Course Point Chapter 15
A client who is 16 weeks pregnant has a lower blood pressure than that of prepregnancy levels. What should the nurse realize as being the cause for this lower blood pressure?
A decrease in the second trimester may occur because of placental growth. Reference: Chapter 15: Pregnancy - Page 263
The nurse is assisting a primigravida on calculating the due date of her baby using Naegele rule. The most important information provided by the mother is:
the first day of the last menstrual period. Reference: Chapter 15: Pregnancy - Page 253-254
Implantation generally occurs at which place on the uterus?
the upper posterior surface Reference: Chapter 15: Pregnancy - Page 252
A antepartum client learns that the fetus has a genetic anomaly that will affect cognitive and musculoskeletal development. The client is discussing this with the spouse and the nurse. The client and spouse want to know what options are available to them. What is the first thing that the nurse needs to do to help this couple with decision making?
Assist the couple in identifying their values. Reference: Chapter 15: Pregnancy - Page 226
A nurse is teaching a group of primigravida women who are in their first trimester. One of the women asks the nurse about sexual activity during pregnancy. Which information would the nurse most likely incorporate into the response?
Because of pelvic congestion, women may experience increased clitoral sensitivity. Reference: Chapter 15: Pregnancy - Page 265
A nurse is conducting a program about the importance of prenatal care for a group of women in a community health clinic. Which information would the nurse include when describing the purpose of prenatal care? Select all that apply.
Establish a baseline of present health Determine the gestational age of the fetus Monitor for fetal development and maternal well-being. Identify women at risk for complications. Reference: Chapter 15: Pregnancy - Page 272
A pregnant woman who had stress incontinence during a previous pregnancy asks the nurse what could be done to manage this in her current pregnancy. What should the nurse recommend to the client?
Kegel exercises Reference: Chapter 15: Pregnancy - Page 269
A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn? Select all that apply.
Limit consumption of food before bedtime Sleep in a semi-Fowler position Avoid overeating. Reference: Chapter 15: Pregnancy - Page 270
A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?
Perform Kegel exercises. Reference: Chapter 15: Pregnancy - Page 269
The nurse is obtaining a fetal nonstress test and having difficulty maintaining the fetal heart rate. What nursing action is most helpful?
Recline the client backward. Reference: Chapter 15: Pregnancy - Page 279
A nurse is caring for a client in her second trimester of pregnancy. During a regular follow-up visit the client reports varicosities of the legs. Which instruction should the nurse provide to help the client alleviate varicosities of the legs?
Refrain from crossing legs when sitting for long periods. Reference: Chapter 15: Pregnancy - Page 268
The nurse is caring for a client who has a retroverted uterus. The nurse would explain that this means her:
entire uterus is tipped backward. Reference: Chapter 15: Pregnancy - Page 277
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?
The uterus contracts and squeezes the cord against the fetus. Reference: Chapter 15: Pregnancy - Page 259-260
Which reason explains why women should be encouraged to perform Kegel exercises after delivery?
They promote blood flow, enabling healing and muscle strengthening. Reference: Chapter 15: Pregnancy - Page 269
The nurse is planning care for several pregnant clients. Which client is at the highest risk for nutritional deficiency while pregnant?
woman with a 1-year-old infant Reference: Chapter 15: Pregnancy - Page 270
A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next?
Tell the client these are normal findings during pregnancy. Reference: Chapter 15: Pregnancy - Page 265
Assessment for surfactant level is a primary estimation of fetal maturity. The purpose of surfactant is to:
prevent alveoli from collapsing on expiration. Reference: Chapter 15: Pregnancy - Page 257
The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?
rubella Reference: Chapter 15: Pregnancy - Page 259
A pregnant client is visiting the clinic and complains about the tiny blanched slightly raised end arterioles on her face neck arms and chest. The nurse should explain that these are normal during pregnancy and are referred to as:
telangiectasias. Reference: Chapter 15: Pregnancy - Page 261
The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best?
"At 36 weeks' gestation, the fundus is in the normal expected location." Reference: Chapter 15: Pregnancy - Page 264
A nurse is educating a prenatal client at her second visit. The client is worried about "blotchy brown spots" on her forehead. The nurse reassures the client about this change by giving which appropriate response?
"Avoid sun because it will make the discoloring darker." Reference: Chapter 15: Pregnancy - Page 271
The nurse is concerned that a pregnant client is not adjusting emotionally to being pregnant. Which statement indicates that the client may need additional counseling?
"I need to get right back to work after delivery." Reference: Chapter 15: Pregnancy - Page 275-276
During a physical assessment the nurse palpates a pregnant client's fundus at the level of the umbilicus. What statement should the nurse make to the client about this assessment finding?
"You are at 20 weeks of your pregnancy." Reference: Chapter 15: Pregnancy - Page 264
A mother comes in with her 17-year-old daughter to find out why she has not had a menstrual cycle for a few months. Examination confirms the daughter is pregnant with a fundal height of approximately 24 cm. The nurse interprets this finding as indicating that the daughter is approximately how many weeks pregnant?
24 Reference: Chapter 15: Pregnancy - Page 280
The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding?
50% effaced. Reference: Chapter 16: Labor and Delivery - Page 296
A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?n
Before reporting to the RN, determine the uterine contraction pattern. Reference: Chapter 16: Labor and Delivery - Page 303
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?
Continue to monitor the client and the fetal heart rate.. Reference: Chapter 16: Labor and Delivery - Page 306
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate?
Document this and continue to monitor the murmur at future visits. Reference: Chapter 15: Pregnancy - Page 263
The nurse is teaching a pregnant client in her last trimester about interventions to help reduce risks of complications during pregnancy. Which of the following are recommended guidelines?
During the last month, rest on the left side for at least an hour, morning and afternoon. Reference: Chapter 15: Pregnancy - Page 267
A nursing instructor is explaining the stages of fetal development to a group of nursing students. The instructor determines the session is successful after the students correctly choose which time period as representing the pre-embryonic stage?
From fertilization to the end of the second week after fertilization Reference: Chapter 15: Pregnancy - Page 256
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy excited and confident to introverted and restless. Assessment reveals heart rate 100 blood pressure 137/85 mm Hg and hyperventilation. EFM reveals no variability for almost 20 minutes then evident variability with no late decelerations. Which action should the nurse prioritize?
Help the client regain control of her breathing technique. Reference: Chapter 16: Labor and Delivery - Page 297
A pregnant woman tends not to eat for long periods of time because of her busy work schedule. What process safeguards her fetus from becoming hypoglycemic during this time?
Somatomammotropin helps to regulate glucose levels. Reference: Chapter 15: Pregnancy - Page 259
During a yearly gynecologist appointment a woman tells the nurse that she and her spouse hope to become pregnant soon. In reviewing the client's current health status what will the nurse recommend to this client for a healthy pregnancy? Select all that apply.
Stop smoking immediately Eat a healthy diet with fruits and vegetables Avoid all alcohol intake. Reference: Chapter 15: Pregnancy - Page 276
The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage?
Stretching and breathing exercises such as yoga Reference: Chapter 15: Pregnancy - Page 275
A primigravida client has come to the clinic for a prenatal checkup. What teaching topics would help to promote a healthy pregnancy for this client?
Swimming in a pool is a recommended exercise during pregnancy. Reference: Chapter 15: Pregnancy - Page 275
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm cervix is 100% effaced and 5 cm dilated membranes are intact and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor?
first, active Reference: Chapter 16: Labor and Delivery - Page 294-295
The nursing instructor is presenting the basic physiologic changes in the woman that can occur during a pregnancy. The instructor determines the session is successful when the students correctly choose which change in the respiratory function during pregnancy as normal?
increased tidal volume Reference: Chapter 15: Pregnancy - Page 262
A woman is taking vaginal progesterone suppositories during her first trimester because her body does not produce enough of it naturally. She asks the nurse what function this hormone has in her pregnancy. What should the nurse explain is the primary function of progesterone?
maintains the endometrial lining of the uterus during pregnancy Reference: Chapter 15: Pregnancy - Page 252
A nurse is conducting a class with group of pregnant women who are all in their first trimester of pregnancy. During the class the women are discussing the various discomforts that they are experiencing. The nurse would expect to hear reports about which discomforts? Select all that apply.
nausea-urinary frequency-breast tenderness Reference: Chapter 15: Pregnancy - Page 268-269
The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus?
"The gloves they provide irritate my hands, so I don't use them." Reference: Chapter 15: Pregnancy - Page 275
The nurse has identified the diagnosis of imbalanced nutrition for a pregnant client. Which assessment data did the nurse use to identify this diagnosis for the client?
The client does not want to gain any weight while pregnant. Reference: Chapter 15: Pregnancy - Page 274
The nurse is assessing a young female who just found out she is pregnant. She is now reporting vague abdominal discomfort. After noting the client has a history of PID the nurse predicts the health care provider will give priority to ruling out which situation?
Ectopic pregnancy Reference: Chapter 15: Pregnancy - Page 277
During a routine prenatal visit a pregnant woman reports a white thick vaginal discharge. She denies any itching or irritation. Which action would the nurse take next?
Tell the woman that this is entirely normal. Reference: Chapter 15: Pregnancy - Page 269
The nurse-midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell sign. Which description illustrates this alteration?
The cervix softens. Reference: Chapter 15: Pregnancy - Page 265
The nurse is caring for a client who prefers resting on her back during the labor process. To facilitate client wishes which nursing action is required?
Utilize a wedge under one hip Reference: Chapter 16: Labor and Delivery - Page 296
Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.
Vaginal rugae stretch and smooth out. The cervix dilates to 10 cm. The cervix softens. Reference: Chapter 16: Labor and Delivery - Page 284,286
The nursing instructor has finished leading a general discussion with a group of nursing students exploring the labor and birthing process. The instructor determines the session is successful when the students correctly state which goal should be a priority?
Work with the labor client to plan pain management options. Reference: Chapter 16: Labor and Delivery - Page 311-312
Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and birth. The nurse would prepare to screen clients for gestational diabetes at which time during the pregnancy?
between 24 and 28 weeks' gestation Reference: Chapter 15: Pregnancy - Page 278
During a routine antepartum visit a pregnant woman says "I've noticed my gums bleeding a bit since I've become pregnant. Is this normal?" The nurse bases the response on the understanding of which effect of pregnancy?
influence of estrogen and blood vessel proliferation Reference: Chapter 15: Pregnancy - Page 270
The nurse is teaching a pregnant woman about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as being released when the newborn sucks at the breast?
oxytocin Reference: Chapter 15: Pregnancy - Page 262
Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as:
pica. Reference: Chapter 15: Pregnancy - Page 270
A nurse is providing care to a woman who has just found out that she is pregnant. The nurse is describing the events that have occurred and the structures that are forming. When describing the trophoblast to the client the nurse would explain that this structure forms:
placenta. Reference: Chapter 15: Pregnancy - Page 251-252
During the initial prenatal visit the nurse performs what assessment to guide teaching about nutrition during pregnancy?
prepregnancy BMI Reference: Chapter 15: Pregnancy - Page 274
Early in pregnancy frequent urination results mainly from which of the following?
pressure on the bladder from the uterus Reference: Chapter 15: Pregnancy - Page 266
A pregnant client in her second trimester visits a health care center. She informs the nurse that at times she experiences difficulty breathing. What would the nurse identify as the most likely cause of the client's report?
pressure on the diaphragm by the growing fetus Reference: Chapter 15: Pregnancy - Page 262
A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears the nurse should mention the role of the hormone that softens the cervix and collagen in the joints which allows dilation (dilatation) and enlargement of the birth canal. What is this hormone?
relaxin Reference: Chapter 15: Pregnancy - Page 259
A client is concerned about the mercury levels in fish and asks the nurse which fish are safe to eat. The best response is:
shrimp, canned tuna, pollack, and catfish. Reference: Chapter 15: Pregnancy - Page 274
Which of these cardiac variations if found in the client who is pregnant should the nurse recognize as a normal finding in pregnancy?
soft systolic murmur Reference: Chapter 15: Pregnancy - Page 263
A number of inherited diseases can be detected in utero by amniocentesis. Which disease can be detected by this method?
trisomy 21 (Down syndrome) Reference: Chapter 15: Pregnancy - Page 279
A woman has a positive pregnancy test and comes to the nurse with left lower quadrant pain. Bimanual examination reveals a tender mass. Which of the following is suspected?
tubal pregnancy Reference: Chapter 15: Pregnancy - Page 277