ANTEPARTUM
101. The nurse is planning care for a
16-year-old client in the prenatal clinic. Adolescents are prone to which
complication during pregnancy?
|
|
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.
102. 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?
|
|
"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.
103. The nurse obtains the antepartum history of
a client who's 6 weeks pregnant. Which finding should the nurse discuss with
the client first?
|
|
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.
104. As a client progresses through pregnancy,
she develops constipation. What is the primary cause of this problem during
pregnancy?
|
|
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.
105. Which of the following functions would the
nurse expect to be unrelated to the placenta?
|
|
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.
106. 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:
|
|
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.
107. 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:
|
|
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.
109. 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?
|
|
"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.
110. 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
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.
111. 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:
|
|
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.
112. 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?
|
|
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.
113. 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?
|
|
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.
114. A pregnant client comes to the facility for
her first prenatal visit. When providing teaching, the nurse should be sure to
cover which topic?
|
|
Labor
techniques
|
B.
|
Danger
signs during pregnancy
|
C.
|
Signs
and symptoms of pregnancy
|
D.
|
Tests
to evaluate for high-risk
pregnancy
|
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 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.
115. 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?
|
|
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.
116. 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?
|
|
"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."
|
|
|
"Exercise
to raise the heart rate
above
140 beats/minute for 20
minutes
daily."
|
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.
117. During her first prenatal visit, a client
expresses concern about gaining weight. Which of the following would be the
nurse's best action?
|
|
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
|
|
|
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.
118. 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
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
119. 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?
|
|
Sedative
use
|
B.
|
Dehydration
|
|
|
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.
120. 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?
|
|
"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.
121. 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:
|
|
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.
122. A client with pregnancy-induced
hypertension (PIH) probably exhibits which of the following symptoms?
|
|
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.
123. 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:
|
|
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.
124. The nurse is performing a physical
examination of a primigravid client who's 8 weeks pregnant. At this time, the
nurse expects to assess:
|
|
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.
125. 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
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
126. 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?
|
|
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.
127. 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:
|
|
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.
128. 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:
|
|
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.
129. During a physical examination, a client
who's 32 weeks pregnant becomes pale, dizzy, and light-headed while supine.
Which action should the nurse immediately take?
|
|
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.
130. 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?
|
|
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.
131. 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
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.
132. 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?
|
|
Low
educational level
|
B.
|
Low
self-esteem
|
C.
|
Multiparity
|
D.
|
Poor
diet
|
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.
133. A pregnant client's last menstrual period
began on October 12. The nurse calculates the estimated date of delivery (EDD)
as:
|
|
June
5.
|
B.
|
June
19.
|
C.
|
July
5.
|
D.
|
July
19.
|
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.
134. 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?
|
|
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
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.
135. 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:
|
|
increased
uterine contractions
|
B.
|
pulmonary
edema.
|
C.
|
asthma
exacerbation.
|
D.
|
hypertensive
crisis
|
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.
136. 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?
|
|
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.
137. 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?
|
|
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?
|
|
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.
138. When determining maternal and fetal
well-being, which of the following assessments is least important?
|
|
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.
139. 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:
|
|
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 well-being; 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.
140. 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:
|
|
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.
141. A client asks how long she and her husband
can safely continue sexual activity during pregnancy. How should the nurse
respond?
|
|
"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.
142. The nurse is caring for a client in the
first 4 weeks of pregnancy. The nurse should expect to collect which assessment
findings?
|
|
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.
143. 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?
|
|
"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.
144. The nurse is providing care for a pregnant
16-year-old 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:
|
|
"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.
145. A client, 2 months pregnant, has
hyperemesis gravidarum. Which expected outcome is most appropriate for her?
|
|
"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.
146. 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
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.
147. Which of the following would the nurse
expect to assess as presumptive signs of pregnancy
|
|
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
148. At what gestational age would a
primigravida expect to feel quickening?
|
|
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.
149. A pregnant client who's diabetic is at risk
for having a large-for-gestational-age infant because of which of the
following?
|
|
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.
150. 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?
|
|
"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
breast-feeding 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.
151. The nurse assesses a client for signs and
symptoms of ectopic pregnancy. What is the most common finding associated with
this antepartum complication?
|
|
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.
152. Which of the following is the approximate
time that the blastocyst spends traveling to the uterus for implantation?
|
|
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.
153. When evaluating a pregnant client's fundal
height, the nurse should measure in which way?
|
|
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.
154. 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:
|
|
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.
155. 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?
|
|
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.
156. 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?
|
|
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.
157. The nurse is assessing a pregnant woman.
Which signs or symptoms indicate a hydatidiform mole?
|
|
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.
158. 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?
|
|
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.
159. 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:
|
|
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.
160. 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?
|
|
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.
161. 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?
|
|
Amniocentesis
|
B.
|
Chorionic
villi sampling
|
C.
|
Fetoscopy
|
D.
|
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
162. During routine preconception counseling, a
client asks how early a pregnancy can be diagnosed. What is the nurse's best
response?
|
|
"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.
163. 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:
|
|
be
able to suck and swallow
|
B.
|
open
the eyes.
|
C.
|
have
audible heart sounds.
|
|
|
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.
164. 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?
|
|
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.
165. 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?
|
|
"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.
166. 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?
|
|
"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.
167. 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?
|
|
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.
168. 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?
|
|
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.
169. 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?
|
|
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.
