Chapter 65 Exam NCLEX
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?
"Do you plan to have any other children?"
During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?
"I need to increase the fiber in my diet to control my blood glucose and prevent constipation"
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"
The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an udnerstanding of this term?
"It is the fetal movement that is felt by the mother"
The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning?
"The iron is needed for the red blood cells"
A contraction stress test is schedule for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?
"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."
The nursing student is asked to descirbe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure?
"The uterus weighs about 2 ounces."
The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The clietn asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
"You will need to bottle-feed your newborn"
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. (4)
1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions
The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made? Select all that apply. (2)
1. Prevents large particles such as bacteria from passing to the fetus 2. Provides an exchange of nutrients and waste products between the mother and the fetus
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. (2)
1. Proteinuria 2. Hypertension
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. (3)
1. Round shape 2. Diagonal conjugate measures 12.5 cm to 13 cm 3. Blunt, somewhat widely separated ischial spines A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth
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 funal height at this visit in centimeters and should expect which finding?
26 cm
During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?
150 beats per minute - Fetal heart rate depends on gestational age. It is notmally 160 to 170 beats per minute during the trimester, but it slows with fetal growth to 110 to 160 beats per minute near or at term
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 measurements will be noted between which weeks of gestation?
16 and 20 weeks' gestation - Known as Quickening
The pregnant woman complains of beign awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?
Dorsiflex the client's foot while extending the knee
The 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
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 (Goodell's sign)
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 is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first?
Clear and maintain an open airway
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
A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulaiton, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus neosus if the student states which about the ductus venosus?
Connects the umbilical vein to the inferior vena cava
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
The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5 year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?
G=2, T=1, P=0, A=0, L=1
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
The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes taht occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation
The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nagele's rule, the nurse determines the estimated date of birth is which date?
July 27, 2020
The client is in her second trimeste 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, which the hips and knees at a right angle
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 client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?
Provides an exchange of nutrients and waste products between the mother and the fetus
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
Tell the client that these are common and they may occur throughout the pregnancy
The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?
The bladder must be full during the examination
The nurse is monitoring a client with a mild gestational hypertension (GH). Which data indicate that GH is a concern?
The client complains of a headache and blurred vision.
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components?
Two umbilical arteries and one umbilical vein
The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?
Where fertilization occurs
