NCLEX Maternity Practice Q find more

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care?

urine toxicology screening

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?

"Each pregnancy has a unique psychosocial meaning."

After the nurse instructs a pregnant client about swimming and bathing during pregnancy, which client statement indicates the need for additional teaching?

"I can relax in a hot tub for about 20 minutes."

A client who tells the nurse that she would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful?

"It is important to take my temperature at about the same time every morning before arising."

A client is a gravida 2 para 1 and is currently 12 weeks gestation. She states that she drank beer throughout her last pregnancy. The client asks the nurse if it is okay to have a few drinks during this current pregnancy. Which of the following responses by the nurse would be most appropriate?

"It is not safe to consume alcohol during pregnancy."

During her fourth clinic visit, a client who's 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond?

"No because the live viral vaccine is contraindicated during pregnancy." -Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus, which can have teratogenic effects on the fetus. Needing a physician's order isn't a valid reason for withholding an immunization. Recommending pregnancy termination forces the nurse's viewpoint on the client rather than allowing the client to decide for herself. Exposure to rubella virus may have teratogenic effects if the client is exposed during the first trimester.

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed.

Which statement by the client indicates an understanding of teaching regarding use of corticosteroids during preterm labor?

"The corticosteroids may help my baby's lungs mature."

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?

"Walk briskly for 10 to 15 minutes daily, and gradually increase this time."

A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color?

Blue Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink

While assisting a primiparous client with her first breastfeeding session, which action should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?

Brush the neonate's lips lightly with the nipple.

When planning a class for primigravid clients about the common physiologic changes of pregnancy, which information should the nurse include in the teaching plan?

Cardiac output increases by 25% to 50% during pregnancy.

A 28-year-old multigravida at 32 weeks' gestation is admitted to the hospital because of vaginal bleeding. Which action should the nurse do first?

Check fetal heart rate and maternal blood pressure

A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?

Common discomforts of pregnancy

A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. What should the nurse do next?

Continue monitoring the client and fetus.

Which instruction should a nurse give to a client who's 26 weeks pregnant and complains of constipation?

Encourage her to increase her intake of roughage and to drink at least six glasses of water per day.

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 symptoms. How should the nurse intervene?

Explain that urinary frequency is expected during the first trimester.

Using Nägele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of childbirth is what date?

February 17

A client has her first prenatal visit at 15 weeks' gestation. Which finding requires further investigation?

Fundal height of 18 cm Fundal height (in centimeters) should equal the number of weeks' gestation. This client should have a fundal height of 15 to 16 cm. The blood pressure, urine, and weight findings are within normal limits for this client.

A client at 24 weeks gestation comes to the clinic for a prenatal check-up and informs the nurse that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem?

Gestation hypertension

A client at 32 weeks of gestation has mild preeclampsia. She is discharged home with instructions to remain in bed rest. She would also be instructed to call her health care provider if she experiences which of the following symptoms? Select all that apply.

Headache Blurred vision Epigastric pain Severe nausea and vomiting

A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which instruction should the nurse give the client?

Increase caloric intake to 2,200 calories daily to promote fetal growth.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time?

Instruct the partner on touch, massage, and breathing patterns.

A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client is not in labor. Which nursing intervention should the nurse perform?

Monitor the amount of vaginal blood loss

When magnesium sulfate is administered to a client in labor, its action occurs at which site?

Neural-muscular junctions

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 Nägele's rule, what date should the nurse record as the estimated date of delivery (EDD)?

October 10

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?

Prepare for cesarean birth.

An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which nursing intervention is most appropriate at this time?

Recommend a pregnancy test after acknowledging the client's distress.

After instructing a pregnant client about third trimester edema, the nurse determines that the client needs further instruction when the client makes which statement?

Swelling in my hands and face is to be expected."

A nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor?

The client has a child with cystic fibrosis.

During the first trimester, a nurse evaluates a pregnant client for factors that suggest that she might abuse a child. Which parental characteristic is of most concern to the nurse?

The client states she is stupid and ugly.

A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. What should the nurse tell the client that the test results indicate?

There is evidence of fetal well-being.

A client in the early stages of labor is admitted to the labor and delivery unit. During the admission assessment, the client fails to make eye contact with the nurse. The nurse notes ecchymotic areas on the client's thighs and forearms. The partner is present at the client's bedside. The nurse suspects domestic abuse, how should she respond?

When the partner leaves the room, ask the client if she ever feels unsafe at home.

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What should the nurse do next?

Wrap the neonate in a warm blanket.

The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client?

a darkened private room as close to the nurses' station as possible

A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge?

a. "I know if I get fever or chills or change in lochia to call the health care provider." b. "I have the hospital phone number if I have any questions." c. "I will continue my prenatal vitamins until my postpartum checkup or longer." d. "My fertility can return as early as 21 days after my baby's birth." e. "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance."

A pregnant woman states that she frequently ingests laundry starch. The nurse should assess the client for:

anemia.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. To maintain safety for this client, the priority intervention is to

assess reflexes, clonus, visual disturbances, and headache.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?

decreased deep tendon reflexes

When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, what intervention would be most helpful in facilitating parent-infant bonding?

encouraging the parents to hold their infant

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:

gestational hypertension.

After instructing a female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states that which hormone is evaluated by this test?

human chorionic gonadotropin (hCG)

A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, what is most appropriate for this client?

in vitro fertilization (IVF)

A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find:

irritability and poor sucking.

A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding?

normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation

When explaining to a pregnant client about the need to take supplemental vitamins with iron during her pregnancy, the nurse should instruct the client to take the iron with which liquid to promote maximum absorption?

orange juice

A woman who's 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:

recognize these as normal early pregnancy signs and symptoms.

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:

spinach and beef.

A client and her spouse, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as:

the inability to conceive after 1 year of unprotected attempts.

Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug?

to prevent further blood clot formation

After teaching a pregnant client about potential complications of amniocentesis that must be reported immediately, the nurse determines that the client understands the instruction when she says that she will report:

vaginal bleeding.

A nurse is teaching a client who is 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:

"I need to use insulin each day."

The nurse has discussed sexuality issues during the prenatal period with a primigravida who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says:

"I should not get sexually aroused or have any nipple stimulation."

The nurse is caring for a primigravida at about 9 weeks' gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:

"Nausea and vomiting can be decreased if I eat a few crackers before arising."

During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?

"This test will screen for spina bifida, Down syndrome, or other genetic defects." decreased deep tendon reflexes

A pregnant client is experiencing a thin, odorless, vaginal discharge. What should a nurse tell her to do to prevent vaginal infections?

"Try wearing a panty liner and discarding it after every urination."

A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which response would be most helpful?

"What is it that concerns you about pregnancy, labor, and childbirth?"

When assessing a pregnant client with diabetes mellitus, 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?

+3 urine glucose

Assessment of a nulligravid client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station and completely effaced; and fetal heart rate of 136 bpm. Which should the nurse plan to do next?

Assist the client with comfort measures and breathing techniques.

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 healthy food. The nurse should offer the client information about:

Women, Infants, and Children (WIC).

A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate:

maternal vital signs and fetal heart rate (FHR).

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?

postpartum hemorrhage

A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using:

saline nose drops.

A multigravid client visits the clinic because she suspects that she is pregnant but is unable to tell the nurse when her last menstrual period began. The client has a history of preterm birth. The nurse instructs the client that the gestational age of the fetus can be estimated by which procedure?

ultrasonography

A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching?

"I should contact the health care provider if my temperature is 100.4°F (38°C) or higher."

As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?

Reduced intestinal motility - hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.

The nurse on the antenatal unit is planning care for four clients. The nurse should assess which client first:

a 19-year-old 18 weeks' intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle accident with bright red vaginal bleeding

When explaining the risk for having a child with cystic fibrosis to a husband and wife, the nurse should tell them:

the risk is greatest when both clients have the recessive gene. -Cystic fibrosis is an autosomal recessive genetic disorder. This means that both parents have the gene. There is a one in four chance with each pregnancy from such parents that the child will have cystic fibrosis.