saunders antepartum

The client is wearing knee-high hose.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

A negative test

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results?

Monitoring fetal movement

The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?

"It is the fetal movement that is felt by the mother."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

The client will not develop an opportunistic infection during the remainder of pregnancy.

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal is appropriate?

"I should avoid stressful situations."

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client indicates that she understands her needs?

Avoid exposure to litter boxes used by cats.

A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?

Progesterone maintains the uterine lining for implantation. relaxes smooth muscle.

The 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. According to the nurse, what is the purpose of progesterone?

"I need to check my urine with a dipstick every day for protein and call my health care provider if it is 2+ or more."

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

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

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

Wear a perineal pad to the play.

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 measure is appropriate to suggest to the client?

Fetal demise

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 4, para 0, abortion 3. 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 should lead the nurse to suspect gestational diabetes?

To avoid exercise because of the negative effects on insulin production

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?

"It is best to rest on my right side." Rationale:It is best to rest on the left side to promote blood return.

A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client indicates the need for further teaching?

Any bleeding, such as in the gums, petechiae, and purpura

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. Which assessment should be part of the plan of care?

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

A pregnant client is a gravida III, para 0, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband, knowing that which instruction will assist in promoting family adaptation?

The client is blaming herself.

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?

Hemoglobin 9.1 g/dL

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 laboratory result indicates a physiological consequence of a result of this practice?

"Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids?

High risk for infection

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem do the data best support?

Laser therapy

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?

Fear about the well-being of the fetus

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

Blood pressure changes and the presence of protein in the urine

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." Which should the nurse check further?

"I am eating fresh fruits and vegetables for snacks and for dessert each day."

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 the goal has been achieved when the client makes which statement?

The bladder must be full during the examination. rational: Before 20 weeks' gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks' gestation, the bladder should be emptied to minimize the chance of puncturing the placenta or fetus. Rho(D) immune globulin is administered to Rh-negative women because of the risk of contact with the fetal blood during the examination. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the examination is an important intervention.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

The nurse employed in a primary health care provider's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral?

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?

Dehydration

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority?

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

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

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?

Maternal anemia Preterm labor

The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all that apply.

Increase in circulating volume

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

provide emotional support

The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action?

Test the ultrasound equipment to ensure proper functioning. Rationale: Before 20 weeks of gestation, it is recommended to perform an amniocentesis with the bladder full. This pushes the uterus upward for better visualization. After week 20, the bladder is emptied before the test to minimize the risk of puncturing it during the test

The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action should the nurse take before the procedure to ensure fetal safety?

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

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

Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours. In general, women are advised to count fetal movements for 30 minutes three times a day. Most healthy fetuses move at least 10 times in 2 hours.

The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?

Weight increases by more than 1 pound in a week. Rationale: The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema.

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the primary health care provider (PHCP) and tells the client to call the PHCP if which occurs?

12-16

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

"Breastfeeding my newborn will be the best option for my baby.

A pregnant client is positive for the human immunodeficiency virus (HIV). The nurse educates the client and determines that there is a need for further teaching if the client makes which statement?

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 heart rate is noted?

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation." the client with diabetes needs about 50% to 60% of her caloric intake from carbohydrates and about 12% to 20% from protein. High-fiber foods will control blood glucose levels and prevent constipation.

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?

Cause hemorrhage

The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence?

Establish a therapeutic relationship between the nurse and pregnant client.

In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

July 27, 2020

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date?

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

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

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

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 should recommend which measure to help relieve both discomforts?

An adolescent with multiple heterosexual contacts

The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

Reduce excessive maternal stress and fatigue.

The nurse assists a pregnant client with cardiac disease in identifying 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 accomplish which tasks?

A diet that is high in fluids and fiber to decrease constipation. Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system.

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?

Subcutaneous administration of heparin sodium 5000 units daily

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

Tell the dental office staff that she is pregnant.

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

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

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

Perform Kegel exercises in 10 repetitions, three times per day.

The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions?

Drink DE-caffeinated coffee and tea.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." A contraction stress test assesses placental oxygenation and function and determines the fetus's ability to tolerate labor, as well as its well-being.

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

Oxytocin

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

Placenta previa The primary sign in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy.

A pregnant woman who is at 38 weeks' gestation 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, what does the nurse determine the client may be experiencing?

Fetal heart rate of 180 beats per minute

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?

"This is an emergency; you should come to the clinic within the hour." The woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia.

A woman at 20 weeks of gestation calls the primary health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"The iron is needed for the red blood cells."

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning?

How to check for signs of hypoglycemia and the required treatment

The nurse is assisting in developing a teaching plan for a pregnant client diagnosed with diabetes mellitus. Which instruction is the priority for this client?

The client exhibits no signs of fetal distress.

The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?

Acute anxiety and the need for support

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

Gravida II, para I

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?

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

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

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 document that the fundus of the uterus is located at which area?

1.Small parts are located on the left side of the uterus. 2.Small parts are located on the right side of the uterus. A soft, irregular non-ballottable shape is located just above the symphysis pubis.

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

Compression of the vena cava intervention: supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement

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 which reason?

Findings of abruptio placentae include dark red vaginal bleeding and abdominal pain. A ruptured amniotic sac would include findings such as a watery vaginal drainage. Passage of the mucous plug appears pink or as blood-tinged mucus.

fluids

Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

pregnancy hormones

This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Softening of the cervical tip is Goodell's sign. Softening of the uterine isthmus is Hegar's sign. Rebounding of the fetus is known as ballottement.

pregnancy signs

The client will feel some pressure when the vaginal probe is moved.

The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?

Check for signs of thrombophlebitis. In the pregnant client who complains of leg cramps, the nurse should first check for signs of thrombophlebitis and notify the registered nurse. If thrombophlebitis is not present, the nurse may be instructed to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or have the client stand on a cold surface.

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?

week 5 Rationale:The fetal heart is beating and has developed four chambers by gestational week 5.

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?

"I will continue to take the prescribed oral tetracycline hydrochloride on a daily basis."

A client who is pregnant will be treated by a dermatologist for acne. Which statement if made by the client indicates a need for further teaching?

"Do you plan to have any other children?"

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?

swimming

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

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

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

The nutritional status of the mother significantly influences fetal growth and development.

The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?

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

The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?

The client complains of a headache and blurred vision.

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern?

"It may play a role in the neural development of the fetus." "It increases during pregnancy to stimulate basal metabolic rate."

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 statements by the student indicate an understanding of this hormone? Select all that apply.

16 and 20 weeks' 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 which weeks of gestation?

"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." Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery.

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 should the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

Nuts and green, leafy vegetables

The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?

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

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

T lymphocyte levels

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

Weight compared to last visit is a loss of 2.3 pounds

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding indicates a serious nutritional disorder of pregnancy?

"I will tell the nurse at the hospital that I had an Rh shot during pregnancy." rational: shot are given Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery.

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

Signs of fetal distress

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

"Melasma may reoccur in a subsequent pregnancy. "These brown, splotchy patches will most likely disappear after I deliver my baby." "The dark patches that are on my nose, cheeks and forehead will most likely darken until the baby is delivered."

A client who is in the second trimester of pregnancy develops melasma during pregnancy. Which statements made by the client indicates an understanding of this condition? Select all that apply.

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

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?

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

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

1.Diagonal conjugate measures 12.5 cm to 13 cm 2. round shape 3. Blunt, somewhat widely separated ischial spines

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.

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

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

Fresh Spinach

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

Narrow interspinous diameter Convergent sidewalls Heart shaped

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply.

Irregular and Painless Contractions

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs?

Strengthen the pelvic floor in preparation for delivery.

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose

1.Female organ of coitus 2.Discharge of menstrual flow 3.Allows for fetal passage during the process of birth

The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.

Instruct the client that these are common and may occur throughout the pregnancy.

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 nursing action should be appropriate?

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

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

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 which change that occurs with pregnancy?

Violet bluish color of vaginal mucosa and cervix

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?

1."Fertilization occurs in the outer third of the fallopian tube." 2."Only 1 sperm will penetrate the ovum to produce fertilization." 3."Implantation occurs in the anterior or posterior fundal region of the uterus." 4."The ovary produces hormones to maintain the pregnancy before placental development."

The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.

"It relaxes all smooth muscle, including the uterus." "It maintains the uterine lining for implantation."

The 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 response made by the student indicates an understanding of the function of this hormone? Select all that apply.

Dorsiflex the client's foot while extending the knee.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

2."Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3."Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4."Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5."Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.

Two umbilical arteries and one umbilical vein

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components?

Avoid further stress on the maternal immune system.

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

18

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

"I don't like my face anymore. I always look like I have been crying." Rational: periorbital edema Because this is an adolescent who has not sought early prenatal care, she is at higher risk for the development of gestational hypertension

The 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 client statement indicates a need for further investigation?

Left lower quadrant Rationale: The fetal heart rate is best detected through the fetal back. The findings in this situation support a cephalic presentation. The extremities are on the right side and the back is on the left side. The fetal heart rate is best heard in the left lower quadrant.

The nurse is preparing to monitor a fetal heart rate. The nurse locates a round, ballottable shape just above the symphysis pubis. Fetal small parts are located on the right side of the uterus with a concave shape located on the left side of the uterus. Where should the nurse listen to hear the strongest fetal heart tones?

1.Shallow depth 2.Wide suprapubic arch 3.Compatible with vaginal delivery 4.Flattened anteroposteriorly and wide transversely

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.

Petechiae, oozing from injection sites, and hematuria DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed?

1.Ballottement 2.Chadwick's sign 3.Uterine enlargement rational 1. Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's fingers on palpation);

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?

Where fertilization occurs

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?

26 cm can be plus or minus 2 at second and third trimester

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?

"You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed." Rationale:Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. Rubella titer screening is a standard antenatal test for women during their initial screening

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 is appropriate?

"The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers." "The preembryonic period is the first 2 weeks of fetal development following conception.

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the pre-embryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

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

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

1.Legs 2.Vulva

The 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 areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.

A history of intravenous (IV) drug use in the past year

The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

In a sitting position

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position should the nurse place the client?

1. "Surfactant, which is needed for lung expansion, is present beginning at 28 weeks." 2.."With decreased surfactant, more pressure must be generated to produce inspiration." 3."Surfactant lowers surface tension, reducing the pressure required to keep the alveoli expanded."

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply.

"I am so glad that I can breastfeed my baby after she has been vaccinated."

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?

Increased shortness of breath and bilateral rales

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

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

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

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

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

Connects the umbilical vein to the inferior 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 which about the ductus venosus?

Tell the client that these are common and they may occur throughout the pregnancy.

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?

1.Proteinuria 2.Hypertension

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.

abdominal pain Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized over one region of the uterus or is diffuse over the uterus, with a board like abdomen.

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?