OB Ante & Intra
A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following informative statements will the nurse provide to the client?
"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."
A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client states:
"Breast-feeding after delivery is best for my baby."
A 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 breast-feed the infant after delivery. Which response by the nurse is appropriate?
"Breast-feeding is contraindicated."
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, the nurse determines that the best response would be which of the following?
"Can you tell me more about what you are eating?"
When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?
"Do you have any cats as house pets, and, if so, do you ever come in contact with their soiled kitty litter?"
A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which of the following statements by the client would identify the need for further teaching regarding the hemorrhoids?
"Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born."
During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that goal achievement has occurred when the client states which of the following?
"I am eating fresh fruits and vegetables for snacks and for dessert each day."
A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands about this infection when the client says:
"I am so glad that I can breast-feed my baby after she has been vaccinated."
A nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement by the client indicates an immediate need for further investigation?
"I don't like my face anymore. I always look like I have been crying."
A nurse employed in a health care provider's office is collecting information from a pregnant client. Which of the following statements made by the client likely indicates the need for psychological referral?
"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."
A nurse provides instructions to a client with mild preeclampsia on home care. The nurse evaluates that the teaching has been effective when the client states:
"I need to check my urine with a dipstick every day for protein and call the health care provider if it is 2+ or more."
A nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client would alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?
"I need to gain only ten pounds so that my baby will be small like I am."
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 states:
"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."
A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client would indicate that the client understands her needs?
"I should avoid stressful situations."
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?
"I should choose underwear with a cotton panel liner."
A nurse is instructing 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?
"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
A nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for more teaching regarding possible complications of preeclampsia?
"I should expect that my urine output will decrease."
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?
"I shouldn't have eaten so many sweets before I became pregnant."
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 states:
"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."
Magnesium sulfate is prescribed for a client with severe preeclampsia. Which statement by the student nurse supports the need for further education regarding the action of this medication?
"It increases acetylcholine and blocks neuromuscular transmission."
A perinatal client with a history of heart disease has been instructed on care at home. Which of the following statements if made by the client would indicate the need for further instructions?
"It is best to rest on my right side."
A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term?
"It is the fetal movement that is felt by the mother."
A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which of the following responses, if made by the student, indicates an understanding of the function of this hormone?
"It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."
A nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client says:
"My cervix is completely dilated."
A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help reduce the maternal fears that the newborn will be born with an infection?
"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."
The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process?
"Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."
A 32-week gestational client 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?
"Tell me about your concerns."
A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?
"Tell me what concerns you have."
A pregnant client who is anemic tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure that you are providing the best nutrition and growth potential."
A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
A pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning?
"The iron is needed for the red blood cells."
A contraction stress test is scheduled for the client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following?
"The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."
A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which of the following responses, if made by the student, indicates an understanding of the anatomy of this structure?
"The uterus weighs about 2 ounces."
A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response by the student indicates an understanding of the anatomy of this structure?
"The uterus weighs about 2 ounces."
Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery
"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."
A woman at 20 weeks of gestation calls the health care provider's office and speaks to a nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which of the following is the least helpful response to the client?
"This is an emergency; you should come to the clinic within the hour."
A 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 response by the nurse indicates a lack of understanding of the implications of the client's symptoms?
"This is probably an emergency. Have someone drive you to a hospital now."
A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?
"What an efficient way to record my baby's heart rate."
A nurse shares with a pregnant client that the results of her rubella screening is positive. What 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?
"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."
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 of the following statements by the nurse indicates an understanding of the problem?
"You feel you are having difficulty fulfilling your role as a wife."
A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be appropriate?
"You were wise to call. I will check your rubella titer screening results and we can identify immediately if interventions are needed."
Abdominal ultrasonography is prescribed for a woman who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement to the woman?
"You will be positioned on your back and turned slightly to one side with your head elevated."
A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is isolated:
1 cm above the ischial spines
A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is:
1 cm above the ischial spines
A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is:
1 cm above the ischial spines
A nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds to the client, knowing that the sex of the fetus can be visually recognizable as early as week:
12
A nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document that the FHR is normal if which of the following were noted?
150 beats per minute
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 of the following heart rates is noted?
150 beats per minute
A pregnant client asks a 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:
16 and 20 weeks of gestation
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:
16 and 20 weeks' gestation
A nurse is collecting data on a pregnant client and is preparing to auscultate the fetal heart sounds. The nurse prepares to use a fetoscope, knowing that fetal heart sounds can be heard with a fetoscope by which week of gestation?
18 to 20 weeks
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:
18 weeks of gestation
A nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at gestational week:
20
The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?
28 cm
A nurse is assisting in performing an assessment on a client who is at 32 weeks of gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?
32 cm
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?
5
A client with severe preeclampsia is receiving magnesium sulfate by intravenous infusion. The nurse reviews the laboratory results, knowing that which value is a therapeutic magnesium level?
6 mg/dL
A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Considering the client's behavior, the nurse suspects she is dilated:
8 to 10 cm
A blood glucose measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which should the nurse anticipate to be prescribed for the mother?
A 3-hour glucose tolerance test
A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother?
A 3-hour glucose tolerance test
A pregnant client has been diagnosed with placental abruption. The nurse caring for the client prepares the client for:
A cesarean birth
A nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. The nurse tells the client that:
A cesarean section will be necessary if vaginal lesions are present at the time of labor.
The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated?
A change in the uterine contour
When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which of the following factors would the nurse consider being significant?
A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago
The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following?
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. The nurse interprets these findings as indicating:
A negative test
A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. The nurse analyzes this data as indicative of:
A normal finding
The nurse notes that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. What is the explanation for this increase?
A normal finding
A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign, and the nurse determines that this sign is indicative of:
A softening of the cervix
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:
A softening of the cervix
A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur. The nurse bases the response on which of the following?
A steady increase in insulin will be needed.
A nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which of the following findings would place the client at this risk?
A urinary tract infection
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?
Abdominal pain
A client diagnosed with severe preeclampsia is on magnesium sulfate by continuous intravenous infusion. Which finding suggests to the nurse that the next dose of this medication should be held?
Absence of deep tendon reflexes
A 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:
Acute anxiety and the need for support
A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation?
Adding 1 tablespoon of mineral oil to a bowl of cereal daily
A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which priority action to assist in preventing a crisis from occurring during labor?
Administer oxygen as prescribed throughout labor.
An assessment of a woman at 32 weeks' gestation indicates moderate fetal distress. What is the nurse's priority intervention?
Administer oxygen with a face mask at 7 to 10 L/min.
A nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?
Administering oxygen via face mask
A nurse is monitoring a client who is in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, the nurse immediately:
Administers oxygen via face mask to the mother
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which of the following does the nurse anticipate to be prescribed?
Administration of immune globulin and vaccine in the infant soon after birth
A nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action would be to monitor:
All vital signs, especially heart rate and blood pressure
The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply.
Allows for fetal movement Is a measure of kidney function Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus
A nursing instructor asks a student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply.
Allows for fetal movement Is a measure of kidney function Maintains the body temperature of the fetus Surrounds, cushions, and protects the fetus
A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?
An adolescent with multiple heterosexual contacts
A nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system. When a participant in the class asks where the follicle-stimulating hormone is produced, the nurse responds that it is produced in the:
Anterior pituitary gland
A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's statement, the nurse understands that the client is experiencing which of the following problem?
Anxiety and fear
A nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which of the following problems would the nurse expect to note on the plan of care?
Anxiety related to a slow progress of labor
A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Part of the plan of care for this client should be to monitor for:
Any bleeding, such as in the gums, petechiae, and purpura
The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes:
Are where fertilization occurs
A nursing student is asked to identify the location of the isthmus of the uterus. The student correctly states that the isthmus is the:
Area between the corpus of the uterus and the cervix
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. This action will primarily:
Assist in preventing dehydration and hypoxemia.
A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid doing which of the following at this time to assist in relieving the back discomfort?
Assist the client to ambulate in the room.
A nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the health care provider any early signs of vaginal discharge or perineal tenderness. What is the primary expected outcome for this intervention?
Assists in identifying infections that may need to be treated
A perinatal client is at risk for toxoplasmosis. The nurse should teach the client which of the following to prevent exposure to this disease?
Avoid exposure to litter boxes used by cats.
A 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:
Avoid further stress on the maternal immune system.
A nurse is providing information about health care to a pregnant client who is positive for human immunodeficiency virus (HIV). The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to:
Avoid further stress on the maternal immune system.
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign(s) of pregnancy that the nurse should recognize? Select all that apply.
Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions
The nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?
Baseline fetal heart rate
A 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:
Beans
A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?
Betamethasone
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 16 and 20 weeks' gestation
A client presents at her health care provider's office 10 weeks pregnant with her first pregnancy. Which of the following is a presumptive sign of pregnancy that the client might be expected to have?
Breast changes
The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. Select all that apply.
Bright red vaginal bleeding Soft, relaxed, nontender uterus
A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which of the following? Select all that apply.
Carrying more oxygen on fetal hemoglobin than maternal hemoglobin Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output Bypassing the fetal lungs to circulate oxygen rich blood Using the fetus's beating heart to pump blood in the circulatory system
A nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination will not be performed on the client primarily because it could do which of the following?
Cause profound hemorrhage
Which of the following histories would place a maternity client at risk for uterine rupture?
Cesarean section birth
Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?
Change in uterine shape
A nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
Changes in the shape of the uterus
A nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which of the following?
Characteristics of contractions
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, the nurse should first:
Check for signs of thrombophlebitis.
A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately:
Checks the fetal heart rate
A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client?
Client exhibits no signs of fetal distress.
A nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing:
Complete placenta previa
A client age 23 develops melasma during pregnancy. The nurse notes that the client has started wearing very heavy makeup. The client tells the nurse that she is fearful that her mate will reject her, and that she has decreased her social engagements drastically because of this change. The nurse determines that the client is experiencing which problem?
Concern about her appearance
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?
Consume dry crackers before getting out of bed.
A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:
Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.
A nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which of the following at this time?
Continue monitoring the client because the data reflect acceptable progress.
The client is in the second stage of labor. As the baby begins to crown, the health care provider administers a pudendal nerve block in preparation for an episiotomy. The nurse should:
Continue to assess vital signs and fetal heart rate the same as before the nerve block.
The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?
Continue to monitor the client.
A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?
Contraction stress test
A nurse is assigned to care for a nulliparous client who is having a precipitate delivery. The nurse reports which maternal focused observations?
Decreased periods of uterine relaxation between contractions
A nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which one of the following becomes apparent?
Decreased periods of uterine relaxation between contractions
A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete rupture occurs?
Decreasing blood pressure
A nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, the nurse should specifically monitor which of the following?
Deep tendon reflexes
A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which of the following problems should receive highest priority?
Dehydration
A nurse is providing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which of the following in the discussion?
Describing the appropriate amount of weight gain required during the pregnancy
A nurse is monitoring a client in labor whose membranes rupture spontaneously. The initial nursing action is to:
Determine the fetal heart rate.
A primigravida's membranes rupture spontaneously. The nurse's first action is to:
Determine the fetal heart rate.
The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:
Determine the maternal and fetal vital signs.
A client has just delivered a viable newborn. The first nursing action to initiate attachment is to:
Determine the parents' desires for contact with the newborn.
A nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?
Document the temperature.
The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and tells the partner to:
Dorsiflex the client's foot while extending the knee.
A nurse is providing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse would instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?
Dried fruits
A client who is 8 weeks pregnant calls the clinic and speaks to the nurse about complaints of nausea and vomiting every morning. To promote relief, the nurse suggests:
Eating crackers before arising
A client asks a nurse to describe how her baby is developing. The nurse bases the response on the knowledge that every organ system in the fetus is present by the end of which gestational week?
Eighth
A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client's feelings of anxiety by:
Encouraging the client to discuss her concerns and desires regarding anesthesia options
A client in labor asks the nurse why it is so important to void frequently during labor. The nurse responds, using knowledge that the important reason is to:
Ensure labor progress and prevent injury.
In the prenatal clinic, a nurse is gathering data from a new client for the health history information. What is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?
Establish a therapeutic relationship between the nurse and pregnant client.
A nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which of the following?
Estrogen
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
Estrogen
A nurse assisting to monitor a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client to reflect an attitude of:
Excitement
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. The appropriate nursing response or action at this time would be to:
Explain the purpose of the nurse's actions, and answer all questions.
When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?
Expression of hope for a positive outcome
A 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 health care provider. Choose the warning signs that the nurse places on the list. Select all that apply.
Facial edema Rapid weight gain Visual disturbances Generalized edema
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 of the following client problems does the nurse identify as important at this time?
Fear about the safety of the fetus
A nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following most appropriately describes the mother's problem at this time?
Fear about what is happening
A nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as:
Fear of losing control
A nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse tells the client that she will:
Feel some pressure when the vaginal probe is moved
A nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which of the following psychosocial issues?
Feelings of guilt are often associated with grief.
A client who is 6 months pregnant is attending her first prenatal visit. On the first prenatal visit, the nurse notes that the client is gravida IV, para 0, aborta III. The client is 5 feet, 6 inches tall, weighs 130 pounds, and is 25 years old. She states, "I get really tired after working all day and can't keep up with my housework." Which factor in the above data would lead the nurse to suspect gestational diabetes?
Fetal demise
A nurse is monitoring a client at risk for placental abruption. Which of the following is indicative of this complication?
Fetal distress
A nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. The nurse understands that the first maneuver will assess for which of the following?
Fetal engagement
A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which of the following findings would indicate a need to contact the registered nurse (RN)?
Fetal heart rate of 180 beats per minute
A pregnant woman visiting a health care clinic for the first prenatal visit hears the health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the preembryonic period is the:
First 2 weeks of fetal development following conception
A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is:
Flat and nonfavorable for a vaginal birth
A nurse is instructing a pregnant client on dietary sources of iron. Which of the following food selections made by the client demonstrates an understanding of teaching?
Fresh spinach
Of the following, which would be the appropriate method to use to deliver the placenta after a precipitate delivery?
Gently guide the placenta out after a spontaneous separation.
A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. The nurse's initial action is to:
Gently hold the presenting part upward.
A client delivers a viable male neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be:
Good
A nurse is providing 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 of the following food items in the diet?
Green, leafy vegetables
A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse determines that:
HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.
A nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
Have the client empty her bladder.
A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which of the following laboratory results indicates a physiological consequence of a result of this practice?
Hemoglobin 9.1 g/dL
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 of the following problems do the data best support?
High risk for infection
A 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?
History of substance abuse during this pregnancy
A nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?
How to check for signs of hypoglycemia and the required treatment
A client calls the 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 of the following in the urine?
Human chorionic gonadotropin (hCG)
A nurse is collecting data on a client who is pregnant with twins. Which of the following signs would alert the nurse to a potential problem specifically related to the twin pregnancy?
Hypertension
For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes, lasting 60 to 70 seconds, and strong to palpation. She is 2 cm dilated and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?
Hypertonic
A nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which of the following is an unassociated finding with this diagnosis?
Hypotension
During the antenatal period of a client diagnosed with the human immunodeficiency virus (HIV), the nurse weighs and plots the weight gain pattern routinely and discusses the findings. The primary purpose of this action is to:
Identify appropriate fetal development.
A nurse is collecting data from a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:
In a sitting position
A nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client:
In a sitting position
A maternity nurse is providing an inservice educational session to nursing students regarding the process of conception. The nurse determines that a nursing student understands this process if the student states that fertilization of a mature ovum occurs in which of the following areas?
In the distal third of the fallopian tube
A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding?
Increase in fundal height
A nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which statement accurately describes the normal cardiovascular symptom experienced during pregnancy?
Increase in pulse
A nurse in a prenatal clinic is teaching a group of pregnant clients about anemia. Which statement is accurate about the cause of physiological anemia of pregnancy or hemodilution?
Increased blood volume of the mother
A nurse is reviewing the laboratory results of a pregnant client and notes that the hemoglobin level is decreased. Physiological dilutional anemia is documented in the client's record by the health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation?
Increased blood volume of the mother during pregnancy
A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will likely have:
Increased efficiency of contractions
A nurse is collecting data on a pregnant woman who is human immunodeficiency virus (HIV) positive during the 32nd gestational week. The nurse reviews the data and determines that which finding requires further follow up?
Increased shortness of breath and bilateral rales
A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?
Inevitable
A nurse assisting in the care of a woman in labor should focus primarily on which of the following at the time of delivery?
Infant
A nurse-midwife is performing an assessment on a pregnant client and is assessing the client for the presence of ballottement. The nurse who is assisting understands that the nurse-midwife will implement which to test for the presence of ballottement?
Initiate a sudden tap on the cervix.
During a prenatal visit of a client diagnosed with placenta previa, the health care provider defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk?
Initiating severe hemorrhage
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate?
Instruct the client that these are common and may occur throughout the pregnancy.
A nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which of the following at the client's bedside?
Intravenous (IV) supplies
A nurse is teaching a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which of the following occurs?
Irregular, painless contractions
Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:
Is a systematic method for palpating the fetus through the maternal abdominal wall
The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment:
Is effective in protecting the newborn from Neisseria gonorrhoeae and chlamydia
A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage:
Is light stroking of the abdomen to facilitate relaxation during labor
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 provides instructions to the client regarding therapeutic management of tuberculosis and tells the client that:
Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.
Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal?
It is pale, straw-colored with flecks of vernix.
A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
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, what would be the estimated date of delivery (EDD)?
January 12
A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which of the following treatments would the nurse consider to be safe for this maternity client?
Laser therapy
A nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?
Lateral Sims'
A client in preterm labor is placed on bedrest. The nurse assists the client to which of the following advantageous positions?
Left lateral
A pregnant client asks the prenatal clinic nurse what the fetal period of development means? The nurse tells the woman that the fetal period is the:
Longest period of fetal development
A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse initially include in the plan of care?
Maintain complete bedrest, monitor IV fluid intake, and monitor the fetal heart rate.
A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse includes which of the following in the plan of care?
Maintain continuous electronic fetal monitoring.
A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. The nurse tells the woman that the purpose of progesterone is to:
Maintain the uterine lining for implantation.
A 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:
Massaging the abdomen during contractions using both hands in a circular motion
A nurse is collecting data from a client who is pregnant with twins. The nurse understands that which of the following complications is likely associated with a twin pregnancy?
Maternal anemia
A nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record would support this diagnosis?
Maternal hypertension
A nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?
Maternal hypertension
The maternity nurse prepares the client for which of the following techniques commonly used to relieve shoulder dystocia?
McRoberts' maneuver
The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client?
Measuring the fundal height
A nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. The nurse would expect documentation that the fundus of the uterus is noted at which area?
Midway between the symphysis pubis and the umbilicus
A nurse is reviewing the health care record of a pregnant client at 16 weeks' gestation. The nurse would expect documentation that the fundus of the uterus is noted at which of the following areas?
Midway between the symphysis pubis and the umbilicus
The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which of the following areas?
Midway between the symphysis pubis and the umbilicus
A nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) HIV to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?
Minimize the potential for developing infections.
A nurse is assigned to care for a client admitted with severe preeclampsia. What is the priority nursing intervention for this client?
Minimizing the client's exposure to external stimuli
A nurse is caring for a client in preterm labor when her membranes rupture. The initial nursing action is to:
Monitor the fetal heart rate.
A nurse assigned to care for a client with mild preeclampsia would anticipate which specific nursing intervention for this client?
Monitoring fetal movement
A nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?
Monitoring fetal status
A nurse is assigned to care for a client experiencing dystocia. In planning care, the nurse would consider the highest priority to be frequent:
Monitoring for changes in the physical and emotional condition of the mother and fetus
A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:
Notify the registered nurse (RN) immediately
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which of the following nursing actions is appropriate?
Notify the registered nurse (RN).
A nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which of the following at this time?
Notify the registered nurse of a possible maternal infection.
A nurse is providing information to a pregnant woman about food items high in folic acid. Which of the following mid-afternoon snacks should be recommended to supply folic acid?
Nuts and green, leafy vegetables
A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.
Oliguria Proteinuria 3+ Blood pressure 168/116 mm Hg
A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which manifestation of this complication?
Oozing from injection sites
A 15-year-old client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which of the following treatments for acne will likely be avoided with this client?
Oral tetracycline hydrochloride
A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?
Pain level is "4" while a progressive labor pattern continues.
A prenatal client with vaginal bleeding is admitted to the labor unit. Which of the following signs or symptoms indicates placenta previa?
Painless vaginal bleeding
A nurse is providing instructions to a client about preterm labor. The nurse would do which of the following as the effective method for teaching the client to monitor for preterm uterine contractions?
Palpate for uterine contractions at the same time as the client.
A nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as the effective teaching method?
Palpate for uterine contractions at the same time as the client.
A nurse is providing instructions to a pregnant woman regarding measures that will strengthen the perineal floor muscles. The nurse instructs the client to:
Perform Kegel exercises in 10 repetitions, three times per day.
The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes:
Petechiae, oozing from injection sites, and hematuria
A 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. What is the first nursing action?
Place a wedge pillow under the client's right side.
A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse take first?
Place the client in the Trendelenburg position.
A nurse is caring for a woman in the delivery room. The health care provider prescribes an oxytocic medication for the woman to stimulate uterine contractions and prevent hemorrhage. The nurse understands that this medication will be administered after delivery of the:
Placenta
A nurse should prepare to give a prescribed oxytocic medication after delivery of the:
Placenta
A 38-week gestational pregnant woman arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing:
Placenta previa
A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. The nurse immediately:
Places a gloved hand into the vagina and holds the presenting part off of the umbilical cord
A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:
Placing external fetal monitors so that each fetal heart rate is monitored separately
A nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?
Potential for infection
A nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy?
Pregnancy greatly increases the risk of malnourishment for the mother.
A nurse caring for a client diagnosed with placental abruption would plan to:
Prepare the client for a cesarean birth.
A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. What is the appropriate nursing action?
Prepare the client for a cesarean delivery.
At 5:00 AM a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 AM with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to:
Prepare the client for a cesarean delivery.
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted?
Presence of accelerations
A nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:
Prevent dehydration and hypoxemia.
During the intrapartum period, a nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:
Prevent dehydration and hypoxemia.
A nurse is assigned to assist in caring for a client in labor. The nurse would determine that which of the following would least likely indicate dystocia?
Progressive changes in the cervix
A nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is:
Prolactin
A maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phase, if stated by the nursing student, indicates a need to further research this area?
Proliferative phase
The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? Select all that apply.
Proteinuria Hypertension Generalized edema
A nurse is planning interventions for counseling a maternal client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time would be which of the following?
Provide emotional support.
A nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:
Provide pain relief measures.
A nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which of the following nursing interventions would be least likely to assist in meeting her emotional needs?
Providing the mother with pamphlets and booklets to read about the pregnancy
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. What is the appropriate action to deliver the placenta?
Pull gently on the cord as the mother bears down.
A nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which of the following would the nurse check first?
Pulse
If a precipitate delivery is imminent, which of the following would be the appropriate nursing action?
Put on sterile gloves, and gently guide the baby's head and shoulders out.
A nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
A nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to:
Reduce excessive maternal stress and fatigue.
A nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that its primary purpose is to:
Reduce the risk of injuring the bladder during the surgery.
A nurse is reinforcing the positive effects of breathing and relaxation techniques to a pregnant, cardiac client who has an 18-month-old child. What is the primary outcome for these interventions?
Reducing maternal stress and fatigue
A client who consumes alcohol frequently is in the first trimester of pregnancy. What is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?
Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures
A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?
Report the time of last food intake to the health care provider.
During an initial prenatal visit, the nurse notes that the client's hemoglobin level is indicative of iron deficiency anemia. Which additional client data would also support this finding?
Reports of fatigue
A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which of the following information would be of concern to the nurse?
Respirations of 10 breaths per minute
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection?
Respirations of 10 breaths per minute
A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines that the client's primary physiological need at this time is:
Rest between contractions
A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which of the following data would best alert the nurse to early signs of hypovolemic shock?
Restlessness and agitation
Following delivery, a client experiences subinvolution of the uterus. The nurse develops a plan of care, recalling that which of the following is the primary cause for this occurrence?
Retained placental fragments
A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid (INH) and rifampin (Rifadin). The nurse plans to implement which intervention?
Reviewing daily nutritional intake with the client
A nurse is caring for a client who was admitted to the maternity unit at 8:00 AM with contractions occurring every 2 minutes, lasting 1½ minutes, and is dilated 4 cm with a cervical effacement of 60%. At 10:30 AM, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which of the following?
Ruptured uterus
A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium sulfate therapy is effective if:
Seizures do not occur.
A 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?
She has a history of chronic hypertension.
A nurse is assisting in caring for a client in labor. The nurse recognizes that the risks for uterine rupture during labor and delivery include:
Shoulder dystocia
A nurse is collecting data from a client with placenta previa during an office visit. The nurse checks which of the following items as first priority?
Signs of fetal distress
A nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.
Signs of fetal distress High level of maternal anxiety Failure of the fetus to descend
A nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for:
Signs of shock
A 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. The nurse tells the client that estrogen:
Stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation
A nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse would first:
Stop the oxytocin infusion.
A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to:
Strengthen the pelvic floor in preparation for delivery.
A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed?
Subcutaneous administration of heparin sodium 5000 units daily
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in the:
Supine position with a wedge under the right hip
The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the:
Supine position with a wedge under the right hip
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened?
Support the mother in her reaction to the newborn infant.
A nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which of the following findings is least likely associated with DIC?
Swelling of the calf of one leg
A pregnant client asks a nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following?
Swimming
A nurse is reviewing the health history of a pregnant client. Which of the following data, if noted in the client's health history, would indicate a risk for spontaneous abortion?
Syphilis
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 of the following laboratory studies would further support the presence of HIV?
T lymphocyte levels
A pregnant client is a gravida III, para 0, abortus II. She is placed on bedrest at home because of preterm labor. The nurse provides information to the husband, knowing that which of the following will assist to promote family adaptation?
Teaching the husband to perform passive range of motion and provide back rubs for his wife
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
Tell the client that these are common and they may occur throughout the pregnancy.
Which finding in the prenatal client supports the medical diagnosis of placental abruption?
Tender, rigid abdomen
A nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which of the following actions will the nurse take before the procedure to ensure the maintenance of fetal safety during the procedure?
Test the ultrasound equipment to ensure proper functioning.
The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client:
That the bladder must be full during the exam
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. The nurse bases the response on which of the following?
The breast changes are a result of the secretion of estrogen and progesterone.
The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving?
The client complains of a headache and blurred vision.
A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem should direct care for this client?
The client feels hopeless about the situation.
During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." The nurse needs to further check:
The client for blood pressure changes and protein in the urine
A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem should initially direct nursing care at this time?
The client is blaming herself.
A client beginning week 30 of gestation comes to the clinic for a routine visit. Which of the following observations by the nurse indicates a need for teaching?
The client is wearing knee-high hose.
A nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?
The client will be able to identify measures to prevent infection.
When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?
The client will not develop an opportunistic infection during the remainder of pregnancy.
A nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is a cephalic presentation. The nurse understands that this is:
The common presentation
A 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 to detect complications caused by:
The increase in circulating volume
The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is:
The most favorable for labor and birth
A nurse is preparing to instruct a pregnant client about nutrition. The nurse plans to include which of the following in this client's teaching plan?
The nutritional status of the mother significantly influences fetal growth and development.
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?
To avoid exercise because of the negative effects on insulin production
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 provides a list of instructions for the client regarding management of care. Choose the instructions that the nurse places on the list. Select all that apply.
To note the color of blood on each perineal pad To watch for the evidence of the passage of tissue To note the quantity of blood on each perineal pad To count the number of perineal pads used on a daily basis
A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs:
To regain her breathing pattern
A client in the prenatal clinic presents with a blood pressure reading of 134/90 mm Hg, which is an elevation from last month's reading of 104/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?
Trace amount of protein
A 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 of the following would be a part of the teaching plan for this class?
Travel precautions and use of shoulder seat belts
A nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?
Turn client to her side and administer oxygen by mask at 8 to 10 L/min.
A 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:
Turn the client onto her left side.
In providing initial care to the newborn following delivery, the priority action of the nurse is to:
Turn the infant's head to the side.
When examining the umbilical cord immediately after birth, the nurse expects to observe:
Two arteries
A nurse is collecting initial data on a newborn in the delivery room. Which observation would the nurse expect to note when examining the umbilical cord of the newborn?
Two arteries and one vein
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of:
Two umbilical arteries and one umbilical vein
A 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 finding would support potential further maternal compromise?
Vaginal spotting twice since the last prenatal visit
A clinic nurse is teaching a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the health care provider. Which of the following would be included on the list? Select all that apply.
Visual disturbances Rapid weight gain Generalized or facial edema Vaginal bleeding
A nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in this area?
Vulva
A nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which of the following areas, knowing that venous congestion is most commonly noted here?
Vulva
A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which of the following is appropriate to suggest to the client?
Wear a perineal pad to the play.
A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:
Wedge-shaped and narrow and nonfavorable for a vaginal birth
A nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is:
Wedge-shaped, narrow, and nonfavorable for a vaginal birth
A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week?
Week 28
A pregnant client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the sex of the fetus can usually be determined by:
Weeks 12 to 16
A nurse is gathering data from a pregnant client about physiological risk factors. The nurse would be sure to obtain which priority data?
Weight and height
During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding would indicate a serious nutritional disorder of pregnancy?
Weight compared to last visit is a loss of 2.3 pounds.
A nurse is preparing a client for an emergency cesarean delivery. Which of the following information regarding the client has priority?
When was the last time the client ate or drank?
A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?
White blood cell count of 35,000 mm3
A nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?
With the hips elevated
A nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student states:
"FSH and LH are released from the anterior pituitary gland."
A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone?
"It increases during pregnancy to stimulate basal metabolic rate."
The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term?
"It is the fetal movement that is felt by the mother."
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." The appropriate response by the nurse is which of the following?
"Tell me what you mean when you say that your baby has moved."
A nurse is collecting data from a prenatal client. The nurse determines that which of the following places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?
A history of intravenous (IV) drug use in the past year
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is:
A manual pelvic examination
A nurse assists the nurse-midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (−) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity for the client?
Complete bedrest
While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of:
Compression of the vena cava
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 that it:
Connects the umbilical vein to the inferior vena cava
A nurse in the labor room is caring for a client in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?
Document the findings and continue to monitor the fetal patterns.
The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to:
Drink decaffeinated coffee and tea.
The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?
It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.
The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2012. Using Nägele's rule, the nurse determines the estimated date of birth to be:
July 27, 2013
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to:
Keep the client in a side-lying position.
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?
Left lateral
The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse recommends which measure to help relieve both discomforts?
Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.
A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by:
Massaging the abdomen during contractions using both hands in a circular motion
A nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which of the following is the most important information for the nurse to document on the strip?
Maternal vital signs
A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client?
Uterine hyperstimulation
The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?
Uterine tenderness on palpation
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 teaches the client about the signs that need to be reported to the health care provider (HCP) and tells the client to call the HCP if:
Weight increases by more than 1 pound in a week.
A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted?
Fetal tachycardia
A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply.
Flushing Depressed respirations Extreme muscle weakness
The nurse is collecting data during the admission assessment of 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 would document the GTPAL for this client as:
G = 2, T = 1, P = 0, A = 0, L = 1
The nurse is collecting data during the admission assessment of 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 would document which gravida and para status on this client?
Gravida II, para I
A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is:
Oxytocin
The advantages of using spinal anesthesia for delivery of a fetus include which of the following? Select all that apply
Ease of administration Absence of fetal hypoxia Immediate onset of anesthesia
A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which of the following, if identified by the student, indicates an understanding of this process?
Fallopian tube
A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing?
Fetal heart rate of 180 beats per minute
A nurse is assisting in performing Leopold's maneuvers. When the client asks what these are for, the nurse's best response is that these maneuvers help to determine:
Fetal position
A nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. The student describes the procedure correctly if the student states to:
Place a rolled blanket under the right abdominal flank and hip area.
After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of:
Placental separation
The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta:
Provides an exchange of nutrients and waste products between the mother and the fetus
A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs?
Providing the mother with pamphlets and booklets to read about the pregnancy
The plan of care for a pregnant teen should include teaching regarding which of the following concerning dental care?
Tell the dental office staff that she is pregnant.
