NCLEX 4000 Antepartum
reassuring her such feelings are normal in the beginning of pregnancy.
A 20-year-old female's pregnancy is confirmed at a clinic. She says her partner will be excited but she is concerned because she herself isn't excited. She fears this feeling may mean she'll be a bad mother. The nurse should respond by:
"These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after birth."
A 30-year-old primiparous client at 34 weeks' gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they're permanent. What should the nurse tell her?
The inability to conceive after 1 year of unprotected attempts.
A client and her spouse, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as:
"As long as you wish, if the pregnancy is normal."
A client asks how long her husband can safely continue sexual activity during pregnancy. How should the nurse respond?
promote fetal lung maturity.
A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:
October 10
A client comes to the office for her first prenatal visit. She reports that January 3 was the first day of her last menstrual period. According to Nagele's rule, what date should the nurse record as the estimated date of delivery (EDD)?
Ask the clinic case manager to speak with the client.
A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She doesn't have transportation. How can the nurse help this client be compliant with her care?
"Consult with your heath care provider before takng any medications."
A client has come to the clinic for her first prenatal visit. The nurse should include which statement about using drugs safely during pregnancy in her teaching?
Fundal height of 18 cm
A client has her first prenatal visit at 15 weeks' gestation. Which finding requires further investigation?
"I can see you're upset; however, you must wait at least 1 year before becoming a parent again."
A client has just expelled a hydatidiform mole. She's visibly upset and wants to know when she can try to become pregnant again. How should the nurse respond?
Prepare for cesarean bith.
A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action?
deficient fluid volume
A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary diagnosis for this client?
Common discomforts of pregnancy
A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?
Administer RH (D) (RhoGAM) immune globulin.
A client is admitted for an amniocentesis. Initial assessment findings include: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 g/dl, hematocrit 35%, and type O-negative blood. Which action is most important to include in the client's care plan after the 20-minute amniocentesis has been completed?
A history of pelvic inflammatory disease
A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for the risk factors for this abnormal condition, the nurse expects to find:
Renal malformations
A client is diagnosed with oligohydramnios during a clinic visit. Before the client gives birth, the nurse should notify the nurses working in the nursery about the diagnosis so they are aware of which complication that's commonly associated with oligohydramnios?
"Each pregnancy has a unique psychosocial meaning to it."
A client is expecting her second child in 6 months. During the psychosocial assessment, she says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response?
For diagnostic purposes when fetal development is in question
A client is having a level 2 ultrasound. A nurse knows that physicians order this procedure:
Review premonitory signs of labor with the client
A client is in the 38th week of her 1st pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action?
Left lateral
A client is in the 8th month of pregnancy. To enhance CO and renal function, the nurse should advise her to use which body position?
Decreased urine output
A client is receiving IV magnesium sulfate for severe preeclampsia. The nurse should monitor for:
Continuity of care
A client who is 24 weeks pregnant states that her employer has changed health insurance. She's worried she won't be able to continue care at her current facility. A nurse informs him that because she's an established client at the facility, she'll continue to receive care through delivery. this is referred to as:
"The client consumes no alcohol."
A client who is 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client?
Fetal tone Fetal breathing movements Amniotic fluid volume
A client who is 41 weeks pregnant is about to undergo a biophysical profile (BPp) to evaluate her fetus's well-being. The nurse knows that which components are included in a BPP? Select all that apply.
have audible heart sounds.
A client who's 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse anticipates that at 16 weeks' gestation, the client's fetus will:
Both estrogen and progesterone levels are rising.
A client who's 16 weeks pregnant tells the nurse that she has many mood swings. Which statement accurately describes estrogen and progesterone levels during this client's stage of pregnancy?
Dehydration
A client who's 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crises during pregnancy?
Monitor the amount of vaginal blood loss.
A client who's 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which nursing intervention should the nurse perform?
"What changes have you made at home to get ready for the baby?"
A client who's 37 weeks pregnant comes to the clinic for a checkup. To assess the client's preparation for parenting, the nurse might ask which question?
"Walk briskly for 10 to 15 minutes daily, and gradually increase this time."
A client who's 4 months pregnant asks the nurse how much and what type of exercise she should get during pregnancy. How should the nurse counsel her?
9 to 12 weeks' gestation
A client who's 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:
Teaching her to dorsiflex her foot during the cramp
A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps?
low birth weight.
A client who's 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus may be at risk for:
"Folic acid, 400 mcg, improves pregnancy outcomes by preventing certain complications."
A client who's planning a pregnancy asks the nurse about ways to promote a heathy pregnancy. What is the nurse's best response?
Tea and gelatin dessert
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:
One pregnancy resulted in an abortion and one resulted in a preterm neonate who's living
A client's prenatal record shows that she's a gravida 2. para 0111, From this information, the nurse knows that she has been pregnant twice. What else does this information reveal about her obstetric history?
an unknown cause.
A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from:
"Client will exhibit uterine growth within the expected norms for gestational age."
A client, 2 months pregnant, has hyperemesis gravidarum. Which expected outcome is most appropriate for her?
changes in cervical effacement and dilation after 1 to 2 hours.
A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for:
Place the client on the left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation.
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take first?
gestational hypertension.
A client, age 39, attends a regular prenatal check-up. She's 32 weeks pregnant. When assessing the client, the nurse should stay especially alert for signs and symptoms of:
Explain that these are expected problems for the latter stages of pregnancy
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places 3 pillows under her head. After listening to the client's concerns, the nurse should take which action?
Dietitian
A hospitalized client who is 26 weeks pregnant has been diagnosed with gestational diabetes. She's overweight and doesn't understand the diet a physician has suggested for her. To help the client understand the diet, the nurse should ask the physician to order consults with a:
establishng a schedule of prenatal visits.
A low-risk client who's 6 weeks pregnant comes to the clinic for her first prenatal visit. At this time, the nurse should assign highest priority to:
ask another new nurse to assist her.
A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:
Abdominal pain
A nurse assesses a pt for signs and symptoms of ectopic pregnancy. Which assessment finding should the nurse expect?
Return to the facility if fever occurs
A nurse determines that a client is in false labor. After obtaining discharge orders, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time?
Amenorrhea and abdominal fullness and tenderness
A nurse is assessing a client who's 6 weeks pregnant. Which findings best supports a suspicion of ectopic pregnancy?
1lb (0.45 kg)
A nurse is assessing a pregnant client in her second trimester. The nurse weighs the client, then compares her current and previous weights. During the second trimester, how much weight should the client gain per week?
assess the client's readiness to stop.
A nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to hep the woman stop smoking is to:
Abnormally high human chorionic gonadotropin (hCG) levels
A nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole?
Bilateral dependent edema
A nurse is assessing the lungs of a client who's 36 weeks pregnant. Which finding should the nurse expect?
Blurred vision
A nurse is assisting in developing a teaching plan for a client who's about to enter the 3rd trimester of pregnancy. The teaching plan should include identification of which danger sign that must be reported immediately?
"I can lie in any comfortable position, but I should stay off my back."
A nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching?
Calcium gluconate
A nurse is caring for a client receiving IV magnesium sulfate. Which drug is the antidote for magnesium toxicity?
Maternal vital signs and fetal heart rate
A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing the client, the nurse's highest priority is to evaluate:
On admission to the facility
A nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?
Breast sensitivity
A nurse is caring for a pt in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
Promoting adequate hydration
A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What intervention should the plan include to halt premature labor?
Between 18 and 20 weeks' gestation
A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that she can expect to feel the fetus move at which time?
This position impedes blood flow to the fetus.
A nurse is discussing posture with a client who's 18 weeks pregnant. Why should the nurse caution her to avoid the supine position?
Inform the client of the risks to the fetus and ask if she'd like a referral to a smoking cessation support group.
A nurse is doing an assessment of a pregnant client who states that she smokes one pack of cigarettes each day. The nurse should:
The umbilicus
A nurse is palpating the uterus of a client who's 20 weeks pregnant to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus?
Left upper abdominal quadrant
A nurse is preparing to auscultate fetal heart tones in a pregnant client. Abdominal palpation reveals a hard, round mass under the left side of the rib cage; a softer, rounder mass just above the symphysis pubis; small, irregular shapes in the right side of the abdomen, and a long, firm mass on the left side of the abdomen. Based on these findings, what is the best place to auscultate fetal heart tones?
"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."
A nurse is providing care for a pregnant 16-year-old. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
Try to get more rest by going to bed earlier
A nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:
milk
A nurse is reviewing a pregnant client's nutrition status. To determine whether she has an adequate intake of vitamin A, the nurse should asses her diet for consumption of:
Have the client drink orange juice
A nurse prepares a client who's 28 weeks pregnant for a non-stress test. Which intervention is most likely to stimulate fetal movements during this test?
Blue
A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn what color?
Hb 9 g/L; HCT 30%
A pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and performing a physical examination, the nurse reviews the client's laboratory test results, Which findings suggest iron deficiency anemia?
Danger signs during pregnancy
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?
This symptom is normal and results from the fetus exerting pressure on the bladder.
A pregnant client in her 3rd trimester asks why she needs to urinate frequently again, like she did during the 1st trimester. What should the nurse tell her?
Try wearing a panty liner and discarding it after every urination.
A pregnant client is experiencing a thin, odorless, vaginal discharge. What should a nurse tell her to do to prevent vaginal infections?
grapelike clusters.
A pt makes a routine visit to the prenatal clinic. Although she's 14 weeks pregnant, the size of her uterus approximates an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:
assess the fetal heart rate
A pt that's 32 weeks pregnant presents to the ED with bright red bleeding and abdominal pain. A nurse should first:
Progesterone
A pt who is 14 weeks pregnant states, "Ever since I've been pregnant, I've had a hard time moving my bowels." Increased levels of what hormone are responsible for this common discomfort of pregnancy?
Chromosomal defects Neural tube defects Sex of the fetus
A pt who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characterstics or problems? Select all that apply
Edema
A pt who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the clients fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?
"Abstain from sexual intercourse unless you use a condom."
A pt who's 32 weeks pregnant is hospitalized with preterm labor. After preterm labor is arrested, she's discharged with a prescription for terbutaline (Brethne). Which instruction should the nurse provide during discharge teaching?
placenta previa.
A woman in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history, the nurse should suspect:
Hyperemesis gravidarum
A woman in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?
recognize these as normal early pregnancy signs and symptoms.
A woman who's 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:
Amniocentesis to temporarily relieve discomfort
After developing severe hydramnios, a primigravid client exhibits dyspnea, along with edema of the legs and vulva. Which procedure should the nurse expect the client to undergo and why?
demonstrating signs of hyper-stimulation syndrome.
After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. This assessment indicates the client is:
Sit at her bedside and allow the client to express her feelings
An obstetric ultrasound reveals that the client's fetus has spina bifida. The mother is concerned about raising a chid with a congenital abnormality and she starts to cry. Which response by the nurse is best?
reduced intestinal motility
As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
Strong braxton hicks contractions Mild contractions lasting 20-40 seconds Cervical dilation of 7 cm 100% cervical effacement Uncontrollable urge to push
Assessment of a client progressing through labor reveals the following findings. Order the findings in the most likely sequence in which they would have occurred. Use all options.
Provide her with the information and teach her the skills she'll need to understand and cope during birth.
Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client?
Family history of spina bifida in sister
At 15 weeks gestation, a client is scheduled for a serum alpha-fetoprotein test. Which maternal history finding best explains the need for this test?
the fetus isn't in distress at this time
During a non-stress test, a nurse notes 3 fetal heart rate increases of 20 BPM, each lasting 20 seconds. These increases only occur during fetal movement. What does this finding indicate?
Turn the client on her left side.
During a physical examination, a client who's 32 weeks pregnant becomes pale, dizzy, and light-headed while supine. Which action should the nurse immediately take?
Divide daily food intake into 5 or 6 meals.
During a prenatal visit, a pregnant client with cardiovascular disease and slight functional limitations reports increased fatigue. To help combat the problem, the nurse should advise her to:
I'll increase my intake of unrefined grains
During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates understanding of the nurse's instructions?
Eat small, frequent meals
During a routine prenatal visit, a pregnant client reports heartburn. To minimize the discomfort, the nurse should include which suggestion in the care plan?
Imbalanced nutrition: Less than body requirements related to limited food intake
During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client?
This test will screen for spina bifida, down syndrome, or other genetic defects
During prenatal screening, a nurse tells a pt that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?
Eustachian tube vascularization
During the sixth month of pregnancy, a pt reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms?
"It's a legal document that helps establish and verify your health care wishes in the event that you can't speak for yourself or your baby
The hospital where a client plans to give birth asks her to provide signed documents before delivery. The client asks the nurse to explain what an advanced directive is. What's the nurses best response?
Signs of orthostatic hypotension
The nurse is preforming a routine assessment on a pregnant client. For which assessment should the nurse assess late in pregnancy?
7 days
What is the approximate time that the blastocyst spends traveling to the uterus for implantation?
Deficient fluid volume
What is the primary nursing diagnosis for a client with a ruptured ectopic pregnancy?
Overcoming fears she may have about the unknown, loss of control, and death
What key psychosocial tasks must a pregnant dent accomplish during the third trimester?
Amenorrhea and quickening
What signs should the nurse expect to assess as presumptive signs of pregnancy?
I support your commitment; however, you may have to supplement each feeding with formula
When assessing a client during her first prenatal visit, the nurse discovers that the client has a reduction mammoplasty. The mother Indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding success?
+3 urine glucose
When assessing a pregnant client with DM, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). Which laboratory value makes this client more susceptible to such infections?
From the symphysis pubis notch to the highest level of the fundus.
When evaluating a pregnant client's fundal height, the nurse should measure in which way?
"If I have blurred or double vision, I could call the clinic immediately."
When evaluating a pregnant client's knowledge of symptoms to report immediately, which statement indicates to the nurse that the client understands the information given to her?
At about 28 weeks' gestation and again within 72 hours of birth
When should a client who's Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies receive Rh0(D) immune globulin (RhoGAM) to prevent isoimmunization?
Abruptio placentae
Which condition poses the greatest risk to a 32-year-old client who is 15 weeks pregnant and has a history of hypertension?
Health Insurance Portability and Accountability Act (HIPAA)
Which document states that clients have a right to confidentiality of medical records and a right to privacy limiting access to that information to health care providers associated with their care:
Encourage her to increase her intake of roughage and to drink at least six glasses of water per day.
Which instruction should a nurse give to a client who's 26 weeks pregnant and complains of constipation?
Place a nonskid mat on the floor of the tub or shoulder.
Which instruction should a nurse include in a home-safety teaching plan for a pregnant client?
Providing for dietary needs
Which intervention listed in the care plan for a pt with an ectopic pregnancy requires revisions?
Complete facility and unit orientation
Which measure must a graduate nurse take before working on the antepartum unit?
Insulin
Which medication is considered safe during pregnancy?
level of emotional maturity.
While caring for a pregnant adolescent, a nurse should develop a care plan that incorporates the adolescent's:
"I'll need a signed consent from your daughter to give you medical information."
a 15-year-old female who is 26 weeks pregnant has been admitted to the labor and delivery unit with complaint of abdominal pain. her parents want to speak to a nurse about her condition. how should the nurse respond?
human chorionic gonadotropin (hCG)
a client calls to schedule a pregnancy test. the nurse knows that most pregnancy test measure which hormone?
ketones in the urine
a client in the 13th week of pregnancy develops hyperemesis gravidarum. which lab finding indicates the need for further evaluation?
umbilical cord prolapse
a client undergoes an amniotomy.
Risk for deficient fluid volume
a client who's 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. she's admitted for treatment of an ectopic pregnancy. the nurse should give the highest priority to what nursing diagnosis?
explain that urinary frequency is expected during the first trimester
a client who's 2 months pregnant complains of urinary frequency and says she gets up several times at night to go to the bathroom. she denies other urinary system. how should the nurse intervene?
increased plasma volume
a client who's 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. which pregnancy-related physiologic change places her at greatest risk for more severe cardiac problems?
delivery
a client's membranes rupture during the 30th week of pregnancy. eighteen hours later, the nurse measures the client's temperature at 101.8 F. after initiating ordered antibiotic therapy, the nurse should prepare the client for:
take the vitamin on a full subject
a newly pregnant pt tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. in addition to telling the client how important taking the vitamins are, the nurse should advise her to:
learning disability
a nurse asks a pregnant pt about her alcohol use. the client admits that she sometimes has several glasses of wine with dinner. her alcohol consumption puts her fetus at risk for which condition?
hypertension, edema, proteinuria
a nurse in a prenatal clinic is assessing a client who's 24 weeks pregnant. which findings lead this nurse to suspect that the client has mild preeclampsia?
maternal fetal activity count
a nurse is assessing a client who's 29 weeks pregnant. what is the most cost-effective method for assessing fetal well-being?
use birth control for at least a year
a nurse is caring for a client after evacuation of a hydatidiform mole. the nurse should tell the woman to:
name of procedure, how it's preformed, description of alternate methods available, potential risk for mother and fetus, risks associated if the procedure isn't performed
a nurse is caring for a pt who is scheduled amniocentesis. what information about the procedure should the nurse provide before the client signs the consent form?
labor may need to be induced early.
a nurse is providing care for a pregnant pt with gestational diabetes. the client asks the nurse if gestational diabetes will affect the birth. the nurse should know that:
they're usually felt in the abdomen
a nurse is teaching a pregnant pt how to distinguish prelabor contractions from true labor contractions. which statement about prelabor contractions is accurate?
the client's consumption of 6-8 beers on the weekends.
a nurse obtains an antepartum history of the client who's 6 weeks pregnant. which finding is a concern?
penicillin G potassium (Pfizerpen) IV to a pt
a pregnant client is diagnosed with group B streptococcus chorioamnionitis. the nurse will expect to administer which medication to prevent fetal transmission?
July 19th
a pregnant pt's LMP began on October 12th. using Nagele's rule the nurse calculates the EDD as:
Terbutaline (Brethine)
a pt is admitted to the facility in preterm labor. to halt her uterine contractions, the nurse expects the physician to order:
Should be referred to community resources available for pregnant woman.
an 18-year-old pregnant woman tells the nurse she is concerned she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't have insurance. The nurse should recognize that the client:
7 days after fertilization
during a health-teaching session, a pregnant pt asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. which answer should the nurse supply?
evaluating the client for edema
during each prenatal checkup, a nurse obtains a pt's weight and blood pressure and measures fundal height. what is another essential part of each prenatal checkup?
"No because the live vaccine is contraindicated in pregnancy."
during her 4th clinical visit, a client who's 5 months pregnant tells the nurse that she was exposed to rubella during the past week and asks whether she can be immunized now. how should the nurse respond?
the client states that she is stupid and ugly
during the first trimester, a nurse evaluates a pregnant pt for factors that suggest she might abuse a child. which paternal characteristic is of most concern to the nurse?
use an ergonomically correct desk chair
lower back pain is a common complaint among pregnant clients. which comfort measure should a nurse include in her teaching plan for a pregnant client?
accepting the biological fact of pregnancy
on her second visit to the prenatal facility, a client states, "i guess I really am pregnant. I've missed 2 periods now." based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy?
between 23 and 27 weeks gestation
when providing health teaching to a primigravid pt, the nurse tells the pt that she's likely to experience Braxton hicks contractions. when does a client usually feel these contractions?
in the first third of the fallopian tube
when teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs:
Fetal heartbeat and fetal movement on palpation
which findings are considered positive signs of pregnancy?
Top of the uterus
A client who is 37 weeks pregnant comes to the office for a prenatal visit. The nurse performs Leopold's maneuvers to assess the position of the fetus. After performing the maneuvers, the nurse suspects that the physician will attempt external version. Where did the nurse palpate the head of the fetus?
"The community health nurse will check me and my baby and talk with my physician."
A client who's 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community heath nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home heath visits?
Gestational trophoblastic disease
A client who's 3 months pregnant with her first child reports that she has had increasing morning sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal heart tones. The nurse should suspect which complication of pregnancy?
Braxton Hicks contractions.
A client who's pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing:
Rupture of membranes Intrauterine infection Painful, regular contractions Active bleeding
A client with cervical incompetence undergoes cerclage. What complications should the nurse monitor for following the procedure? Select all that apply.
Headache Blurred vision Epigastric pain Severe nausea and vomtng
A pregnant pt at 32 weeks' gestation has mid preeclampsia. She is discharged to home with instructions to remain on bed rest. She should also be instructed to call her physican if she experiences which worsening symptoms? Select all that apply.
a third-degree laceration.
A pt has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called:
"Selective reduction has been used to decrease the possibility of complications during pregnancy and birth. I'll ask the physician to speak with both of you."
A pt who has been treated for infertity is now pregnant. During a routine ultrasound at 8 weeks' gestation, she learns that five fetuses are visualized. Concerned that five infants wouldn't survive and that his wife couldn't handle the stress of the pregnancy, the pt's husband asks the nurse about selective reduction. What is the nurse's best response?
The client will maintain adequate fetal tissue perfusion.
After an amniotomy, which client goal should take the highest priority?
18 to 20 weeks
At what gestational age should a primigravida expect to start feeling quickening?
8 days after conception.
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?
document the finding, which is normal during pregnancy.
When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take?
restrict the amount of fluid administered.
When caring for a client with preeclampsia during labor, the nurse should:
It's engaged.
When performing a vaginal examination on a pregnant client, the nurse determines that the parietal diameter of the fetal head has reached the pelvic inlet. Which statement best describes the position of the fetus at this time?
ask the pt to void.
A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should:
"Involve your son in planning and preparing for a sibling."
A pregnant client asks how she can best prepare her 3-year-old son for the upcoming birth of a sibling. The nurse should make which suggestion?
To detect maternal antibodies against fetal Rh-positive factor
After determining that a pregnant client is Rh-negative, a physician orders an indirect Coombs' test. What is the purpose of performing this test in a pregnant client?
3+ edema in the lower extremities.
At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of gestational hypertension. Based on this diagnosis, the nurse expects assessment to reveal:
At the beginning of each fetal movement
During a non-stress test (NST), the electronic tracing heart rate displays a relatively flat line for fetal movement, making it too difficult tp evaluate the fetal heart rate (FHR). To mark the strip, a nurse should instruct the dent to push the control button at which time?
19 weeks
During a prenatal visit, a nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age?
Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.
During her first prenatal visit, a client expresses concern about gaining weight. What is the nurse's first action?
Human chorionic gonadotropin (hCG)
During the first 3 months, which hormone is responsible for maintaining pregnancy?
Abdominal pain, vaginal bleeding, and a positive pregnancy test
Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?
Herbal remedies
A client asks about complementary therapies for relief of discomforts related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching?
Assess the location and consistency of the uterus.
A client at 35 weeks' gestation complains of severe abdominal pain and passing clots. The client's vital signs are blood pressure 150/100 mm Hg, heart rate 95 beats/minute, respiratory rate 25 breaths/minute, and fetal heart tones 160 beats/minute. The admitting nurse must determine the cause of the bleeding and respond appropriately to this emergency. Which action should the nurse do first?
"You're feeling ambivalent, which is normal during the first trimester."
A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn't know whether she's ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer?
Warning signs of compications
A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy?
Support from her partner
A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy?
"You should gain 25 to 35 lb."
A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response?
blurred vision.
A client is in the last trimester of pregnancy. The nurse should instruct her to notify her primary health care provider immediately if she notices:
Inform the physician and prepare for discharge; this client has a reassuring strip
A client is told that she needs to have a non-stress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next?
prepare for the physician to confirm membrane rupture.
A client tells the nurse that she thinks her amniotic membranes broke 2 hours ago. The nurse's priority is to:
Report a heart rate greater than 120 beats/minute to the physician.
A client treated with terbutaline (Brethine) for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
1-hour glucose tolerance test to screen for gestational diabetes.
A client who is 11 weeks pregnant comes to the office for a routine prenatal visit. After reading the urine dipstick laboratory test results below, which test is the most appropriate for this client? Color: yellow Odor: slightly fruity Appearance: clear Specific gravity: 1.015 pH: 6 Moderate glucose and ketones No proteins, bilirubin, blood or nitrates
Women, Infants, and Children (WIC)
A client who is 18 weeks pregnant is losing weight. She tells a nurse that she's out of work and, after paying bills, has no money to buy heathy food. The nurse should offer the client information about:
Evaluate vital signs. Evaluate fetal heart tones. Monitor the amount of vaginal bleeding. Monitor intake and output.
A client who is 32 weeks pregnant is being monitored in the antepartum unit for gestational hypertension. She suddenly complains of continuous abdominal pain and vaginal bleeding. Which nursing interventions should be included in the care of this client? Select all that apply.
proteinuria, headaches, and double vision.
A client with gestational hypertension is likely to exhibit:
To prevent seizures
A client with gestational hypertension receives magnesium sulfate, 4 gn 50% solution 1.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client?
"Insuin requirements usually decrease during the first trimester."
A client with type 1 diabetes has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide?
The fetus isn't in distress at this time.
A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the heath of her fetus. Her BPP score is 8. What does this score indicate?
crackles on auscutation.
A client, 7 months pregnant, is receiving the tocolytic agent terbutaline (Brethine), 17.5 mcg/minute I.V., to halt uterine contractions. She also takes prednisone (Orasone), 5 mg by mouth twice per day, to control asthma. To detect an adverse interaction between these drugs, the nurse should monitor the client for:
Discourage breast feeding because HIV can be transmitted through breast milk
A nurse has a pt at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the pt when she says that she wants to breast-feed her neonate?
A glass of orange juice
A nurse is caring for a 16-year-old pregnant adolescent. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?
5 weeks' gestation
A nurse is obtaining a medication history from a pt who suspects she's pregnant. At which week of gestation does placental transport of substances to and from the fetus begin?
"Do you have any cats at home?"
A nurse is obtaining a prenatal history from a pt who's 8 weeks pregnant. To help determine whether the pt is at risk for a TORCH infection, the nurse should ask:
Hegar's sign.
A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess:
midway between the symphysis pubis and the umbilicus.
A nurse is performing a prenatal assessment on a client who is 32 weeks pregnant. She performs Leopold's maneuvers and determines that the fetus is in the cephalic position. Identify where the nurse should place the Doppler to auscultate fetal heart tones.
Iron deficiency anemia
A nurse is planning care for a 16-year-old adolescent in the prenatal clinic. Adolescents are prone to which complication during pregnancy?
be taught about diet.
A nurse is providing care for a pregnant pt in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the pt will need to:
spinach and beef.
A nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat:
The client has a child with cystic fibrosis
A nurse is reviewing a client's prenatal history, Which finding indicates a genetic risk factor?
ampulla
A nurse is teaching a course on the anatomy and physiology of reproduction. In the illustration of the female reproductive organs, identify the area where fertilization occurs.
produces maternal antibodies.
A nurse is teaching a pregnant client about the role of the placenta. The nurse realizes further teaching is needed when the client states that the placenta:
"I need to use insuin each day."
A nurse is teaching a pt who's 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling this client's blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says:
11 weeks' gestation
A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?
send a registered letter asking the client to contact the clinic
A nurse receives the result of a pregnant client's human immunodeficiency virus (HIV) testing. When the nurse attempts to notify the client of the results, she can't locate her. The nurse should:
Stop the discharge process and notify the physician immediately.
A pregnant adolescent admitted with premature uterine contractions was successfully treated with I.V. fluids. She is eager to return to high school to take a math test. The nurse's discharge examination reveals vaginal blood pooling under the adolescent's buttocks that's painless to the pt. which action should the nurse take?
To relieve pressure on the umbilical cord
A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. Why should the nurse apply manual pressure to the baby's head?
1%
A pregnant client asks the nurse about the percentage of congenital abnormalities caused by drug exposure. How should the nurse respond?
"No, it can initiate premature uterine contractions."
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
5 milligrams/deciliter
A pregnant client at 26 weeks' gestation takes a 1-hour glucose tolerance test as part of a recommended screening for gestational diabetes. A result of greater than or equal to what number of milligrams/deciliter indicates the need for further testing? Record your answer using a whole number.
Keeping crackers at the bedside to eat before getting out of bed
A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, she's been unable to eat enough and has lost weight. Which non-pharmacologic intervention should the nurse recommend?
report the suspected abuse to the local poilce or authorities.
A pregnant client presents to the emergency department with complaints of back pain for the second time in a month. She is accompanied by her spouse, who refuses to let the client speak for herself. The client's spouse states that the client is clumsy and falls down the front steps of the house a lot. inspecting the panful area, the nurse notes bruising on the clients lower department. The nurse should first:
Insuln acts as a growth hormone on the fetus.
A pregnant client with diabetes mellitus is at risk for having a large-for-gestational-age neonate because:
Above the symphysis pubis
Where is the best place for a nurse to detect fetal heart sounds for a client in the first trimester of pregnancy?
"Take rest periods during the day."
Which instruction should a nurse include in an injury prevention plan for a pregnant client?
