Saunders NCLEX Review OB Questions
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? A. Ambulate frequently. B. Wear support stockings. C. Apply warm, moist packs to the legs. D. Remain on bed rest, with the legs elevated.
A (Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis.)
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.) A. Ballottement B. Chadwick's sign C. Uterine enlargement D. Braxton Hicks contractions E. Outline of fetus via radiography or ultrasound F. Fetal heart rate detected by a non electronic device
ABCD (The probable signs of pregnancy include uterine enlargement, Hegar's sign, Goodell's sign, Chadwick's sign, ballottement, Braxton Hicks contractions, and a positive pregnancy test that measures for HcG.)
After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? A. To the right of the abdomen. B. At the level of the umbilicus. C. About 4cm above the level of the umbilicus. D. One finger breadth above the symphysis pubis.
B (After delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 finger breadths below it and in the midline of the abdomen.)
The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? A. Maintain strict bed rest. B. Monitor the vital signs every 2 hours. C. Perform firm fundal massage every 2 hours. D. Keep the client and her family members informed of her progress.
D (Keeping the client and her family informed about her condition will help minimize fear and apprehension.)
The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? (Select all that apply.) A. Avoid stimulation. B. Decrease fluid intake. C. Expose all of the newborn's skin. D. Monitor the skin temperature closely. E. Reposition the newborn every 2 hours. F. Cover the newborn's eyes with shields or patches.
DEF (Phototherapy is the use of intense fluorescent lights reduce serum bilirubin levels in the newborn. Injury from treatment can occur.)
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? A. Support the mother in her reaction to the newborn. B. Encourage the mother to breastfeed soon after birth. C. Tell the mother that it is important to hold the newborn. D. Document a complete account of the mother's reaction in the birth record.
A (Women who have experienced precipitous labor and delivery often describe feelings of disbelief that her labor has progressed so rapidly. TO assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn.)
The nurse is assisting with planning care for a postpartum woman who has small vulvar hematoma. To assist with reducing the swelling, the nurse should perform which action? A. Check vital signs every 4 hours. B. Measure the fundal height every 4 hours. C. Prepare a heat pack for application to the area. D. Prepare an ice pack for application to the area.
D (The application of ice will reduce the swelling caused by hematoma formation in the vulvar area.)
The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? A. Turning on the apnea and cardiorespiratory monitor. B. Connecting the resuscitation bag to the oxygen outlet. C. Setting up the intravenous line with 5% dextrose in water. D. Setting the radiant warmer control temperature at 36.5ºC.
B (The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment.)
The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? (Select all that apply.) A. Uterine rigidity B. Uterine tenderness C. Severe abdominal pain D. Bright red vaginal bleeding E. Soft, relaxed, contender uterus
DE (Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed contender uterus.)
The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? A. Checks the vital signs. B. Begins fundal massage. C. Encourages ambulation. D. Encourages the client to drink fluids.
A (Signs/symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and restlessness; and third. The nurse should check the vital signs.)
The nurse is assigned to assist with caring for a neonate born to a mother who is HIV-positive. The nurse understand that which should be included in the plan of care? A. Monitoring the neonate's vital signs routinely. B. Maintaining standard precautions at all times while caring for the neonate. C. Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream. D. Initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate.
B (The neonate born to a mother who is HIV-positive must beached for with struct attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others.)
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? A. Quickening B. Braxton Hicks contractions C. Consistent increase in fundal height D. Fetal heart rate of 180 beats/minute
D (The fetal heart rate depends on the gestational age. It is 160-170 beats per minute during the first trimester, and it slows with fetal growth to approximately 120-160 beats per minute.)
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? A. The bladder must be full during the examination. B. The bladder must be empty during the examination. C. She should not eat or drink anything 4-6 hours before the examination. D. She will be given RhoD immune globulin because she is Rh positive
A (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.)
The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? A. Monitor the vital signs B. Elevate the head of the bed C. Increase the intravenous flow rate D. Administer oxygen by face mask, as prescribed
D (Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration)
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? A. Lie on the left side with the feet dorsiflexed B. Soak the feet in hot water after performing 10 pelvic tilt exercises C. Lie on the right side with the feet elevated on a pillow and a heating pad on the back D. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle
D (The position described in option D will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities.)
The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first? A. Administer oxygen by face mask. B. Clear and maintain an open airway. C. Check the blood pressure and the fetal heart tones. D. Prepare for the administration of intravenous magnesium sulfate.
B (The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise. Options A, C, and D may be components of care, but they are not the first.)
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? A. 6 and 8 weeks' gestation B. 8 to 10 weeks' gestation C. 10 to 12 weeks' gestation D. 16 to 20 weeks' gestation
D (Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity.)
The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta? A. Cushions and protects the fetus B. Maintains the body temperature of the fetus C. Surrounds the fetus and allows for fetal movement D. Provides an exchange of nutrients and waste products between the mother and the fetus
D (The placenta provides an exchange of nutrients and waste products between the mother and the fetus.)
The nurse is talking to a pregnant client with HIV infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? A. "You will need to bottle-feed your newborn." B. "You will need to feed your newborn by nasogastric tube feeding." C. "You will be able to breast-feed for 6 months and then you will need to switch to bottle feeding." D. "You will be able to breast feed for 9 months and then you will need to switch to bottle feeding."
A (Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast feeding.)
The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? A. Alcohol is the only agent used to clean the cord. B. It takes 21 days for the cord to dry up and fall off. C. Cord care is done only at birth to control bleeding. D. The process of keeping the cord clean and dry will decrease bacterial growth.
D (The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7-14 days. Agents other than alcohol may be prescribed to clean the cord.)
The nurse is assigned to care for a client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? A. The inverted uterus returning to normal. B. The gradual reversal of the uterine muscle into the abdominal cavity. C. The descent of the uterus into the pelvic cavity, which occurs at a rate of 2cm/day. D. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1cm/day.
D (Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately 1 fingerbreadth or 1 cm per day.)
The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? (Select all that apply.) A. Rest during the acute phase. B. Wear a supportive, nonunderwire bra. C. Maintain a fluid intake of at least 3000mL. D. Continue to breastfeed if the breasts are not too sore. E. Take prescribed antibiotics until the soreness subsides. F. Avoid decompression of the breasts by breastfeeding or breast pumping.
ABCD (Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, wearing a supportive nonunderwire bra, maintaining fluid intake of at least 3000mL/day, and taking analgesics to relieve discomfort.)
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? A. "Uterine contractions are stimulated by Leopold's maneuvers." B. "The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." C. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." D. "Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions."
B (A contraction stress test assesses placental oxygenation and function and determines the fetus's ability to tolerate labor, as well as its well-being. The test is performed if the non stress test is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under stimulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30- minute baseline strip is recorded.)
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? A. Eliminate between-meal snacks. B. Drink decaffeinated coffee and tea. C. Lie down for 30 minutes after eating. D. Substitute salt in cooking for other spices.
B (Caffeine, like spices, may cause heartburn and needs to be avoided. Spices tend to trigger heartburn. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.)
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? A. A low-calorie diet to ensure the absence of weight gain B. A diet that is high in fluids and fiber to decrease constipation C. A diet that is low in fluids and fiber to decrease blood volume D. Unlimited sodium intake to increase the circulating blood volume
B (Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system.)
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign is consistent with FAS? A. A length of 19 inches B. Abnormal palmar creases C. A birth weight of 6 pounds and 14 ounces D. A head circumference that is appropriate for gestational age
B (Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress.)
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? A. Leopold's maneuvers B. A manual pelvic examination C. Hemoglobin and hematocrit evaluation D. External electronic fetal heart rate monitoring
B (Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a non engaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help to estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia.)
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9cm dilated and is experiencing precipitous labor. Which is the priority nursing action? A. Prepare for an oxytocin infusion. B. Keep the client in a side-lying position. C. Prepare the client for epidural anesthesia. D. Encourage the client to start pushing with the contractions.
B (Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal repercussion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation.A side-lying position can assist with providing blood flow to the uterus by preventing vena-cava and abdominal aorta compression.)
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 20th, 2019. Using Nagele's Rule, the nurse determines the estimated date of birth is which date? A. July 12th, 2020 B. July 27th, 2020 C. August 12th, 2020 D. August 27th, 2020
B (The accurate use of Nagele's rule requires that the woman have a regular 28 day cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate.)
A pregnant HIV-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? A. "I will be sure to wash my hands before feeding the newborn." B. "I will breastfeed, especially for the first six weeks postpartum." C. "I will be sure to wash my hands before and after bathroom use." D. "I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."
B (The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum periods. HIV can occur during breastfeeding, thus HIV-positive clients need to bottle-feed their neonates.)
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? A. Contact the health care provider B. Instruct the client to maintain bed rest for the remainder of the pregnancy C. Tell the client that these are common and they may occur throughout the pregnancy D. Call the maternity unit and inform them that the client will be admitted in a prelabor condition
C (Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options A, B, + D are unnecessary and inappropriate actions.)
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? A. It maintains the uterine lining for implantation B. It stimulates the metabolism of glucose and converts glucose to fat C. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation D. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed
C (Estrogen stimulates uterine development to provide an environment for the fetus and it stimulates the breasts to prepare for lactation.)
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? A. Dorsiflex the client's foot while flexing the knee B. Plantarflex the client's foot while flexing the knee C. Dorsiflex the client's foot while extending the knee D. Plantarflex the client's foot while extending the knee
C (Leg cramps often occur when the pregnant women stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. Therefore, the remaining options are incorrect.)
After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a truckle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? A. This is a normal expectation after episiotomy. B. The mother should be allowed bathroom privileges only. C. The bright red bleeding is abnormal and should be reported. D. The perineal assessment should be performed more frequently.
C (Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm.)
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? A. "I know I can never have another child." B. "I am glad I won't have to have these shots if I have another child." C. "I will have to have an injection once a month until the baby is born." D. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
D (As described in the question, it is accepted practice to administer RHoD immune globulin to an Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery.)
A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? A. Breastfeed only during the daytime hours. B. Apply cold compresses to the breast before feeding. C. Avoid the use of a bra while the breasts are engorged. D. Massage the breasts before feeding to stimulate let-down.
D (Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and well-fitting bra at all times, taking a warm shower, or applying warm compresses just before feeding, and alternating breasts during feeding.)
The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102ºF. Which is the appropriate nursing action? A. Apply cool packs to the abdomen. B. Continue to monitor the temperature. C. Remove the blanket from the client's bed. D. Notify the RN, who will then contact the primary health provider.
D (During the first 24 hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, if the temperature is more than 2ºF above normal, this may indicate infection, and the PCP will need to be notified.)
The nurse administers erythromycin ointment to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? A. Prevents cataracts in the neonate born to a woman who is susceptible to rubella. B. Protects the neonate's eyes from possible infections acquired while hospitalized. C. Minimizes the spread of microorganisms to the neonate from invasive procedures during labor. D. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.
D (Erythromycin ophthalmic ointment 0.5% is red as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae.)
A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client? A. "You will need to be isolated from your newborn after delivery." B. "There is little risk to your baby during your pregnancy, birth, and after delivery." C. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." D. "You will be evaluated at the time of delivery for hepatic genital tract lesions. If they are present, a cesarean delivery will be needed."
D (If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate.)
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? A. Connects the pulmonary artery to the aorta B. Is an opening between the right and left atria C. Connects the umbilical vein to the inferior vena cava D. Connects the umbilical artery to the inferior vena cava
C (The ductus venosus connects the umbilical vein to the inferior vena cava.)
The nurse working in a prenatal clinic reviews a client's chart ands 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. Round shape B. Shallow depth C. Narrow pubic arch D. Diagonal conjugate measures 12.5cm to 13cm E. Blunt, somewhat widely separated ischial spines
ADE (A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. Characteristics of a gynecoid pelvis include round shape, blunted ischial spines that are widely separated, a diagonal conjugate of at least 12.5 cm to 13 cm, a wide pelvic arch, and an adequate depth.)
The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning? A. "Iron supplements will give me diarrhea." B. "The iron is needed for the red blood cells." C. "Meat does not provide iron and should be avoided." D. "My body has all the iron it needs and I don't need to take supplements."
B (A nutritional supplement that is commonly needed during pregnancy for the red blood cell is iron. Anemia in pregnancy is primarily caused by iron deficiency.)
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 placentae is accompanied by which additional finding? A. Soft abdomen on palpation. B. Uterine tenderness on palpation. C. No complaints of abdominal pain. D. Lack of uterine irritability or titanic contractions.
B (Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta.)
A client asks the nurse why her newborn baby needs an injection of Vitamin K. The nurse should make which statement to the client? A. "Your newborn needs vitamin K to develop immunity." B. "The vitamin K will protect your newborn from becoming jaundiced." C. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." D. "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."
C (Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding.)
The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? A. Monitor the urinary output B. Monitor the maternal pulse C. Turn the client onto her side D. Monitor the maternal blood pressure
C (With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side.)
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? A. The organ of copulation B. Where the fetus develops C. Where fertilization occurs D. The organ that secretes estrogen and progesterone
C (Each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization)
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 bpm. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? A. Reassure the client. B. Apply perineal pressure. C. Monitor fundal height. D. Prepare the client for surgery.
D (The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding.)
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? A. Vital signs B. Fundal height C. Presence of calf pain D. Level of consciousness (LOC)
A (Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised.)
The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? A. "It is the fetal movement that is felt by the mother." B. "It is the compressibility of the lower uterine segment." C. "It is the irregular, painless contractions that occur throughout pregnancy." D. "It is the soft blowing sound that can be heard when the uterus is auscultated."
A (Quickening is a fetal movement that appears usually at weeks 16 to 20, when the expectant mother first notices subtle fetal movements that gradually increase in intensity.)
A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? A. "I don't need birth control because I will be breastfeeding." B. "I need to increase my caloric intake by 500 calories a day." C. "I shouldn't use soap to wash my breasts because I will be breastfeeding." D. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."
A (Amenorrhea may occur during breastfeeding, but the client can still ovulate without menstruating.)
The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? A. Begin with the eyes and face. B. Start with the dirtiest area first. C. Begin with the feet and work upward. D. Only wash the diaper area, because this is the only part of the baby that gets soiled.
A (Bathing should start at the eyes and face, which are usually the cleanest areas.)
The nursing student is asked to describe the size of the uterus in a non pregnant client. Which response indicates an understanding of the anatomy of this structure? A. "The uterus weighs about 2 ounces." B. "The uterus weighs about 2.2 pounds." C. "The uterus has a capacity of about 50 milliliters." D. " The uterus is round in shape and weighs approximately 1000 grams."
A (Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60g and it has a capacity of about 10mL. At the end of pregnancy, the uterus weighs approximately 1000g and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.)
Which findings indicate to the nurse that placental separation has occurred? (Select all that apply.) A. Lengthening of umbilical cord. B. Sudden trickle or spurt of blood. C. Fundus is boggy following separation. D. Change from globular to discoid shape. E. Fetal membranes are seen at the introitus.
ABE (As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, a sudden trickle or spurt of blood appears and fetal membranes may appear at the introitis. The fundus changes from discoid to globular shape. The fundus should not become boggy.)
Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? A. The maneuvers measure the height of the maternal fundus. B. The maneuvers determine the "lie" and "attitude" of the fetus. C. The maneuvers are a systematic method for palpating the fetus through the maternal back. D. The maneuvers are a systemic method for palpating the fetus through the maternal abdominal wall.
D (Leopold's maneuvers comprise a systemic method for palpating the fetus through the maternal abdominal wall.)
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 22cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding? A. 22cm B. 26cm C. 32cm D. 40cm
B (During the second and third trimesters, the fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2cm.)
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 which is the priority nursing action? A. Monitor the maternal vital signs B. Notify the RN immediately C. Continue monitoring labor and the fetal heart rate D. Encourage relaxation and breathing techniques between contractions
B (Fetal bradycardia between contractions may indicate the need for immediate medical management.)
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 gravid and para status on this client? A. Gravida 1, Para I B. Gravida 2, Para 1 C. Gravida 2, Para 2 D. Gravida 3, Para 2
B (Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants.)
The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? A. Estimate the fetal size B. Check pelvic adequacy C. Administer an analgesic D. Determine the maternal and fetal vital signs
D (To evaluate a woman's physical well-being, her temperature, pulse, respirations, and blood pressure are checked.)
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? A. Red B. Pink C. White D. Serosanguineous
A (The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days.)
The nurse should monitor for which signs associated with respiratory distress syndrome in a preterm newborn? A. Tachypnea and retractions B. Acrocyanosis and grunting C. Hypotension and bradycardia D. The presence of a barrel chest with acrocyanosis
A (The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions or audible grunts.)
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? A. A softening of the cervix B. The presence of fetal movement C. The presence of HcG in the urine D. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus
A (During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination.)
The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? A. A change in the uterine contour B. Sudden and sharp abdominal pain C. A shortening of the umbilical cord D. A decreased in blood loss from the introitus
A (Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness, but not sudden and sharp abdominal pain.)
The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? A. Baseline fetal heart rate B. Intensity of contractions C. Maternal blood pressure D. Frequency of contractions
A (The nurse should first determine the baseline fetal heart rate. Although options B, C, and D are components of the data collection process, the fetal heart rate is the priority.)
A primigravida's membranes rupture spontaneously. Which action should the nurse take first? A. Determine the fetal heart rate. B. Prepare for immediate delivery. C. Monitor the contraction pattern. D. Note the amount, color, and odor of the amniotic fluid.
A (When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord.)
The nurse is monitoring a client with mild gestational hypertension. Which data indicate that GH is a concern? A. Urinary output has increased. B. There is no evidence of proteinuria. C. The client complains of a headache and blurred vision. D. The blood pressure reading has returned to the prenatal baseline.
C (Options A, B, and D are all signs that gestational hypertension is not present. Option C is a symptom of the worsening of gestational hypertension and is a concern that needs to be reported.)
The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? (Select all that apply.) A. Proteinuria B. Hypertension C. Low-grade fever D. Increased pulse rate E. Increased respiratory rate
A, B (Signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia.)
The nurse caring for a client with abruptio placentae is monitoring the client for signs of DIC. The nurse should suspect DIC if which is observed? A. Rapid clotting times B. Pain and swelling of the calf of one leg C. Laboratory values that indicate increased platelets D. Petechiae, oozing from injection sites, and hematuria
D (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.)
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? A. G=3, T=2, P=0, A=0, L=1 B. G=2, T=1, P=0, A=0, L=1 C. G=1, T=1, P=1, A=0, L=1 D. G=2, T=0, P=0, A=0, L=1
B (A woman who is pregnant with twins and who has already had a child's a gravid of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0 and the number of live births is 1.)
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? A. Two umbilical veins and one umbilical artery B. Two umbilical arteries and one umbilical vein C. Arteries that carry oxygenated blood to the fetus D. Veins that carry deoxygenated blood to the fetus
B (Blood pumped by the fetus's heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then returned by one umbilical vein. The umbilical arteries carry deoxygenated blood and waste products from the fetus and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus.)
A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? (Select all that apply.) A. Use only baby wipes to cleanse the penis. B. Remove the yellow exudate which forms by 24 hours post circumcision. C. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. D. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. E. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.
CDE (The glans penis is normally dark red. Use only water to cleanse the glans penis until complete healing has occurred around day 5 or 6. Diapers should be changed at least every 4 hours to inspect the glans penis for drainage or signs of infection. After circumcision, a small amount of bloody drainage is expected.)
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? A. "I can eat more sweets now because I need more calories." B. "I need more fat in my diet so that the baby can gain enough weight." C. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." D. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."
D (An increase is calories is needed during pregnancy but concentrated sugars should be avoided because they can cause hyperglycemia. Per health care provider recommendations, fat intake should be 20% to 30% of the total calories. In addition, 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.)
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 should place the client in which position? A. Prone position B. Semi-Fowler's position C. Trendelenburg's position D. Supine position with a wedge under the right hip
D (Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The best position to prevent this would be side lying, with the uterus displaced off of the abdominal vessels.)
The nursing instructor asks a nursing student to list the functions of amniotic fluid. The student needs further teaching if which responses are made? (Select all that apply) A. Allows for fetal movement B. Is a measure of kidney function C. Surrounds, cushions, and protects the fetus D. Maintains the body temperature of the fetus E. Prevents large particles such as bacteria from passing to the fetus F. Provides an exchange of nutrients and waste products between the mother and the fetus
EF (The amniotic fluid surrounds, cushions, and protects the fetus. The placenta, not the amniotic fluid, prevents large particles such as bacteria from passing to the fetus, and the placenta provides an exchange of nutrients and waste products between the mother and the fetus. Amniotic fluid allows the fetus to move freely, it maintains the body temperature of the fetus, and it helps to measure kidney function because the amount of fluid is based on the amount of urination from the fetus.)
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? A. A full bladder B. Emotional instability C. Insufficient iron intake D. Compression of the vena cava
D (Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy.)
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 what position? A. Squatting B. Side-lying C. Tailor sitting D. Semi-Fowler's
B (Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her side. Squatting, tailor sitting, and semi-Fowler's position are incorrect because they would not prevent hypotension.)
The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection? A. A darkened drying stump. B. A moist cord with discharge. C. A purple stump that shows pinkness around the base. D. A purple stump that shows some moistness at the base.
B (Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base.)
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? A. "Have either of you ever had surgery?" B. "Do you plan to have any other children?" C. "Do either of you have any other children?" D. "Do either of you have problems with high blood pressure?"
B (Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility.)
After birth the nurse prevents hypothermia as a result of evaporation by performing which action? A. Warming the crib pad B. Closing the doors of the room C. Drying the baby with a warm blanket D. Turning on the overhead radiant warmer
C (Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry, evaporation is prevented.)
The nurse is assisting uncaring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? A. Urinary output B. Blood glucose level C. Total bilirubin level D. Hemoglobin and hematocrit levels
B (The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce CNS abnormalities and cognitive impairment if it is not corrected immediately.)
During a prenatal visit, the nurse checks the fetal heart rate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted? A. 80 bpm B. 100 bpm C. 150 bpm D. 180 bpm
C (Fetal heart rate depends on gestational age. It is normally 160-170 bpm during the first trimester, but it slows with fetal growth to 110-160 bpm near or at term.)
