurse is reviewing the laboratory results of a pregnant client and notes that the hemoglobin level is decreased. Physiological dilutional anemia is documented in the client's record by the primary health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation?

Increased blood volume of the mother during pregnancy

The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use?

Palpate for uterine contractions at the same time as the client.

The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?

Place the client in a supine position and place a wedge under the right hip.

The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action should the nurse take before the procedure to ensure fetal safety?

Test the ultrasound equipment to ensure proper functioning.

The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.

1."Fertilization occurs in the outer third of the fallopian tube." 2."Only 1 sperm will penetrate the ovum to produce fertilization." 4."Implantation occurs in the anterior or posterior fundal region of the uterus." 5."The ovary produces hormones to maintain the pregnancy before placental development."

The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse should instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?

Dried fruits

A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?

Inevitable

A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which is the estimated date of delivery (EDD)?

January 12

The nursing instructor asks the nursing student to identify the reason that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which response indicates that the student understands the rationale of this physiological response?

"Blood volume and cardiac output increase resulting in a faster pulse."

The nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which statement made by the client should the nurse question to receive more information?

"I have had mild vaginal spotting twice since my last prenatal visit."

The nurse reinforces instructions to a client with mild preeclampsia on home care. Which comment by the client indicates that teaching is effective?

"I need to check my urine with a dipstick every day for protein and call my health care provider if it is 2+ or more."

A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a primary health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur at this time. Which statement is true?

"Your normal insulin dosage will have to be decreased."

The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. Which assessment findings are most likely present at this time? Select all that apply.

3.Fetal heart tones can be heard by Doppler. 4.Braxton Hicks contractions may be felt by the mother. 5.The fundus is located midway between the symphysis pubis and the umbilicus.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?

A softening of the cervix

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?

A urinary tract infection

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?

Check for signs of thrombophlebitis.

The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?

Document the temperature.

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?

Gravida II, para I

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?

Hemoglobin 9.1 g/dL

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?

Laser therapy

A pregnant woman who is at 38 weeks' gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, what does the nurse determine the client may be experiencing?

Placenta previa

The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy?

She has a history of chronic hypertension.

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.

2."Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3."Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4."Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5."Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply.

2.Bypassing the fetal lungs to circulate oxygen rich blood 4.Using the fetus's beating heart to pump blood in the circulatory system 5.Carrying more oxygen on fetal hemoglobin than maternal hemoglobin 6.Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones should the nurse identify as present at this time? Select all that apply.

2.Sex recognizable 3.Blood forming in marrow 5.Kidneys able to secrete urine

The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply.

2.Vaginal bleeding 3.Excessive vomiting 4.No fetal heart activity 5.Larger than normal uterine size 6.Elevated levels of human chorionic gonadotropin (hCG)

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

1.Ballottement 2.Chadwick's sign 3.Uterine enlargement 4.Braxton Hicks contractions

A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.

1.Edema 3.Proteinuria 4.Thrombocytopenia

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply.

1.Hegar's sign 3.Goodell's sign 5.McDonald's sign

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

1.Small parts are located on the left side of the uterus. 2.Small parts are located on the right side of the uterus. 5.A soft, irregular non-ballottable shape is located just above the symphysis pubis.

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?

A diet that is high in fluids and fiber to decrease constipation

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?

"I am so glad that I can breastfeed my baby after she has been vaccinated."

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.

1.Proteinuria 2.Hypertension

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

Drink decaffeinated coffee and tea.

The nurse working in a prenatal clinic receives a telephone call from a client at 22 weeks of gestation. The client reports some vaginal discharge and has started to experience menstrual-like cramps and diarrhea. Which responses by the nurse indicate an understanding of the implications of the client's signs/symptoms? Select all that apply.

1."Lie on your left side for an hour and try to drink some fluids." 2."It is important that you urinate frequently to keep your bladder empty." 4."Palpate for contractions and call back if there are more than four contractions in the next hour." 5."Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"

A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.

1.Clear fluid 4.White flecks in the amniotic fluid 5.Presence of glucose and protein in the amniotic fluid

During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply.

1.Reports of fatigue 2.Pink mucous membranes

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.

1.Shallow depth 2.Wide suprapubic arch 4.Compatible with vaginal delivery 5.Flattened anteroposteriorly and wide transversely

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

3."The preembryonic period is the first 2 weeks of fetal development following conception." 6."The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers."

The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.

3.Increases blood flow to the uterine vessels 4.Stimulates development of the breast ducts 5.Causes vascular changes in the mucous membranes of the nose and mouth

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply.

3."Surfactant, which is needed for lung expansion, is present beginning at 28 weeks." 4."With decreased surfactant, more pressure must be generated to produce inspiration." 5."Surfactant lowers surface tension, reducing the pressure required to keep the alveoli expanded."

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which should the nurse specifically monitor?

Deep tendon reflexes

A client who is 6 months pregnant is attending her first prenatal visit. On the first prenatal visit, the nurse notes that the client is gravida 4, para 0, abortion 3. The client is 5 feet, 6 inches tall, weighs 130 pounds, and is 25 years old. She states, "I get really tired after working all day and can't keep up with my housework." Which factor in the above data should lead the nurse to suspect gestational diabetes?

Fetal demise

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?

Isoniazid plus rifampin will be required for a total of 9 months.

The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action?

Provide emotional support.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

The client is wearing knee-high hose.

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

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

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

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

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

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

Which history places a maternity client at risk for uterine rupture?

Cesarean section birth

The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?

Monitoring fetal movement

A woman is 24 weeks pregnant. She had a previous stillborn neonate at 38 weeks' gestation and a pregnancy that ended at 34 weeks with the birth of a stillborn girl. She states she has a 4-year-old son and an 8-year-old daughter who live with her at home and were both born at 38 weeks. What is her gravidity and parity, using the five-digit system (GTPAL)?

G (5) T (0) P (4) A (0) L (2)

The nurse shares with a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?

"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

A client presents at her primary health care provider's office 10 weeks pregnant with her first pregnancy. Which are presumptive signs of pregnancy that the client might be expected to have? Select all that apply.

1.Fatigue 2.Breast changes 4.Nausea and vomiting

The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother.

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?

26cm

A woman at 20 weeks of gestation calls the primary health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"This is an emergency; you should come to the clinic within the hour."

The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply.

2.Liver 3.Beans

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

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

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

Calcium gluconate

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription should the nurse anticipate for the client?

A 3-hour glucose tolerance test

The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to this group? Select all that apply.

2.The number of red blood cells will be increased during pregnancy. 3.At term, the heart rate has increased by 15 to 20 beats per minute. 6.In a supine position, some degree of compression of the vena cava will occur.

The primary health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.

2.Vaginal secretions increase. 4.Bluish discoloration of the vagina. 5.Higher levels of glycogen in vaginal secretions.

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the primary health care provider (PHCP) and tells the client to call the PHCP if which occurs?

Weight increases by more than 1 pound in a week.

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement?

"I am eating fresh fruits and vegetables for snacks and for dessert each day."

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

Weight and height