ANTEPARTUM A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response? A. "You should gain less than 10 lb." B. "You should gain 10 to 15 lb." C. "You should gain 16 to 24 lb." D. "You should gain 24 to 32 lb." Rationale: For a client entering pregnancy in her ideal weight range, a gain of 24 to 32 lb (11 to 15 kg) is adequate to meet her needs and the needs of her fetus. Weight gain below the recommended range predisposes the client to complications during pregnancy, labor, and delivery. The nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to: A. take sleeping pills for a restful night's sleep B. try to get more rest by going to bed earlier. C. take her prenatal vitamins. D. tell her not to worry because the fatigue will go away soon. Rationale: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should do which of the following? A. Ask her to void. B. Instruct her to drink 1 L of fluid. C. Prepare her for I.V. anesthesia. D. Place her on her left side Rationale: To prepare a client for amniocentesis, the nurse should ask her to empty her bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before
amniocentesis to locate the placenta). I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output. When assessing a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). Which condition makes this client more susceptible to such infections? A. Electrolyte imbalances B. Decreased insulin needs C. Hypoglycemia D. Glycosuria Rationale: Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially Candida vaginitis) and UTIs, because the hormonal changes of pregnancy affect vaginal pH and the bladder. Electrolyte imbalances and hypoglycemia aren't associated with vaginal infections or UTIs. Insulin requirements may decrease in early pregnancy; however, as the client's food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise. After developing severe hydramnios, a primigravid client exhibits dyspnea, along with edema of the legs and vulva. Which procedure should the nurse expect her to undergo and why? A. Artificial rupture of the membranes to reduce uterine pressure B. Amniocentesis to temporarily relieve discomfort C. I.V. oxytocin administration to induce labor D. Cesarean delivery to prevent further fetal damage Rationale: A client with hydramnios may undergo amniocentesis to relieve discomfort. However, because fluid production continues, the relief is temporary. Artificial rupture of the membranes, I.V. oxytocin administration, or cesarean delivery wouldn't relieve hydramnios. A client who's 2 months pregnant complains of urinary frequency and says she gets up several times at night to go to the bathroom. She denies other urinary symptoms. How should the nurse intervene? A. Advise the client to decrease her daily fluid intake.
B. Refer the client to a urologist for further investigation. C. Explain that urinary frequency isn't a sign of urinary tract infection (UTI). D. Explain that urinary frequency is expected during the first trimester
infection, prolactin-secreting pituitary tumor, pseudocyesis, or premenstrual syndrome. Abdominal enlargement can result from ascites, obesity, or uterine or pelvic tumor, and the perception of Braxton Hicks contractions can result from hematometra or a uterine tumor.
Rationale: Urinary frequency is expected during the first trimester as the growing uterus exerts pressure on the client's bladder. Although the client should increase fluid intake during pregnancy, she should avoid drinking fluids after 6 p.m. to reduce the need to get up at night. Because urinary frequency is a normal discomfort of pregnancy and the client has no other signs or symptoms of UTI, referral to a urologist is unnecessary. Urinary frequency, dysuria, and voiding of small amounts of urine indicate UTI.
A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to prescribe: A. betamethasone (Celestone). B. dinoprostone (Prepidil). C. ergonovine (Ergotrate Maleate). D. ritodrine (Yutopar).
A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention? A. Urine specific gravity 1.010 B. Serum potassium 4 mEq/L C. Serum sodium 140 mEq/L D. Ketones in urine Rationale: Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. The other laboratory values listed are all within normal limits. Which findings would be considered positive signs of pregnancy? A. Fatigue and skin changes B. Quickening and breast enlargement C. Fetal heartbeat and fetal movement on palpation D. Abdominal enlargement and Braxton Hicks contractions Rationale: Fetal heartbeat and fetal movement on palpation are considered positive signs of pregnancy because they can't be caused by any other condition. Fatigue can be caused by chronic illness or anemia. Skin changes can result from cardiopulmonary disorders, estrogenprogesterone oral contraceptives, obesity, or a pelvic tumor. Excessive flatus or increased peristalsis can cause the perception of quickening. Breast changes can be related to hyperprolactinemia induced by tranquilizers,
Rationale: Ritodrine, a beta-receptor agonist, is approved by the Food and Drug Administration for inhibition of preterm uterine contractions. Betamethasone is used to accelerate surfactant production in preterm labor. Dinoprostone is used to induce fetal expulsion and promote cervical dilation and softening. Ergonovine maleate is used to impede uterine blood flow - for example, in hemorrhage. A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response? A. "I can see you're upset. Why don't we discuss this with you at a later time when you're feeling better." B. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." C. "Let me check with your physician and get you something that will help you relax." D. "Pregnancy should be avoided until all of your testing is normal." Rationale: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 12 months by an experienced health care provider. Discussing this situation at a later time and checking with the physician to give the client something to relax ignore the client's immediate concerns. Saying to wait until all tests are normal is vague and provides the client with little information. During a routine prenatal visit, a pregnant client reports heartburn. To minimize her discomfort, the
nurse should include which suggestion in the plan of care? A. Eat small, frequent meals. B. Limit fluid intake sharply. C. Drink more citrus juice. D. Take sodium bicarbonate.
it. D. Warm milk to room temperature before adding lactase replacement tablets.
Rationale: To relieve heartburn, the nurse should advise a pregnant client to eat smaller meals at shorter intervals; drink six to eight 8-oz glasses of fluid daily to minimize regurgitation and reflux of stomach contents; and avoid citrus juice, which may act as a gastric irritant and worsen heartburn, and sodium bicarbonate, which may disrupt the body's sodium-potassium balance.
Rationale: A client with lactose intolerance must take lactase replacement drops or tablets whenever milk or a milk product is consumed. The drops must be added to a carton of milk at least 24 hours before the milk is consumed to ensure proper action. Lactase replacement drops and tablets are available without a prescription. Milk need not be warmed to room temperature before adding lactase replacement products.
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: A. eat three well-balanced meals per day. B. exercise 1 hour before each meal. C. take a vitamin and mineral supplement D. divide daily food intake into five or six meals. Rationale: To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue. A client, 8 weeks pregnant, has a history of lactose intolerance. To prevent a nutritional deficiency as a result of lactose intolerance, the nurse teaches her about lactase replacement. Which teaching point is appropriate? A. Add lactase replacement drops to milk immediately before drinking it. B. Ask the physician for a lactase prescription that allows unlimited refills. C. Add lactase replacement drops to milk at least 24 hours before drinking
After an amniotomy, which client goal should take the highest priority? A. The client will express increased knowledge about amniotomy. B. The client will maintain adequate fetal tissue perfusion C. The client will display no signs of infection. D. The client will report relief of pain. Rationale: Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief. A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone? A. Human chorionic gonadotropin (hCG) B. Human placental lactogen C. Human chorionic thyrotropin D. Estradiol Rationale: Widely used pregnancy tests detect hCG in the blood and urine by immunologic tests specific for the beta subunit of hCG. Human placental lactogen, human chorionic thyrotropin, and estradiol are hormones produced by the placenta; however, they aren't used to detect pregnancy. During the first 3 months, which of the following hormones is responsible for maintaining pregnancy? A. Human chorionic gonadotropin (HCG) B. Progesterone
C. Estrogen D. Relaxin Rationale: HCG is the hormone responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial HCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest. The nurse is developing a teaching plan for a client who's 2 months pregnant. The nurse should tell the client that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation C. Between 21 and 23 weeks' gestation D. Between 24 and 26 weeks' gestation Rationale: A pregnant woman can usually detect fetal movements (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus isn't developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. The nurse is discussing posture with a client who's 18 weeks pregnant. Why should the nurse caution her to avoid the supine position? A. This position impedes blood flow to the fetus. B. This position may trigger heart palpitations. C. This position may cause gastroesophageal reflux D. This position promotes pregnancy-induced hypertension (PIH). Rationale: After the 4th month of pregnancy, the client should avoid the supine position because it allows the gravid uterus to compress veins, blocking blood flow to the fetus. No evidence suggests that the supine position triggers heart palpitations, causes esophageal reflux, or promotes PIH. A nurse is obtaining a medication history from a client who suspects she's pregnant. At which
week of gestation does placental transport of substances to and from the fetus begin? A. 1st week B. 2nd week C. 5th week D. 8th week Rationale: Placental transport of substances to and from the fetus begins in the 5th week. What key psychosocial tasks must a woman accomplish during the third trimester? A. Resolving grief over the loss of old roles B. Developing a mother image C. Coping with common discomforts and changes D. Overcoming fears she may have about the unknown, loss of control,
Rationale: During the third trimester, a key psychosocial task is to overcome fears the woman may have about the unknown, labor pain, loss of selfesteem, loss of control, and death. During the first trimester, the mother copes with the common discomforts and changes. During the second trimester, psychosocial tasks include mother-image development, coping with body image and sexuality changes, and prenatal bonding. When questioned, a pregnant client admits she sometimes has several glasses of wine with dinner. Her alcohol consumption puts her fetus at risk for which condition? A. Alcohol addiction B. Anencephaly C. Down syndrome D. Learning disability Rationale: Maternal alcohol use during pregnancy may cause fetal and neonatal central nervous system deficits such as learning disabilities. It also may lead to characteristic physical anomalies and growth retardation. Maternal alcohol use doesn't cause alcohol addiction in the fetus or neonate. Anencephaly occurs when the cranial end of the neural tube fails to fuse before the 26th day of gestation; this condition isn't related to maternal alcohol use. Down syndrome results from a chromosomal disorder.
A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. Why should the nurse apply manual pressure to the baby's head? A. To slow the delivery process B. To reinsert the umbilical cord C. To relieve pressure on the umbilical cord D. To rupture the membranes Rationale: Manual pressure is applied to the baby's head by gently pushing up with the fingers to relieve pressure on the umbilical cord. This intervention is effective if the cord begins to pulsate. The mother may also be placed in the knee-chest or Trendelenburg position to ensure blood flow to the baby. This intervention isn't done to slow the delivery process. A prolapsed cord necessitates emergency cesarean section. The nurse shouldn't attempt to reinsert the umbilical cord because this would further compromise blood flow. At this point, the membranes are probably ruptured. Which of the following instructions should the nurse give to a client who's 26 weeks pregnant and complains of constipation? A. Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. B. Tell her to ask her caregiver for a mild laxative C. Suggest the use of an over-the-counter stool softener Tell her to go to the evaluation unit D. because constipation may cause contractions Rationale: The best instruction is to encourage the client to increase her intake of high-fiber foods (roughage) and to drink at least six glasses of water per day. Mild laxatives and stool softeners may be needed, but dietary changes should be tried first. Straining during defecation and diarrhea can stimulate uterine contractions, but telling the client to go to the evaluation unit doesn't address her concern. The nurse is teaching a client who's 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy
alone has been unsuccessful in controlling this client's blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says: A. "I won't use insulin if I'm sick." B. "I need to use insulin each day." C. "If I give myself an insulin injection, I don't need to watch what I eat." D. "I'll monitor my blood glucose levels twice a week." Rationale: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily.
The nurse is preparing to auscultate fetal heart tones in a pregnant client. Abdominal palpation reveals a hard, round mass under the left side of the rib cage; a softer, round mass just above the symphysis pubis; small, irregular shapes in the right side of the abdomen; and a long, firm mass on the left side of the abdomen. Based on these findings, what is the best place to auscultate fetal heart tones? A. Right lower abdominal quadrant B. Right upper abdominal quadrant C. Left upper abdominal quadrant D. Left lower abdominal quadrant Rationale: In this client, abdominal palpation reveals that the fetus is lying in a breech position with its back facing the client's left side. Because fetal heart tones are best heard through the fetus's back, the nurse should place the fetoscope or ultrasound stethoscope in the left upper abdominal quadrant for auscultation. Although placement in other locations might allow auscultation of fetal heart tones, the tones would be less clear. A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures
the client's temperature at 101.8° F (38.8° C). After initiating prescribed antibiotic therapy, the nurse should prepare the client for: A. amniocentesis. B. delivery. C. sonography. D. tocolytic therapy. Rationale: After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor. A client, 18 weeks pregnant, arrives in the emergency department. A short time later, her placental membranes rupture spontaneously. The physician prescribes carboprost (Hemabate), 250 mcg/ml I.M., and asks about her obstetric history. Why is this history important? A. Increased gravidity slows carboprost's onset of action. B. Increased parity slows carboprost's onset of action. C. Increased gravidity or parity speeds carboprost's onset of action. D. Carboprost's onset of action is faster if gravidity is greater than parity. Rationale: Carboprost's onset of action occurs about 16 hours after I.M. injection. However, onset is faster with increased gravidity (number of pregnancies) or parity (number of live births) and is slower with increased fetal gestational age. During each prenatal checkup, the nurse obtains the client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup? A. Evaluating the client for edema B. Measuring the client's hemoglobin (Hb) level C. Obtaining pelvic measurements D. Determining the client's Rh factor Rationale: During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of pregnancy-induced hypertension (PIH). If edema exists, the nurse should assess for high blood pressure and proteinuria - other signs of PIH. Hb is measured during the first
prenatal visit and again at 24 to 28 weeks' gestation and at 36 weeks' gestation. The pelvis is measured and the Rh factor determined during the first prenatal visit. Which medication is considered pregnancy? A. Aspirin B. Magnesium hydroxide C. Insulin D. Oral antidiabetic agents
safe
during
Rationale: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm. A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. She tells the nurse she doesn't know whether she's ready to have a baby, even though this was a planned pregnancy. Which response should the nurse offer? A. "You may want to discuss these concerns with a social worker." B. "You're feeling ambivalent, which is normal during the first trimester." C. "You need to share these feelings with your partner." D. "You may want to consider having an abortion." Rationale: The first trimester is known as the trimester of ambivalence because the client or the couple may experience mixed feelings. During this trimester, resolution of ambivalence is the family's key psychosocial task. Discussing these feelings with a social worker or the client's partner would be inappropriate at this time. (However, if further assessment reveals there is a problem, referral to a social worker and discussion with the partner may be appropriate.) Suggesting that the client consider having an abortion is a leading statement and would be inappropriate. A client makes a routine visit to the prenatal clinic. Although she's 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: A. an empty gestational sac. B. grapelike clusters.
C. a severely malformed fetus. D. an extrauterine pregnancy. Rationale: In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.
me prenatal care so that I won't have to see my physician." Rationale: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home — this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician.
A client who's 37 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting, the nurse might ask which question? After determining that a pregnant client is RhA. "Are you planning to have epidural anesthesia?" negative, the physician orders an indirect Coombs' B. "Have you begun prenatal classes?" test. What is the purpose of performing this test in a C. "What changes have you made at home to get ready for the baby?" pregnant client? D. "Can you tell me about the meals you typically eat each day?" A. To determine the fetal blood Rh factor B. To determine the maternal blood Rh factor Rationale: During the third trimester, the C. To detect maternal antibodies against pregnant client typically perceives the fetus as a fetal Rh-negative factor separate being. To verify that this has occurred, D. To detect maternal antibodies against the nurse should ask whether she has made fetal Rh-positive factor appropriate changes at home such as obtaining infant supplies and equipment. The type of Rationale: The indirect Coombs' test measures the anesthesia planned doesn't reflect the client's number of antibodies against fetal Rh-positive factor preparation for parenting. The client should have in maternal blood. The maternal blood Rh factor is begun prenatal classes earlier in the pregnancy. determined before the indirect Coombs' test is done. The nurse should have obtained dietary No maternal antibodies against fetal Rh-negative information during the first trimester to give the factor exist. client time to make any necessary changes. A client who's 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home health visits? A. "The community health nurse will help fix my meals." B. "The community health nurse will give me my antihypertensive medication." C. "The community health nurse will check me and my baby and talk with my physician." D. "The community health nurse will give
The nurse determines that a client is in false labor. After obtaining discharge orders from the nursemidwife, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time? A. "Drink coffee or tea to maintain hydration." B. "Apply cold compresses to relieve discomfort." C. "Maintain a supine position to promote rest." D. "Return to the facility if fever occurs." Rationale: The nurse should instruct a client in false labor to return to the health care facility if she develops signs or symptoms of infection, such as a
fever; if her membranes rupture; if vaginal bleeding occurs; or if her contractions become more intense. The nurse should suggest warm milk or herbal tea, which promote relaxation and rest, instead of coffee or caffeinated tea. Taking a warm tub bath or shower - not applying cold compresses - helps relieve discomfort. A semiupright position with pillows placed under the client's knees promotes rest. The nurse uses nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color? A. Pink B. Blue C. Yellow D. Green Rationale: Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink. A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time? A. Breathing techniques during labor B. Common discomforts of pregnancy C. Infant care responsibilities D. Neonatal nutrition Rationale: During the first trimester, a pregnant client is most concerned with her own needs. Because she's likely to experience discomforts of pregnancy, such as morning sickness, fatigue, and urinary frequency, the nurse should teach her how to relieve these discomforts. The nurse should teach labor breathing techniques during the second half of the pregnancy, when the client is most strongly motivated to learn them. The postpartum period is the best time to teach about infant care responsibilities and neonatal nutrition if the client didn't attend prenatal classes. Otherwise, infant care is taught during the third trimester and reinforced in the postpartum period. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take first? A. Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal
oxygenation. B. Administer I.V. oxytocin, as ordered, to stimulate uterine contractions and prevent further hemorrhage. C. Ease the client's anxiety by assuring her that everything will be all right. D. Massage the client's fundus to help control the hemorrhage. Rationale: The client's signs and symptoms indicate abruptio placentae, which decreases fetal oxygenation. To maximize fetal oxygenation, the nurse should place the client on her left side to increase placental blood flow to the fetus and administer supplemental oxygen, as ordered, to increase the blood oxygen level. Administering oxytocin isn't appropriate because this drug stimulates contractions, which further reduce fetal oxygenation. The nurse can't assure the client that everything will be all right, only that everything possible will be done to help her and her fetus. Fundal massage is used only during the postpartum period to control hemorrhage. Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy? A. Abdominal pain, vaginal bleeding, and a positive pregnancy test B. Hyperemesis and weight loss C. Amenorrhea and a negative pregnancy test D. Copious discharge of clear mucous and prolonged epigastric pain Rationale: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucous isn't indicative of an ectopic pregnancy and referred shoulder pain, not epigastric pain, should be expected. A client has come to the clinic for her first prenatal visit. The nurse should include which of the following statements about using drugs safely during pregnancy in her teaching? A. "During the first 3 months, avoid all medications except ones prescribed by your caregiver." B. "Medications that are available over the counter are safe for you to use, even
early on." C. "All medications are safe after you've reached the 5th month of pregnancy." D. "Consult with your health care provider before taking any medications." Rationale: Because all medications can be potentially harmful to the growing fetus, telling the client to consult with her health care provider before taking any medications is the best teaching. The client needs to understand that any medication taken at any time during pregnancy can be teratogenic. The nurse is caring for a client who's on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy? A. Hypoglycemia B. Crackles C. Bradycardia D. Hyperkalemia Rationale: Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia. Where is the best place for the nurse to detect fetal heart sounds for a client in the first trimester of pregnancy? A. Above the symphysis pubis B. Below the symphysis pubis C. Above the umbilicus D. At the umbilicus Rationale: In the first trimester, fetal heart sounds are loudest in the area of maximum intensity, just above the client's symphysis pubis at the midline. Fetal heart sounds aren't heard as well in the other locations.
A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed
several clots. What is the primary nursing diagnosis for this client? A. Deficient knowledge B. Deficient fluid volume C. Anticipatory grieving D. Pain Rationale: If bleeding and clots are excessive, this client may become hypovolemic, leading to a diagnosis of Deficient fluid volume. Although the other diagnoses are applicable to this client, they aren't the primary diagnosis. A client is in the last trimester of pregnancy. The nurse should instruct her to notify her primary health care provider immediately if she notices A. blurred vision B. hemorrhoids C. increased vaginal mucus. D. dyspnea on exertion. Rationale: Blurred vision or other visual disturbances, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for the client and fetus. Although hemorrhoids may be a problem during pregnancy, they don't require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.
The nurse is reviewing a pregnant client's nutritional status. To determine whether she has an adequate intake of vitamin A, the nurse should assess her diet for consumption of: A. fish. B. cereals. C. meat. D. dairy products. Rationale: Common food sources of vitamin A include dairy products, liver, egg yolks, fruits, and vegetables. Fish and meat are good sources of protein. Cereals, especially whole grains, are good sources of niacin, vitamin B1, and vitamin B6.
After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. This assessment indicates the client is: A. exhibiting normal signs of an ovulatory stimulant. B. demonstrating signs of hyperstimulation syndrome. C. is probably pregnant. D. is having a reaction to the menotropins Rationale: Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing care includes emotional support to reduce anxiety and management of symptoms. These signs aren't signs of pregnancy and aren't normal reactions to ovulatory stimulants. A nurse in a prenatal clinic is assessing a 28year-old who's 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? A. Glycosuria, hypertension, seizures B. Hematuria, blurry vision, reduced urine output C. Burning on urination, hypotension, abdominal pain D. Hypertension, edema, proteinuria Rationale: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia. A client is 2 months pregnant. Which factor should the nurse anticipate as least likely to affect her psychosocial transition during pregnancy? A. Previous health promotion activities B. Previous parenting experiences C. Support from her partner D. Whether the pregnancy was planned or unplanned
Rationale: Many factors can influence the smoothness of a pregnant client's psychosocial transition. Previous health promotion activities are least likely to affect this transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy. A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? A. To lower blood pressure B. To prevent seizures C. To inhibit labor D. To block dopamine receptors Rationale: Magnesium sulfate is given to prevent and control seizures in clients with PIH. Betaadrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors. A client's prenatal record shows that she's a gravida 2, para 0111. From this information, the nurse knows that she has been pregnant twice. What else does this information reveal about her obstetric history? A. One pregnancy resulted in a term neonate who's living and one resulted in a preterm neonate who's living. B. One pregnancy resulted in an abortion and one resulted in a term neonate who's living. C. One pregnancy resulted in an abortion and one resulted in a preterm neonate who's living. D. One pregnancy resulted in a term neonate who's living and one resulted in a preterm neonate who died. Rationale: A client's previous pregnancies are documented according to her number of Term infants, number of Preterm infants, number of Abortions, and number of Living children (or TPAL). In the TPAL method, the first element (0, in this case) indicates the number of term neonates. The second element (1) indicates the number of preterm neonates delivered. The third element (1) represents
the number of spontaneous or therapeutic abortions. The fourth element (1) represents the number of children alive. One pregnancy that resulted in a term neonate who's living and one that resulted in a preterm neonate who's living would be documented as para 1102. One pregnancy that resulted in an abortion and one that resulted in a term neonate who's living would be documented as para 1011. One pregnancy that resulted in a term neonate who's living and one that resulted in a preterm neonate who died would be documented as para 1101. A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effects." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins." Rationale: Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn't promote sodium retention. Castor oil isn't known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.
Infertility in a 25-year-old couple is defined as which of the following? A. The couple's inability to conceive after 6 months of unprotected attempts B. The couple's inability to sustain a pregnancy C. The couple's inability to conceive after 1 year of unprotected attempts D. A low sperm count and decreased motility Rationale: The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse.
When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her? A. "I'll report increased frequency of urination." B. "If I have blurred or double vision, I should call the clinic immediately." C. "If I feel tired after resting, I should report it immediately." D. "Nausea should be reported immediately." Rationale: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. The nurse is developing a plan of care for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? A. Encouraging ambulation B. Serving a nutritious diet C. Promoting adequate hydration D. Performing nipple stimulation Rationale: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions. The nurse is assessing a client who's 6 weeks pregnant. Which findings best support a suspicion of ectopic pregnancy? A. Amenorrhea and adnexal fullness and tenderness B. Nausea, vomiting, and slight uterine enlargement C. Grapefruit-size uterine enlargement and vaginal spotting D. Amenorrhea, sudden weight gain, and audible fetal heart tones above the symphysis pubis
Rationale: Signs and symptoms of ectopic pregnancy include amenorrhea and adnexal fullness and tenderness. Nausea, vomiting, and vaginal spotting may occur in ectopic pregnancy, but the uterus doesn't enlarge because it remains empty. Weight gain may accompany ectopic pregnancy; however, fetal heart tones aren't audible above the symphysis pubis in clients with this disorder. A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to do which of the following? A. Slow contractions B. Enhance fetal growth C. Prevent infection D. Promote fetal lung maturation Rationale: Betamethasone is given to promote fetal lung maturity by enhancing the production of surface-active lipoproteins. It has no effect on contractions, fetal growth, or infection. A client with type 1 diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide? A. "Insulin requirements don't change during pregnancy. Continue your current regimen." B. "Insulin requirements usually decrease during the last two trimesters." C. "Insulin requirements usually decrease during the first trimester." D. "Insulin requirements increase greatly during labor." Rationale: Maternal insulin requirements usually decrease during the first trimester from rapid fetal growth and maternal metabolic changes, necessitating adjustment of the insulin dosage. Maternal insulin requirements fluctuate throughout pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish from extreme maternal energy expenditure. A client who's 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client
isn't in labor. Which nursing intervention should the nurse perform? A. Allow the client to ambulate with assistance B. Perform a vaginal examination to check for cervical dilation C. Monitor the amount of vaginal blood loss. D. Notify the physician for a fetal heart rate of 130 beats/minute. Rationale: Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute. A client tells the nurse that she suspects her amniotic membranes broke 2 hours ago. Because the goal of care for this client is to prevent infection (chorioamnionitis), the plan of care should include: A. assessing the fetal heart rate once every hour. B. limiting vaginal examinations to once every hour. C. assessing vital signs, especially temperature, every 4 hours. D. confirming membrane rupture by using a sterile speculum and cotton-tipped applicator to assess fluid. Rationale: To prevent infection, the nurse must use sterile technique to assess amniotic fluid and thus confirm membrane rupture. The nurse should assess the fetal heart rate every 30 minutes because fetal tachycardia signals chorioamnionitis. Vaginal examinations introduce bacteria into the vagina and should be performed only when necessary - for example, before narcotic administration and to assess suspected cord prolapse. The nurse should assess vital signs, especially temperature and pulse, every 2 hours to detect early signs of infection. Which drug will the physician probably order to treat a pregnant client who is experiencing morning sickness?
A. B. C. D.
Prochlorperazine (Compazine) Diphenhydramine (Benadryl) Trimethobenzamide (Tigan) Phosphorated carbohydrate solution (Emetrol
Rationale: The physician will probably order phosphorated carbohydrate solution for a pregnant client who is experiencing morning sickness. Prochlorperazine, diphenhydramine, and trimethobenzamide may produce congenital anomalies and aren't recommended to treat morning sickness caused by pregnancy.
genetic defects. Ultrasonography and nonstress testing, although noninvasive, are expensive and require the use of medical facilities, which may place extra demands on the client's time. A client who's 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by: A. 5 to 8 weeks' gestation. B. 9 to 12 weeks' gestation. C. 14 to 17 weeks' gestation. D. 18 to 22 weeks' gestation. Rationale: Nausea, vomiting, urinary frequency, and urinary urgency normally subside between 9 and 12 weeks' gestation
A pregnant client in her second trimester visits the health care practitioner for a regular prenatal checkup. During the assessment, the nurse weighs the client, then compares her current and previous weights. During the second trimester, how much weight should the client gain per week? A. 0.5 lb (0.23 kg) B. 1 lb (0.45 kg) C. 1.5 lb (0.68 kg) D. 2 lb (.91 kg) Rationale: During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A woman with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy. The nurse is assessing a client who's 29 weeks pregnant. What is the least invasive and demanding method for assessing fetal wellbeing? A. Maternal fetal activity count B. Chorionic villi sampling C. Ultrasonography D. Nonstress test Rationale: Maternal fetal activity count is the least invasive and demanding method for assessing fetal well-being. To use this method, the client simply counts, records, and reports the number of times the fetus kicks during a designated period each day. Chorionic villi sampling is invasive and expensive and should be reserved for pregnant clients at risk for
A pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and performing a physical examination, the nurse reviews the client's laboratory test results. Which findings suggest iron deficiency anemia? A. Hemoglobin (Hb) 15 g/L; hematocrit (HCT) 33% B. Hb 13 g/L; HCT 32% C. Hb 10 g/L; HCT 35% D. Hb 9 g/L; HCT 30 Rationale: With iron deficiency anemia, the Hb level is below 11 g/L and HCT drops below 32%. The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that: A. the delivery may need to be induced early. B. the delivery must be by cesarean. C. the mother will carry to term safely. D. it's too early to tell
Rationale: Early induction or early cesarean are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary. A woman who's 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should: A. recognize these as normal early pregnancy signs and symptoms. B. question her further about these signs and
symptoms. C. tell her that she'll need blood work and urinalysis D. tell her that she may be excessively worried. Rationale: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic. What is the primary nursing diagnosis for a client with a ruptured ectopic pregnancy? A. Anxiety B. Pain C. Deficient fluid volume D. Anticipatory grieving Rationale: Ruptured ectopic pregnancy is associated with hemorrhage and requires immediate surgical intervention; therefore, Deficient fluid volume is the primary diagnosis. The other options are correct but aren't the primary nursing diagnosis. This client is probably experiencing anxiety because this is a surgical emergency. Pain is also present and should be addressed as warranted. The client with ruptured ectopic pregnancy may experience anticipatory grieving at the loss of her fetus. A client is admitted for an amniocentesis. Initial assessment findings include the following: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 gm, hematocrit 35%, and type O-negative blood. Which of the following actions would be most important to include in the client's plan of care after the 20-minute amniocentesis has been completed? A. Administer RhoGAM. B. Check for rupture of membranes. C. Assess uterine activity. D. Provide additional fluid. Rationale: To prevent maternal sensitization, RhoGAM must be given after any invasive procedure on an Rh-negative client. All the other aspects are important but the administration of RhoGAM is the priority.
The nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? A. Absent pedal pulses B. Bilateral dependent edema C. Sluggish capillary refill D. Unilateral calf enlargement Rationale: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis. During her fourth clinic visit, a client who's 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond? A. "Yes but immunization against rubella requires a physician's order." B. "No because the live viral vaccine is contraindicated during pregnancy." C. "Yes and you should consider pregnancy termination because rubella has teratogenic effects." D. "No because the vaccine can be given only during the first trimester." Rationale: Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus, which can have teratogenic effects on the fetus. Needing a physician's order isn't a valid reason for withholding an immunization. Recommending pregnancy termination forces the nurse's viewpoint on the client rather than allowing the client to decide for herself. Exposure to rubella virus may have teratogenic effects if the client is exposed during the first trimester. The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate? A. They're regular. B. They're usually felt in the abdomen. C. They start in the back and radiate to the abdomen D. They become more intense during walking.
Rationale: Prelabor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking. A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but is concerned because she herself isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by: A. referring her to counseling. B. telling her such feelings are normal in the beginning of pregnancy C. exploring her feelings. D. recommending she talk her feelings over with her husband. Rationale: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time. The nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor? A. The client is 25 years old. B. The client has a child with cystic fibrosis. C. The client was exposed to rubella at 36 weeks' gestation. D. The client has a history of preterm labor at 32 weeks' gestation. Rationale: Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age isn't a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn't correlate with genetic defects. When should a client who's Rh(D)-negative and D-negative and who hasn't already formed Rh
antibodies receive Rh(D) human immunoglobulin (RhIg) to prevent isoimmunization? A. At about 28 weeks' gestation only B. Within 72 hours after delivery only C. At about 28 weeks' gestation and again within 72 hours after delivery D. At about 32 weeks' gestation and again within 24 hours after delivery Rationale: A client who's Rh(D)-negative and Dnegative and who hasn't already formed Rh antibodies should receive RhIg at about 28 weeks' gestation and again within 72 hours after delivery. Giving RhIg only at 28 weeks' gestation wouldn't prevent isoimmunization from occurring after placental separation, when fetal blood enters the maternal circulation. Giving RhIg only within 72 hours after delivery wouldn't prevent isoimmunization caused by passage of fetal blood into the maternal circulation during gestation. Giving RhIg at 32 weeks' gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies already have formed by then. Giving RhIg within 24 hours after delivery would be too soon because maternal sensitization occurs in approximately 72 hours. At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal: A. edema. B. fever. C. glycosuria. D. vomiting. Rationale: Classic signs of PIH include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with various disorders. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit? A. Edema B. Pelvic adequacy C. Rh factor changes D. Hemoglobin alterations Rationale: At each prenatal visit, the nurse should assess the client for edema because edema, increased
blood pressure, and proteinuria are cardinal signs of pregnancy-induced hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation.
A client is in the 8th month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position? A. Right lateral B. Left lateral C. Supine D. Semi-Fowler's Rationale: The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function. During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions? A. "I'll decrease my intake of green, leafy vegetables." B. "I'll limit fluid intake to four 8-oz glasses." C. "I'll increase my intake of unrefined grains." D. "I'll take iron supplements regularly." Rationale: To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids. The use of iron supplements can cause rather than relieve - constipation.
The nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: A. "Do you have any cats at home?" B. "Do you have any birds at home?" C. "Have you recently had a rubeola vaccination?" D. "Have you ever had osteomyelitis?" Rationale: TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus - agents that may infect the fetus or newborn, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections. The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? A. 7 weeks B. 11 weeks C. 17 weeks D. 21 weeks Rationale: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation. The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her baby? A. Encourage breast-feeding so that she can get her rest and get healthier. B. Encourage breast-feeding because it's healthier for the baby C. Encourage breast-feeding to facilitate bonding. D. Discourage breast-feeding because HIV can be transmitted through breast milk. Rationale: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.
During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client? A. Activity intolerance related to decreased tissue oxygenation B. Risk for infection related to metabolic and vascular abnormalities C. Imbalanced nutrition: Less than body requirements related to limited food intake D. Impaired gas exchange related to respiratory effects of substance abuse Rationale: A substance abuser may spend more money on drugs than on food and other basic needs, leading to a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to limited food intake. Activity intolerance might be a relevant nursing diagnosis if the client were having trouble sleeping or getting adequate rest; however, activity intolerance wouldn't be related to decreased tissue oxygenation in this case. If the client were an I.V. drug abuser, a diagnosis of Risk for infection related to I.V. drug use might be appropriate. Because the question doesn't specify how the client is using cocaine, a diagnosis of Impaired gas exchange related to respiratory effects of substance abuse is inappropriate. A 30-year-old primiparous client at 34 weeks' gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they're permanent. What should the nurse tell her? A. "These streaks are called linea nigra; they'll fade after childbirth." B. "These streaks are called hemangiomas; they're permanent changes of pregnancy." C. "These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after delivery." D. "These streaks are called nevi; they'll fade after the postpartum period." Rationale: The client's weight gain and enlarging uterus, combined with the action of adrenocorticosteroids, lead to stretching of the underlying connective tissue of the skin, creating striae gravidarum in the second and third
trimesters. Better known as stretch marks, these streaks develop most often in skin covering the breasts, abdomen, buttocks, and thighs. After delivery, they typically grow lighter. Linea nigra is a dark line that extends from the umbilicus or above to the mons pubis. In the primigravid client, this line develops at approximately the 3rd month of pregnancy. In the multigravid client, linea nigra typically appears before the 3rd month. Tiny bright hemangiomas may occur during pregnancy as a result of estrogen release. They're called vascular spiders because of the branching pattern that extends from each spot. Nevi are circumscribed, benign proliferations of pigment-producing cells in the skin. When teaching a group of pregnant teens about reproduction and conception, the nurse is correct when stating that fertilization occurs: A. in the uterus. B. when the ovum is released. C. near the fimbriated end. D. in the first third of the fallopian tube. Rationale: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy. When performing a vaginal examination on a pregnant client, the nurse determines that the biparietal diameter of the fetal head has reached the pelvic inlet. Which statement best describes the position of the fetus at this time? A. It's at the ischial spines. B. It's at first station. C. It's engaged. D. It's floating. Rationale: The largest part of the fetus's head, the presenting part, is marked by the biparietal diameter. The largest part of the head is accommodated by the largest part of the passage - the pelvic inlet. Engagement refers to entry of the fetus's head or presenting part into the superior pelvic strait, which is marked by the pelvic inlet. When the fetus's head is at the level of the ischial spines, it's at the pelvic outlet. The ischial spines are designated as zero station. A floating fetus hasn't yet entered the pelvic inlet.
A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? A. Report a heart rate greater than 120 beats/minute to the physician B. Take terbutaline every 4 hours, during waking hours only. C. Call the physician if the fetus moves 10 times in an hour. D. Increase activity daily if not fatigued.
three pillows under her head. After listening to her concerns, the nurse should take which action? A. Make an appointment because the client needs to be evaluated. B. Explain that these are expected problems for the latter stages of pregnancy. C. Arrange for the client to be admitted to the birth center for delivery. D. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.
Rationale: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.
Rationale: The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client doesn't need to be seen or admitted for delivery.
The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? A. On the day of discharge B. When the client expresses readiness to leave the hospital. C. When the client's vomiting has stopped D. On admission to the facility
While caring for pregnant adolescents, the nurse should develop a plan of care that incorporates which health concern? A. Age of menarche B. Family and home life C. Healthy eating habits D. Level of emotional maturity
Rationale: Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge won't be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Such factors as when the client stops vomiting and expresses readiness to learn shouldn't influence when the nurse begins discharge planning. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places
Rationale: When assessing an adolescent initially, the nurse should try to determine the client's level of emotional maturity. This forms the basis for the nursing plan of care. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the client. The nurse is caring for a client after evacuation of a hydatidiform molar pregnancy. The nurse should tell the woman to: A. wait 1 month before trying to become pregnant again. B. make an appointment for follow-up human chorionic gonadotropin (HCG) level monitoring at the end of 1 year. C. discuss options for sterilization with the physician. D. use birth control for at least 1 year. Rationale: After experiencing a hydatidiform molar pregnancy, the client should be counseled to use a
reliable method of birth control for at least 1 year. Because of the risk of choriocarcinoma, her HCG levels need to be monitored monthly for 1 to 2 years. Sterilization isn't necessary after hydatidiform mole. If HCG levels remain low, a woman may try to become pregnant after 1 year. The risk of recurrence of a hydatidiform mole is low. A client is in the 38th week of her first pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action? A. Review premonitory signs of labor with the client. B. Instruct the client to go the health care facility for a nonstress test (NST). C. Ask the client to bring in a urine specimen for urinalysis D. Make an appointment for the client to see the physician today. Rationale: Because the client is describing two premonitory signs of labor, Braxton Hicks contractions and tightening, the nurse should review these normal signs and reassure the client. An NST, used to assess fetal well-being, would be inappropriate unless the client reported changes in fetal activity. Urinalysis wouldn't be indicated unless the client reported symptoms of bladder inflammation, such as dysuria or urinary frequency or urgency. Because the client's findings are normal, she need not see the physician other than at her regular weekly appointment. A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her? A. This symptom is abnormal during the third trimester and may indicate a urinary tract infection. B. This symptom is a normal variation and is easily managed by limiting fluid intake. C. This symptom is normal and results from the fetus exerting pressure on the bladder. D. This symptom is abnormal and should subside after the presenting part of the fetus is engaged. Rationale: During the first trimester, hormonal changes and uterine pressure on the bladder cause urinary frequency and urgency. During the second trimester, when the uterus rises out of the
pelvis, urinary symptoms abate. However, as term approaches, pressure on the bladder by the presenting part of the fetus again causes urinary frequency and urgency. Urinary frequency isn't abnormal unless accompanied by other urinary symptoms, such as burning and pain. Fluids shouldn't be limited during pregnancy. Urinary frequency doesn't subside after the presenting part is engaged. Instead, the presenting part exerts pressure on the bladder. At 15 weeks' gestation, a client is scheduled for a serum alpha-fetoprotein (AFP) test. Which maternal history finding best explains the need for this test? A. Family history of spina bifida in a sister B. Family history of Down syndrome on the father's side C. History of gestational diabetes during a previous pregnancy D. History of spotting during the 1st month of the current pregnancy Rationale: An abnormally high AFP level in the client's serum or amniotic fluid suggests a neural tube defect such as spina bifida. A family history of such defects increases the risk of carrying a fetus with a neural tube defect. Although a low AFP level has been correlated with Down syndrome, it isn't the most accurate indicator. No known correlation exists between gestational diabetes or early vaginal spotting and a certain AFP level at 15 to 20 weeks' gestation. A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: A. a neurologic disorder. B. inadequate nutrition. C. an unknown cause. D. hemolysis of fetal red blood cells (RBCs). Rationale: The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs. A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action? A. Administer amnioinfusion B. Prepare for cesarean delivery
C. Reposition the client. D. Start I.V. oxytocin infusion as prescribed Rationale: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean delivery. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress. When providing health teaching to a primigravid client, the nurse tells the client that she's likely to first experience Braxton Hicks contractions. When do these contractions typically begin? A. Between 18 and 22 weeks' gestation B. Between 23 and 27 weeks' gestation C. Between 28 and 31 weeks' gestation D. Between 32 and 35 weeks' gestation Rationale: Braxton Hicks contractions typically begin between 23 and 27 weeks' gestation. The fetal heartbeat typically can be heard and fetal rebound is possible between 18 and 22 weeks. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks. A pregnant client asks the nurse about the percentage of congenital anomalies caused by drug exposure. How should the nurse respond? A. 1% B. 10% C. 20% D. 60% Rationale: Drug exposure congenital anomalies.
causes
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A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: A. milk and ice pops. B. decaffeinated coffee and scrambled eggs. C. tea and gelatin dessert. D. apple juice and oatmeal.
Rationale: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet. The nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat: A. grains and milk. B. tomatoes and fish. C. eggs and citrus fruit. D. spinach and beef. Rationale: Common food sources of iron include spinach, beef, liver, prunes, pork, broccoli, legumes, and whole wheat breads and cereals. Grains are good sources of carbohydrates; milk is high in vitamin D; and fish, eggs, and milk are high in protein. Tomatoes and citrus fruits are high in vitamins A and C. Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client? A. Provide her with the information and teach her the skills she'll need to understand and cope during birth. B. Provide her with written information about the birthing process. C. Have a more experienced pregnant woman assist her. D. Do nothing in hopes that she'll begin coping as the pregnancy progresses. Rationale: Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs. The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy? A. Iron deficiency anemia
B. Varicosities C. Nausea and vomiting D. Gestational diabetes Rationale: Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes. The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching? A. "I'll need to lie perfectly still." B. "You won't need to come in and check on me while I'm wearing this monitor." C. "I can lie in any comfortable position, but I should stay off my back." D. "I know that the external monitor increases my risk of a uterine infection." Rationale: A woman with an external monitor should lie in the position that is most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection. The nurse obtains the antepartum history of a client who's 6 weeks pregnant. Which finding should the nurse discuss with the client first? A. Her participation in low-impact aerobics three times per week B. Her consumption of six to eight cans of beer on weekends C. Her consumption of four to six small meals daily D. Her practice of taking a multivitamin supplement daily
Rationale: Consuming any amount or type of alcohol isn't recommended during pregnancy because it increases the risk of fetal alcohol syndrome or fetal alcohol effect. If the client is accustomed to moderate exercise, she may continue to engage in low-impact aerobics during pregnancy. Eating frequent, small meals helps maintain the client's energy level by keeping the blood glucose level relatively constant. Taking a multivitamin supplement daily and eating a balanced diet are recommended during pregnancy. As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy? A. Decreased appetite B. Inadequate fluid intake C. Prolonged gastric emptying D. Reduced intestinal motility Rationale: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause. Which of the following functions would the nurse expect to be unrelated to the placenta? A. Production of estrogen and progesterone B. Detoxification of some drugs and chemicals C. Exchange site for food, gases, and waste D. Production of maternal antibodies Rationale: Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.
A client, age 39, visits the nurse practitioner for a regular prenatal check-up. She's 32 weeks pregnant. When assessing her, the nurse should stay especially alert for signs and symptoms of: A. pregnancy-induced hypertension (PIH).
B. iron deficiency anemia. C. cephalopelvic disproportion. D. sexually transmitted diseases (STDs). Rationale: Mature pregnant clients are at increased risk for PIH and are more likely to require cesarean delivery. Also, their fetuses and neonates have a higher mortality and a higher incidence of trisomies. Iron deficiency anemia, cephalopelvic disproportion, and STDs may occur in any client regardless of age. The nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate: A. cervical effacement and dilation. B. maternal vital signs and FHR. C. frequency and duration of contractions. D. white blood cell (WBC) count. Rationale: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information. A client is expecting her second child in 6 months. During the psychosocial assessment, she says, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response? A. "Each pregnancy has a unique psychosocial meaning." B. "The facility requires these answers of all pregnant clients." C. "A second pregnancy may require more psychosocial adjustment." D. "A client can develop couvade with any pregnancy."
Rationale: With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother. The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron? A. A glass of milk B. A cup of hot tea C. A liquid antacid D. A glass of orange juice Rationale: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron. The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: A. start using insulin. B. start taking an oral antidiabetic drug. C. monitor her urine for glucose. D. be taught about diet. Rationale: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels. The nurse prepares a client who's 28 weeks pregnant for a nonstress test (NST). Which intervention is most likely to stimulate fetal movements during this test? A. Having the client drink orange juice B. Instructing the client to brush her hand over a nipple C. Advising the client not to eat for 12 hours before the test D. Positioning the client on her left side Rationale: The NST measures fetal movement and the fetal heart rate. To stimulate fetal movement, the nurse may instruct the client to drink a liquid, such as orange juice, or to touch or rock her abdomen to move the fetus. Brushing a hand over a nipple or
positioning the client on her left side wouldn't stimulate fetal movement. The client should have a snack before the test to help ensure readable fetal movements.
A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next? A. Continue to monitor the baby for fetal distress. B. Notify the physician and transfer the mother to labor and delivery for imminent delivery. C. Inform the physician and prepare for discharge; this client has a reassuring strip. D. Ask the mother to eat something and return for a repeat test; the results are inconclusive. Rationale: Fetal well-being is determined during a nonstress test by two accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the outcome of a nonstress test.
techniques near the end of pregnancy; signs and symptoms of pregnancy, shortly before they're anticipated, based on the number of weeks' gestation; and any tests, a few weeks before they're scheduled. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? A. The fetus should be delivered within 24 hours. B. The client should repeat the test in 24 hours. C. The fetus isn't in distress at this time. D. The client should repeat the test in 1 week. Rationale: The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? A. Labor techniques B. Danger signs during pregnancy C. Signs and symptoms of pregnancy D. Tests to evaluate for high-risk pregnancy
A client who's 4 months pregnant asks the nurse how much and what type of exercise she should get during pregnancy. How should the nurse counsel her? A. "Try high-intensity aerobics, but limit sessions to 15 minutes daily." B. "Perform gentle back-lying exercises for 30 minutes daily." C. "Walk briskly for 10 to 15 minutes daily, and gradually increase this time." D. "Exercise to raise the heart rate above 140 beats/minute for 20 minutes daily."
Rationale: No matter how far the client's pregnancy has progressed by the time of her first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they're expected to occur. For example, the nurse should teach about labor
Rationale: Taking brisk walks is one of the easiest ways to exercise during pregnancy. The client should begin by walking slowly for 10 to 15 minutes per day and increase gradually to a comfortable speed and a duration of 30 to 45 minutes per day. The pregnant client should avoid high-intensity aerobics because these greatly increase oxygen consumption; pregnancy itself not only increases oxygen consumption but reduces oxygen reserve. Starting from the 4th month of pregnancy, the client should
avoid back-lying exercises because in this position the enlarged uterus may reduce blood flow through the vena cava. The client should avoid exercises that raise the heart rate over 140 beats/minute because the cardiovascular system already is stressed by increased blood volume during pregnancy.
During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurse's best action? A. Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. B. Be alert for a possible eating problem and do a further in-depth assessment. C. Report the client's concerns to her caregiver D. Ask her to come back to the clinic every 2 weeks for a weight check. Rationale: Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary. A client who's 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus will develop: A. a neural tube defect. B. a cardiac abnormality. C. intrauterine growth retardation. D. a renal disorder. Rationale: The risk of intrauterine growth retardation may increase with the number of cigarettes a pregnant woman smokes. Neural tube defects, cardiac abnormalities, and renal
disorders are associated with multifactorial genetic inheritance, not maternal cigarette smoking A client who's 24 weeks pregnant has sickle cell anemia. When preparing the plan of care, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy? A. Sedative use B. Dehydration C. Hypertension D. Tachycardia Rationale: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis. A client who's planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which of the following would be the nurse's best response? A. "Pregnancy is a human process; you don't have to worry." B. "You practice good health habits; just follow them and you'll be fine." C. "There is nothing you can do to have a healthy pregnancy; it's all up to nature." D. "Folic acid, 400 mcg, improves pregnancy outcomes by preventing certain complications." Rationale: When counseling a client who's planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The nurse should provide information but not prescribe the drug. It's the client's responsibility to ask the health care provider about a prescription. Telling the client not to worry ignores the client's needs. Telling the client that it's up to nature is inaccurate. Practicing good health habits is important for any person. A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings signify: A. an infection. B. umbilical cord prolapse. C. the start of the second stage of labor. D. the need for labor induction. Rationale: After an amniotomy, a significant change in the FHR may indicate umbilical cord prolapse; an EFM may show large variable decelerations during
cord compressions. The other options aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress. A client with pregnancy-induced hypertension (PIH) probably exhibits which of the following symptoms? A. Proteinuria, headaches, and vaginal bleeding B. Headaches, double vision, and vaginal bleeding C. Proteinuria, headaches, and double vision D. Proteinuria, double vision, and uterine contractions Rationale: A client with PIH complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions aren't associated with PIH.
A client who's 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Of the following nursing diagnoses, the nurse should give the highest priority to: A. Risk for deficient fluid volume B. Anxiety. C. Pain. D. Impaired gas exchange. Rationale: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.
The nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess: A. Hegar's sign. B. fetal outline. C. ballottement. D. quickening. Rationale: When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement isn't elicited until the 4th or 5th month of pregnancy. Quickening typically is reported after 16 to 20 weeks. A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, the nurse expects to find: A. a history of pelvic inflammatory disease B. grand multiparity (five or more births). C. use of an intrauterine device for 1 year D. use of an oral contraceptive for 5 years. Rationale: Pelvic inflammatory disease with accompanying salpingitis is commonly implicated in cases of tubal obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn't associated A client who's 3 months pregnant with her first child reports that she has had increasing morning sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal heart tones. The nurse should suspect which complication of pregnancy? A. Fetal demise B. Ectopic pregnancy C. Hyperemesis gravidarum D. Gestational trophoblastic disease Rationale: Gestational trophoblastic disease causes increased nausea and vomiting, uterine enlargement beyond that expected for the number of weeks' gestation, absence of fetal heart tones, and vaginal spotting. Because the client exhibits most of these signs, she requires further evaluation. In fetal demise, uterine size decreases; the client's fundal height of 20 cm at 3 months' gestation is too large to indicate fetal demise. Absence of fetal heart tones is a sign of
ectopic pregnancy; however, a fundal height of 20 cm doesn't support that diagnosis. Although hyperemesis gravidarum causes increased nausea and vomiting, the client's enlarged uterus suggests a different problem. A client who's pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: A. Braxton Hicks contractions. B. back labor. C. fetal distress. D. true labor contractions. Rationale: Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. Back labor refers to pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green– tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes a day. The first step the nurse should take to help the woman stop smoking is to: A. assess the client's readiness to stop. B. suggest that the client reduce the daily number of cigarettes smoked by one-half. C. provide the client with the telephone number of a formal smoking cessation program. D. help the client develop a plan to stop. Rationale: Before planning any intervention with a client who smokes, it's essential to determine whether or not the client is willing or ready to stop smoking. Commonly, a pregnant
woman will agree to stop for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation. During a physical examination, a client who's 32 weeks pregnant becomes pale, dizzy, and lightheaded while supine. Which action should the nurse immediately take? A. Turn the client on her left side B. Ask the client to breathe deeply C. Listen to fetal heart tones D. Measure the client's blood pressure. Rationale: As the uterus enlarges, pressure on the inferior vena cava increases, compromising venous return and causing blood pressure to drop. This may lead to syncope and accompanying symptoms when the client is supine. Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and blood pressure. Deep breathing wouldn't relieve this client's symptoms. Listening to fetal heart tones and measuring the client's blood pressure wouldn't provide relevant information nor would they treat the client's symptoms. A client who's 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. Which pregnancy-related physiologic change places her at greatest risk for more severe cardiac problems? A. Decreased heart rate B. Increased plasma volume C. Decreased cardiac output D. Increased blood pressure Rationale: Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels. A client, age 19, has an episiotomy to widen her birth canal. Delivery extends the incision into the anal sphincter. This complication is called: A. a first-degree laceration. B. a second-degree laceration. C. a third-degree laceration. D. a fourth-degree laceration.
Rationale: Delivery may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body. During the first trimester, the nurse evaluates a pregnant client for factors that suggest she might abuse a child. Which parental characteristic is a risk factor for committing child abuse? A. Low educational level B. Low self-esteem C. Multiparity D. Poor diet
a cardiac disorder. Rationale: During pregnancy, a systolic ejection murmur over the pulmonic area is a common finding. Typically, it results from increases in blood volume and cardiac output, along with changes in heart size and position. Other cardiac rhythm disturbances also may occur during pregnancy and don't require treatment unless the client has concurrent heart disease. The nurse should document the finding and check for the murmur during the next visit. The nurse need not consult a cardiologist or the primary care health provider and shouldn't tell the client that this finding indicates a cardiac disorder.
Rationale: Typically, the abusive parent has low self-esteem along with many unmet needs. Lack of nurturing experience and inadequate knowledge of childhood growth and development may also contribute to the potential for child abuse. A low educational level, multiparity, and poor diet aren't direct risk factors for committing child abuse.
A client, 7 months pregnant, is receiving the tocolytic agent terbutaline (Bricanyl), 17.5 mcg/minute I.V., to halt uterine contractions. She also takes prednisone (Orasone), 5 mg by mouth twice per day, to control asthma. To detect an adverse interaction between these drugs, the nurse should monitor the client for: A. increased uterine contractions B. pulmonary edema. C. asthma exacerbation. D. hypertensive crisis
A pregnant client's last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as: A. June 5. B. June 19. C. July 5. D. July 19.
Rationale: When administered concomitantly with prednisone or another corticosteroid, terbutaline may cause pulmonary edema. Concomitant administration of a corticosteroid and terbutaline doesn't cause increased uterine contractions, asthma exacerbation, or hypertensive crisis.
Rationale: Using Nägele's rule, the nurse calculates the client's EDD by adding 7 days to the 1st day of the last menstrual period (12 + 7 = 19) and subtracting 3 months from the month of the last menstrual period (October – 3 months = July). This results in an EDD of July 19.
When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take? A. Document the finding, which is normal during pregnancy. B. Consult with a cardiologist. C. Contact the client's primary health care provider. D. Explain that this finding may indicate
On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two periods now." Based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy? A. Identifying the fetus as a separate being B. Assuming caretaking responsibility for the neonate C. Preparing to relinquish the neonate through labor D. Accepting the biological fact of pregnancy Rationale: The first maternal psychological task of pregnancy is to accept the pregnancy as a biological fact. If the client doesn't accept that she's pregnant, she's unlikely to seek prenatal care. Identifying the fetus as a separate being usually occurs after the client feels fetal movements. Assuming caretaking responsibility for the neonate should occur during the postpartum period. Preparing to relinquish the
neonate through labor normally occurs during the third trimester. A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? A. Suggesting that she walk for 1 hour twice per day B. Advising her to take over-the-counter calcium supplements twice per day C. Teaching her to dorsiflex her foot during the cramp D. Instructing her to increase milk and cheese intake to 8 to 10 servings per day Rationale: Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary. During a nonstress test (NST), the nurse notes three fetal heart rate (FHR) increases of 20 beats/minute, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest? A. The client should undergo an oxytocin challenge test B. The test is inconclusive and must be repeated. C. The fetus is nonreactive and hypoxic. D. The fetus isn't in distress at this time. Rationale: In an NST, reactive (favorable) results include two to three FHR increases of 15 beats/minute or more, each lasting 15 seconds or more and occurring with fetal movement. An oxytocin challenge test is performed to stimulate uterine contractions and evaluate the FHR. If results are inconclusive, a nipple stimulation contraction test may be ordered. A nonreactive result occurs when the FHR doesn't rise 15 beats/minute or more over the specified time; a nonreactive result may indicate fetal hypoxia.
When determining maternal and fetal well-being, which of the following assessments is least important? A. Signs of postural hypotension B. Fetal heart rate and activity C. The mother's acceptance of growing fetus D. Signs of facial or digital edema Rationale: Postural hypotension doesn't occur until late in the pregnancy and is easily correctable. Collection of other assessment data, such as fetal heart rate and activity, the mother's acceptance of the growing fetus, and signs of edema, should be started early in the pregnancy because abnormalities can put the mother or the fetus at risk for significant physiologic and psychological problems. A low-risk client who's 6 weeks pregnant comes to the clinic for her first prenatal visit. At this time, the nurse should assign highest priority to: A. establishing a schedule of prenatal visits B. scheduling an ultrasound test to confirm the pregnancy. C. enrolling the client in a childbirth class. D. scheduling genetic testing for the client. Rationale: To promote the health of the client and her fetus, the nurse should establish a regular schedule of prenatal visits. Pregnancy is confirmed by serum human chorionic gonadotropin levels, not ultrasonography. The client undergoes ultrasonography to evaluate fetal growth and wellbeing; this procedure yields different information from one trimester to the next. Childbirth education classes can start at any time during pregnancy. Although the nurse may encourage enrollment, the client decides when to enroll. Genetic testing isn't necessary for a low-risk client. A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for: A. irregular contractions. B. increased fetal movement. C. changes in cervical effacement and dilation after 1 to 2 hours D. contractions that feel like pressure in the abdomen and groin. Rationale: True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the
back to the front of the abdomen and, possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours. A client asks how long she and her husband can safely continue sexual activity during pregnancy. How should the nurse respond? A. "Until the end of the first trimester" B. "Until the end of the second trimester" C. "Until the end of the third trimester" D. "As long as you wish, if the pregnancy is normal" Rationale: During a normal pregnancy, the client and her partner need not discontinue sexual activity. If the client develops complications that could lead to preterm labor, she and her partner should consult with a health practitioner for advice on the safety of sexual activity. The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? A. Presence of menses B. Uterine enlargement C. Breast sensitivity D. Fetal heart tones Rationale: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy. A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client? A. "The client consumes no more than 2 oz of alcohol daily." B. "The client consumes no more than 4 oz of alcohol daily." C. "The client consumes 2 to 6 oz of alcohol daily, depending on body weight." D. "The client consumes no alcohol."
Rationale: A safe level of alcohol intake during pregnancy hasn't been established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose her to complications in early pregnancy. The nurse is providing care for a pregnant 16-yearold client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: A. "Now isn't a good time to begin dieting because you are eating for two." B. "Let's explore your feelings further." C. "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." D. "The prenatal vitamins should ensure the baby gets all the necessary nutrients." Rationale: Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or baby needs; they work in congruence with a balanced diet. A client, 2 months pregnant, has hyperemesis gravidarum. Which expected outcome is most appropriate for her? A. "Client will accept the pregnancy and stop vomiting." B. "Client will gain weight according to the expected pattern for pregnancy." C. "Client will remain hospitalized for the duration of pregnancy to relieve stress." D. "Client will exhibit uterine growth within the expected norms for gestational age." Rationale: For a client with hyperemesis gravidarum, the goal of nursing care is to achieve optimal fetal growth, which can be evaluated by monitoring uterine growth through fundal height assessment. The nurse shouldn't assume that excessive vomiting
signifies the client doesn't accept the pregnancy. Clients with hyperemesis gravidarum rarely gain weight according to the expected pattern. They may be hospitalized briefly to regulate fluid and electrolyte status, but they don't require hospitalization for the duration of pregnancy. In fact, hospitalization may add to the stress of pregnancy by causing family separation and financial concerns. During the 6th month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms? A. A serious neurologic disorder B. Eustachian tube vascularization C. Increasing progesterone levels D. An ear infection Rationale: During pregnancy, increasing levels of estrogen - not progesterone - cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears. Nothing in the question implies that the client has a serious neurologic disorder or an ear infection. Which of the following would the nurse expect to assess as presumptive signs of pregnancy A. Amenorrhea and quickening B. Uterine enlargement and Chadwick's sign C. A positive pregnancy test and a fetal outline D. Braxton Hicks contractions and Hegar's sign Rationale: Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators - for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators such as fetal outline on ultrasound confirm pregnancy At what gestational age would a primigravida expect to feel quickening? A. 12 weeks B. 16 to 18 weeks C. 20 to 22 weeks D. By the end of the 26th week
Rationale: It's important for the nurse to distinguish between a client who's having her first baby and one who has already had a baby. For the client who's pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations. A pregnant client who's diabetic is at risk for having a large-for-gestational-age infant because of which of the following? A. Excess sugar causing reduced placental functioning B. Insulin acting as a growth hormone on the fetus C. Maternal dietary intake of high calories D. Excess insulin reducing placental functioning Rationale: Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size. When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding success? A. "It's contraindicated for you to breast-feed following this type of surgery." B. "I support your commitment; however, you may have to supplement each feeding with formula." C. "You should check with your surgeon to determine whether breast-feeding would be possible." D. "You should be able to breast-feed without difficulty." Rationale: Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breastfeeding after surgery is possible. Still, it's good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother's ability to meet all of her baby's nutritional needs, and some supplemental feeding may be required. Preparing the mother for this
possibility is extremely important because the client's psychological adaptation to mothering may be dependent on how successfully she breast-feeds. The nurse assesses a client for signs and symptoms of ectopic pregnancy. What is the most common finding associated with this antepartum complication? A. Temperature elevation B. Vaginal bleeding C. Nausea and vomiting D. Abdominal pain Rationale: Abdominal pain is the most common finding in ectopic pregnancy, occurring in over 90% of women with this antepartum complication. Temperature elevation, vaginal bleeding, and nausea and vomiting are less commonly associated with ectopic pregnancy. Which of the following is the approximate time that the blastocyst spends traveling to the uterus for implantation? A. 2 days B. 7 days C. 10 days D. 14 weeks Rationale: The blastocyst takes approximately 1 week to travel to the uterus for implantation. The other options are incorrect. When evaluating a pregnant client's fundal height, the nurse should measure in which way? A. Across the abdomen laterally B. From the symphysis pubis notch to the umbilicus C. With a pelvimeter designed to measure fundal height D. From the symphysis pubis notch to the highest level of the fundus Rationale: To measure fundal height, the nurse should stretch a measuring tape over the client's enlarged abdomen and measure from the symphysis pubis notch to the highest level of the fundus, determined by palpation. Measuring across the abdomen and measuring from the symphysis pubis to the umbilicus are incorrect procedures for measuring fundal height. A pelvimeter is used to evaluate the size of the maternal pelvis for delivery, not fundal height.
An 18-year-old pregnant woman tells the nurse that she's concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesn't provide insurance. The nurse should recognize that she: A. may not take care of herself. B. may not be fit to take care of a child. C. needs to take up a second job. D. should be referred to community resources available for pregnant women. Rationale: The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily solve this situation. A woman in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on the history above, the nurse should suspect which of the following conditions? A. Abruptio placentae B. Preterm labor C. Placenta previa D. Threatened abortion Rationale: Placenta previa is associated with painless vaginal bleeding that occurs when the placenta or a portion of the placenta covers the cervical os. In abruptio placentae, the placenta tears away from the wall of the uterus before delivery; the client usually has pain and a boardlike uterus. Preterm labor is associated with contractions and shouldn't involve bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks' gestation. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse should instruct the client to push the control button at which time? A. At the beginning of each fetal movement B. At the beginning of each contraction C. After every three fetal movements D. At the end of fetal movement Rationale: An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with
the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn't allow accurate comparison of fetal movement and FHR changes. The nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole? A. Rapid fetal heart tones B. Abnormally high human chorionic gonadotropin (HCG) levels C. Slow uterine growth D. Lack of symptoms of pregnancy Rationale: In a pregnant woman with a hydatidiform mole, the trophoblast villi proliferate and then degenerate. Proliferating trophoblast cells produce abnormally high HCG levels. No fetal heart tones are heard because there is no viable fetus. Because there is rapid proliferation of the trophoblast cells, the uterus grows fast and is larger than expected for a given gestational date. Because of the greatly elevated HCG levels, a woman with hydatidiform mole often has marked nausea and vomiting. A client who's 16 weeks pregnant comes to the emergency department complaining of vaginal bleeding. Which statement accurately describes estrogen and progesterone levels during this client's stage of pregnancy? A. Both estrogen and progesterone levels are rising B. The estrogen level is much higher than the progesterone level. C. Both estrogen and progesterone levels are declining. D. The estrogen level is much lower than the progesterone level. Rationale: Until the 7th month of pregnancy, both estrogen and progesterone are secreted in progressively greater amounts. Between the 7th and 9th months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio promotes the onset of uterine contractions. A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:
A. switch brands. B. take the vitamin on a full stomach. C. take the vitamin with orange juice for better absorption. D. take the vitamin first thing in the morning. Rationale: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea. A client at 35 weeks' gestation complains of severe abdominal pain and passing clots. The client's vital signs are blood pressure 150/100 mm Hg, heart rate 95 beats/minute, respiratory rate 25 breaths/minute, and fetal heart tones 160 beats/minute. The admitting nurse must determine the cause of the bleeding and respond appropriately to this emergency. Which of the following should the nurse do first? A. Examine the vagina to determine whether her client is in labor. B. Assess the location and consistency of the uterus C. Perform an ultrasound to determine placental placement. D. Prepare for immediate delivery.
Rationale: The nurse must determine whether placenta previa or abruptio placentae is the problem. (Fifty percent of all clients with hypertension will develop abruptio placenta.) In this case, the presenting symptoms are highly suggestive of an abruption, so the nurse must determine the level of the uterus and mark that level on the client's abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because the placenta has detached early is rigid. Bleeding from a placental previa is usually painless. A vaginal examination is contraindicated in the presence of bleeding. Most nurses haven't been taught how to perform an ultrasound. If the client has a placental abruption, birth will most likely be by cesarean section. During a prenatal visit at 20 weeks' gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks' gestation, which procedure is used to detect fetal anomalies?
A. B. C. D.
Amniocentesis Chorionic villi sampling Fetoscopy Ultrasound
Rationale: Ultrasound is used between 18 and 40 weeks' gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the third trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 weeks' gestation to detect genetic disease. Fetoscopy is done at approximately 18 weeks' gestation to observe the fetus directly and obtain a skin or blood sample
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response? A. "8 days after conception" B. "When the woman misses a menstrual period" C. "2 to 3 weeks after fertilization" D. "As soon as hormone levels decline" Rationale: Based on human chorionic gonadotropin (hCG) levels in the blood and urine, pregnancy can be diagnosed as early as 8 days after conception, when the syncytiotrophoblast produces hCG. Sensitive and specific pregnancy tests can detect hCG in the blood and urine even before the first missed menstrual period. A missed period may also be related to other factors, such as poor nutrition, strenuous athletic activity, and certain drugs. Levels of hCG rise rapidly until about the 20th week of gestation. By the 20th week, they decline gradually and stay low for the remainder of gestation. Other hormones, such as human placental lactogen, estrogen, and progesterone, increase during pregnancy. A client who's 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse anticipates that at 16 weeks' gestation, the client's fetus will: A. be able to suck and swallow B. open the eyes. C. have audible heart sounds. D. have open nostrils.
Rationale: Fetal heart tones are usually audible with a fetoscope between 16 and 20 weeks' gestation. The fetus can suck and swallow at about 20 weeks' gestation. The eyes are open at approximately 28 weeks' gestation. The nostrils are open at about 21 to 28 weeks' gestation. During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply? A. 7 days after fertilization B. 14 days after fertilization C. 21 days after fertilization D. 28 days after fertilization Rationale: Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium. During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the 3rd week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures - the primitive streak, notochord, and allantois - form. Early during the 4th week (28 days after implantation), cellular differentiation and organization occur. A pregnant client asks how she can best prepare her 3-year-old son for the upcoming birth of a sibling. The nurse should make which suggestion? A. "Tell your son about the childbirth about 1 month before your due date." B. "Reassure your son that nothing is going to change." C. "Reprimand your son if he displays immature behavior." D. "Involve your son in planning and preparing for a sibling." Rationale: Being involved in the pregnancy helps reinforce a child's position in the family and minimizes feelings of neglect and abandonment. Telling the child about the childbirth only 1 month before the due date wouldn't allow enough time to prepare him for the sibling and would prevent him from conceptualizing the passage of time. Reassuring him that nothing will change would be misleading; instead, the parents should discuss which aspects of family life will be changed by the upcoming birth and which will remain the same. Parents should reward mature behavior and ignore immature behavior. A client who's 32 weeks pregnant is hospitalized with preterm labor. After preterm labor is arrested, she's
discharged with a prescription for oral ritodrine (Yutopar). Which instruction should the nurse provide during discharge teaching? A. "Return to the clinic for a checkup in 6 weeks." B. "Abstain from sexual intercourse unless you use a condom." C. "You can return to your job as a hairdresser in 2 weeks." D. "Take the medication as needed whenever contractions occur." Rationale: A client who's predisposed to preterm labor should abstain from sexual intercourse unless she uses a condom because semen contains prostaglandins that stimulate uterine contractions. A client receiving ritodrine should return to the clinic in 1 to 2 weeks for a regular checkup and evaluation for preterm labor. Returning to work - especially to a job that involves much standing - is contraindicated immediately after preterm labor. Ritodrine must be taken regularly to prevent recurrence of preterm labor. During a prenatal visit, the nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age? A. 12 weeks B. 19 weeks C. 24 weeks D. 28 weeks Rationale: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm. The nurse is assisting in developing a teaching plan for a client who's about to enter the third trimester of pregnancy. The teaching plan should include identification of which danger sign that must be reported immediately? A. Hemorrhoids B. Blurred vision C. Dyspnea on exertion D. Increased vaginal mucus Rationale: During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal
and fetal consequences. Although hemorrhoids may occur during pregnancy, they don't require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.
A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy? A. Signs and symptoms of labor B. Quickening and fetal movements C. Warning signs of complications D. False labor and true labor Rationale: In early childbirth education classes, instruction on the physiologic aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development. Signs and symptoms of labor, quickening and fetal movements, and false and true labor are discussed in later classes.
