NCLEX Intrapartum

The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breastfeed the infant after delivery. Which response by the nurse is appropriate?

1."Breastfeeding is contraindicated."

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?

2."Do you plan to have any other children?"

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 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

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

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?

1.Dehydration

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 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

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."

The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?

2."I need to gain only 10 pounds so that my baby will be small like I am."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

2."The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."

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?

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

A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?

2."You feel you are having difficulty fulfilling your role as a wife."

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?

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

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?

2.A negative test

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?

2.Abdominal pain

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 Nägele's rule, the nurse determines the estimated date of birth is which date?

2.July 27, 2020

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 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?

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

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?

2.Maternal hypertension

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that which primary hormone stimulates postpartum contractions?

2.Oxytocin

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?

3.Consume dry crackers before getting out of bed

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presence of HIV

3.T lymphocyte levels

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?

3.Test the ultrasound equipment to ensure proper functioning.

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?

3.The client is wearing knee-high hose.

A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information?

3.To avoid exercise because of the negative effects on insulin production

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?

3.Weight increases by more than 1 pound in a week.

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?

3.Where fertilization occurs

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?

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

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?

4.Between 16 and 20 weeks' gestation

A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client?

4."Better blood glucose control means fewer effects; let's review your plan of care."

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

4."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.

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?

4."I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?

4."I should choose underwear with a cotton panel liner."

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?

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

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

4."There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

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?

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

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 will be noted between which weeks of gestation?

4.16 and 20 weeks' gestation

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

4.18

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

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

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation?

4.Acute anxiety and the need for support

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?

4.Administration of immune globulin and vaccine in the infant soon after birth

A woman diagnosed previously with gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply.

4.Blood pressure (BP) 165/120 mm Hg 5.Complaints of headache for the last 12 hours

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?

4.Describing the appropriate amount of weight gain required during the pregnancy

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time?

4.Explain the purpose of the nurse's actions and answer all questions.

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which client problem does the nurse identify as the priority at this time?

4.Fear about the well-being of the fetus

The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

4.History of substance abuse during this pregnancy

A client calls the primary health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine?

4.Human chorionic gonadotropin (hCG)

The nurse is collecting data on a pregnant woman who is diagnosed with human immunodeficiency virus (HIV) during the thirty-second gestational week. The nurse reviews the data and determines that which finding requires further follow-up?

4.Increased shortness of breath and bilateral rales

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?

4.Petechiae, oozing from injection sites, and hematuria

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?

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

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?

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

The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects the client will indicate that which medication is prescribed?

4.Subcutaneous administration of heparin sodium 5000 units daily

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?

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

The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?

4.The client will be able to identify measures to prevent infection.

A client in the prenatal clinic presents with a blood pressure reading of 140/90 mm Hg, which is an elevation from last month's reading of 114/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?

4.Trace amount of protein

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?

4.Travel precautions and use of shoulder seat belts

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

Baseline fetal heart rate

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 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?

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

A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes

3."I shouldn't have eaten so many sweets before I became pregnant."

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?

3.12 to 16

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?

3.150 beats per minute

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?

3.22 cm to 26 cm

The nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the primary health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?

3.Assists in identifying infections that may need to be treated

The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal?

3.Avoid further stress on the maternal immune system.

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?

3.Calcium gluconate

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?

3.Check for signs of thrombophlebitis.

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?

3.Connects the umbilical vein to the inferior vena cava

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Determine the fetal heart rate.

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

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn.

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?

1.The insulin needs will increase.

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

"Tell me what you mean when you say that your baby has moved."

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.

"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 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?

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

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 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

A client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic?

1."Tell me about your concerns."

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?

1.A 3-hour glucose tolerance test

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?

1.Laser therapy

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 is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?

1.Placing external fetal monitors so that each fetal heart rate is monitored separately

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 the positive effects of breathing and relaxation techniques to a pregnant client with cardiac issues who has an 18-month-old child. Which primary outcome is the purpose for these interventions?

1.Reducing maternal stress and fatigue

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 collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority?

1.Signs of fetal distress

A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise?

1.Swimming

Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

1.Tell the dental office staff that she is pregnant.

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?

1.The bladder must be full during the examination.

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)?

2.January 12

The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.

2.Earliest taste buds present. 3.Kidneys able to secrete urine. 5.Sex can be determined as internal and external organs are sex specific.

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?

2.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?

2.Gravida II, para I

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 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

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?

3.High risk for infection

The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?

3.Increase in circulating volume

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

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

4.Weight and height

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Side-lying

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

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?

1.She has a history of chronic hypertension.

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.

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, which is the best response by the nurse?

1."Can you tell me more about what you are eating?"

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

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?

1.Week 5

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."

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. Which response is appropriate for the nurse to make?

3."The breast changes are a result of the secretion of estrogen and progesterone."

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.

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?

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

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

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

The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen?

4.Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?

4.Green, leafy vegetables

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?

4.Provides an exchange of nutrients and waste products between the mother and the fetus

The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, which nursing action can the nurse implement that will promote the birth of the placenta?

Putting the baby to the mother's breast and letting the baby suck

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 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?

1.A softening of the cervix

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

1.Pulse

Which findings indicate to the nurse that placental separation has occurred? Select all that apply.

1.Lengthening of umbilical cord 2.Sudden trickle or spurt of blood 5.Fetal membranes are seen at the introitus

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 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?

1.Provide emotional support.

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

A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid and rifampin. The nurse plans to implement which intervention?

1.Reviewing daily nutritional intake with the client

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?

3.Pregnancy greatly increases the risk of malnourishment for the mother.

The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?

3.Providing the mother with pamphlets and booklets to read about the pregnancy