Exam Notes: MCHN - Antepartum Period PART 1

ANTEPARTUM

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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

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.

7. 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.

8. 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, estrogen-progesterone 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, 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.

9. 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).

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.

10. 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.

11.  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.

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.

12. 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.

13. 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 it.
D.	Warm milk to room temperature before adding lactase replacement tablets.

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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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, and death

Rationale:  During the third trimester, a key psychosocial task is to overcome fears the woman may have about the unknown, labor pain, loss of self-esteem, 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.

21. 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.

22. 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.

23. 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
D.	Tell her to go to the evaluation unit 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.

24. 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.

  

25. 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.

26. 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.

27. 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.

28. 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.

29. Which medication is considered safe during pregnancy?

A.	Aspirin
B.	Magnesium hydroxide
C.	Insulin
D.	Oral antidiabetic agents

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.

30. 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.

31. 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.

32. 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?

A.	"Are you planning to have epidural anesthesia?"
B.	"Have you begun prenatal classes?"
C.	"What changes have you made at home to get ready for the baby?"
D.	"Can you tell me about the meals you typically eat each day?"

Rationale:  During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. The type of anesthesia planned doesn't reflect the client's preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

33. 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 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.

34. After determining that a pregnant client is Rh-negative, the physician orders an indirect Coombs' test. What is the purpose of performing this test in a pregnant client?

A.	To determine the fetal blood Rh factor
B.	To determine the maternal blood Rh factor
C.	To detect maternal antibodies against fetal Rh-negative factor
D.	To detect maternal antibodies against fetal Rh-positive factor

Rationale:  The indirect Coombs' test measures the number of antibodies against fetal Rh-positive factor in maternal blood. The maternal blood Rh factor is determined before the indirect Coombs' test is done. No maternal antibodies against fetal Rh-negative factor exist.

35. The nurse determines that a client is in false labor. After obtaining discharge orders from the nurse-midwife, 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 semi-upright position with pillows placed under the client's knees promotes rest.

36. 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.

37. 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.

38. 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. 

39. 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.

40. 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.

41.  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.

42. 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.

43. 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.

44. 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.

45. 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.

46. 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.

47. A nurse in a prenatal clinic is assessing a 28-year-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.

48. 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.

49. 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. Beta-adrenergic 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.

50. 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.