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Monday, May 21, 2012

Exam Notes: MCHN - Antepartum Period PART 3

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?
A.
Iron deficiency anemia
B.
Varicosities
C.
Nausea and vomiting
D.
Gestational diabetes

Rationale:  Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes.

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?
A.
"I'll need to lie perfectly still."
B.
"You won't need to come in and
check on me while I'm wearing this
monitor."
C.
"I can lie in any comfortable position,
but I should stay off my back."
D.
"I know that the external monitor
increases my risk of a uterine infection."

Rationale:  A woman with an external monitor should lie in the position that is most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.

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?
A.
Her participation in low-impact aerobics
three times per week
B.
Her consumption of six to eight cans of
beer on weekends
C.
Her consumption of four to six small
meals daily
D.
Her practice of taking a multivitamin
supplement daily

Rationale:  Consuming any amount or type of alcohol isn't recommended during pregnancy because it increases the risk of fetal alcohol syndrome or fetal alcohol effect. If the client is accustomed to moderate exercise, she may continue to engage in low-impact aerobics during pregnancy. Eating frequent, small meals helps maintain the client's energy level by keeping the blood glucose level relatively constant. Taking a multivitamin supplement daily and eating a balanced diet are recommended during pregnancy.

104. As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
A.
Decreased appetite
B.
Inadequate fluid intake
C.
Prolonged gastric emptying
D.
Reduced intestinal motility

Rationale:  During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.

105. Which of the following functions would the nurse expect to be unrelated to the placenta?
A.
Production of estrogen and
progesterone
B.
Detoxification of some drugs and
chemicals
C.
Exchange site for food, gases, and
waste
D.
Production of maternal antibodies

Rationale:  Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.

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:
A.
pregnancy-induced hypertension (PIH).
B.
iron deficiency anemia.
C.
cephalopelvic disproportion.
D.
sexually transmitted diseases (STDs).

Rationale:  Mature pregnant clients are at increased risk for PIH and are more likely to require cesarean delivery. Also, their fetuses and neonates have a higher mortality and a higher incidence of trisomies. Iron deficiency anemia, cephalopelvic disproportion, and STDs may occur in any client regardless of age.

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:
A.
cervical effacement and dilation.
B.
maternal vital signs and FHR.
C.
frequency and duration of contractions.
D.
white blood cell (WBC) count.

Rationale:  After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information.

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?
A.
"Each pregnancy has a unique
psychosocial meaning."
B.
"The facility requires these answers
of all pregnant clients."
C.
"A second pregnancy may require
more psychosocial adjustment."
D.
"A client can develop couvade with
any pregnancy."

Rationale:  With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother.

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.
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:
A.
start using insulin.
B.
start taking an oral antidiabetic drug.
C.
monitor her urine for glucose.
D.
be taught about diet.

Rationale:  The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels.

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?
A.
Having the client drink orange juice
B.
Instructing the client to brush her hand
over a nipple
C.
Advising the client not to eat for 12 hours
before the test
D.
Positioning the client on her left side

Rationale:  The NST measures fetal movement and the fetal heart rate. To stimulate fetal movement, the nurse may instruct the client to drink a liquid, such as orange juice, or to touch or rock her abdomen to move the fetus. Brushing a hand over a nipple or positioning the client on her left side wouldn't stimulate fetal movement. The client should have a snack before the test to help ensure readable fetal movements.

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?
A.
Continue to monitor the baby for
fetal distress.
B.
Notify the physician and transfer
the mother to labor and delivery for
imminent delivery.
C.
Inform the physician and prepare for
discharge; this client has a reassuring
strip.
D.
Ask the mother to eat something
and return for a repeat test; the results
are inconclusive.

Rationale:  Fetal well-being is determined during a nonstress test by two accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the outcome of a nonstress test.

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?
A.
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?
A.
The fetus should be delivered within
24 hours.
B.
The client should repeat the test in 24
hours.
C.
The fetus isn't in distress at this time.
D.
The client should repeat the test in
1 week.

Rationale:  The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.

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?
A.
"Try high-intensity aerobics, but limit
sessions to 15 minutes daily."
B.
"Perform gentle back-lying exercises
for 30 minutes daily."
C.
"Walk briskly for 10 to 15 minutes
daily, and gradually increase this
time."
D.
"Exercise to raise the heart rate
above 140 beats/minute for 20
minutes daily."

Rationale:  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?
A.
Ask the client how she feels about
gaining weight and provide instructions
about expected weight gain and diet.
B.
Be alert for a possible eating problem and
do a further in-depth assessment.
C.
Report the client's concerns to her
caregiver
D.
Ask her to come back to the clinic every
2 weeks for a weight check.

Rationale:  Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary.

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.
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?
A.
Sedative use
B.
Dehydration
C.
Hypertension
D.
Tachycardia

Rationale:  Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis.

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?
A.
"Pregnancy is a human process;
you don't have to worry."
B.
"You practice good health habits;
just follow them and you'll be fine."
C.
"There is nothing you can do to have
a healthy pregnancy; it's all up to
nature."
D.
"Folic acid, 400 mcg, improves
pregnancy outcomes by preventing
certain complications."

Rationale:  When counseling a client who's planning to become pregnant, the nurse should discuss the role of folic acid in preventing neural tube defects. The nurse should provide information but not prescribe the drug. It's the client's responsibility to ask the health care provider about a prescription. Telling the client not to worry ignores the client's needs. Telling the client that it's up to nature is inaccurate. Practicing good health habits is important for any person.

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:
A.
an infection.
B.
umbilical cord prolapse.
C.
the start of the second stage of labor.
D.
the need for labor induction.

Rationale:  After an amniotomy, a significant change in the FHR may indicate umbilical cord prolapse; an EFM may show large variable decelerations during cord compressions. The other options aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.

122. A client with pregnancy-induced hypertension (PIH) probably exhibits which of the following symptoms?
A.
Proteinuria, headaches, and vaginal
bleeding
B.
Headaches, double vision, and vaginal
bleeding
C.
Proteinuria, headaches, and double
vision
D.
Proteinuria, double vision, and uterine
contractions

Rationale:  A client with PIH complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions aren't associated with PIH.

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:
A.
Risk for deficient fluid volume
B.
Anxiety.
C.
Pain.
D.
Impaired gas exchange.

Rationale:  A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.

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:
A.
Hegar's sign.
B.
fetal outline.
C.
ballottement.
D.
quickening.


Rationale:  When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement isn't elicited until the 4th or 5th month of pregnancy. Quickening typically is reported after 16 to 20 weeks.

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.
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?
A.
Fetal demise
B.
Ectopic pregnancy
C.
Hyperemesis gravidarum
D.
Gestational trophoblastic disease

Rationale:  Gestational trophoblastic disease causes increased nausea and vomiting, uterine enlargement beyond that expected for the number of weeks' gestation, absence of fetal heart tones, and vaginal spotting. Because the client exhibits most of these signs, she requires further evaluation. In fetal demise, uterine size decreases; the client's fundal height of 20 cm at 3 months' gestation is too large to indicate fetal demise. Absence of fetal heart tones is a sign of ectopic pregnancy; however, a fundal height of 20 cm doesn't support that diagnosis. Although hyperemesis gravidarum causes increased nausea and vomiting, the client's enlarged uterus suggests a different problem.

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:
A.
Braxton Hicks contractions.
B.
back labor.
C.
fetal distress.
D.
true labor contractions.

Rationale:  Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. Back labor refers to pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green–tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.

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:
A.
assess the client's readiness to stop.
B.
suggest that the client reduce the daily
number of cigarettes smoked by one-half.
C.
provide the client with the telephone
number of a formal smoking cessation
program.
D.
help the client develop a plan to stop.

Rationale:  Before planning any intervention with a client who smokes, it's essential to determine whether or not the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.

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?
A.
Turn the client on her left side
B.
Ask the client to breathe deeply
C.
Listen to fetal heart tones
D.
Measure the client's blood pressure.

Rationale:  As the uterus enlarges, pressure on the inferior vena cava increases, compromising venous return and causing blood pressure to drop. This may lead to syncope and accompanying symptoms when the client is supine. Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and blood pressure. Deep breathing wouldn't relieve this client's symptoms. Listening to fetal heart tones and measuring the client's blood pressure wouldn't provide relevant information nor would they treat the client's symptoms.

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?
A.
Decreased heart rate
B.
Increased plasma volume
C.
Decreased cardiac output
D.
Increased blood pressure

Rationale:  Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.

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.
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?
A.
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:
A.
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?
A.
Document the finding, which is
normal during pregnancy.
B.
Consult with a cardiologist.
C.
Contact the client's primary health
care provider.
D.
Explain that this finding may indicate
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:
A.
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?
A.
Identifying the fetus as a separate being
B.
Assuming caretaking responsibility for
the neonate
C.
Preparing to relinquish the neonate
through labor
D.
Accepting the biological fact of pregnancy

Rationale:  The first maternal psychological task of pregnancy is to accept the pregnancy as a biological fact. If the client doesn't accept that she's pregnant, she's unlikely to seek prenatal care. Identifying the fetus as a separate being usually occurs after the client feels fetal movements. Assuming caretaking responsibility for the neonate should occur during the postpartum period. Preparing to relinquish the neonate through labor normally occurs during the third trimester.

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?
A.
Suggesting that she walk for 1 hour twice
per day
B.
Advising her to take over-the-counter
calcium supplements twice per day
C.
Teaching her to dorsiflex her foot during
the cramp
D.
Instructing her to increase milk and cheese
intake to 8 to 10 servings per day

Rationale:  Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary.

During a nonstress test (NST), the nurse notes three fetal heart rate (FHR) increases of 20 beats/minute, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest?
A.
The client should undergo an oxytocin
challenge test
B.
The test is inconclusive and must be
repeated.
C.
The fetus is nonreactive and hypoxic.
D.
The fetus isn't in distress at this time.

Rationale:  In an NST, reactive (favorable) results include two to three FHR increases of 15 beats/minute or more, each lasting 15 seconds or more and occurring with fetal movement. An oxytocin challenge test is performed to stimulate uterine contractions and evaluate the FHR. If results are inconclusive, a nipple stimulation contraction test may be ordered. A nonreactive result occurs when the FHR doesn't rise 15 beats/minute or more over the specified time; a nonreactive result may indicate fetal hypoxia.

138. When determining maternal and fetal well-being, which of the following assessments is least important?
A.
Signs of postural hypotension
B.
Fetal heart rate and activity
C.
The mother's acceptance of growing
fetus
D.
Signs of facial or digital edema

Rationale:  Postural hypotension doesn't occur until late in the pregnancy and is easily correctable. Collection of other assessment data, such as fetal heart rate and activity, the mother's acceptance of the growing fetus, and signs of edema, should be started early in the pregnancy because abnormalities can put the mother or the fetus at risk for significant physiologic and psychological problems.

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:
A.
establishing a schedule of prenatal visits
B.
scheduling an ultrasound test to confirm
the pregnancy.
C.
enrolling the client in a childbirth class.
D.
scheduling genetic testing for the client.

Rationale:  To promote the health of the client and her fetus, the nurse should establish a regular schedule of prenatal visits. Pregnancy is confirmed by serum human chorionic gonadotropin levels, not ultrasonography. The client undergoes ultrasonography to evaluate fetal growth and 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:
A.
irregular contractions.
B.
increased fetal movement.
C.
changes in cervical effacement and
dilation after 1 to 2 hours
D.
contractions that feel like pressure in
the abdomen and groin.

Rationale:  True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours.

141. A client asks how long she and her husband can safely continue sexual activity during pregnancy. How should the nurse respond?
A.
"Until the end of the first trimester"
B.
"Until the end of the second trimester"
C.
"Until the end of the third trimester"
D.
"As long as you wish, if the pregnancy
is normal"

Rationale:  During a normal pregnancy, the client and her partner need not discontinue sexual activity. If the client develops complications that could lead to preterm labor, she and her partner should consult with a health practitioner for advice on the safety of sexual activity.

142. The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
A.
Presence of menses
B.
Uterine enlargement
C.
Breast sensitivity
D.
Fetal heart tones

Rationale:  Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.

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?
A.
"The client consumes no more than 2 oz
of alcohol daily."
B.
"The client consumes no more than 4 oz
of alcohol daily."
C.
"The client consumes 2 to 6 oz of alcohol
daily, depending on body weight."
D.
"The client consumes no alcohol."

Rationale:  A safe level of alcohol intake during pregnancy hasn't been established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose her to complications in early pregnancy.

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:
A.
"Now isn't a good time to begin
dieting because you are eating for two."
B.
"Let's explore your feelings further."
C.
"Nutrition is important because
depriving your baby of nutrients can
cause developmental and growth
problems."
D.
"The prenatal vitamins should ensure
the baby gets all the necessary
nutrients."

Rationale:  Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or baby needs; they work in congruence with a balanced diet.

145. A client, 2 months pregnant, has hyperemesis gravidarum. Which expected outcome is most appropriate for her?
A.
"Client will accept the pregnancy and
stop vomiting."
B.
"Client will gain weight according to
the expected pattern for pregnancy."
C.
"Client will remain hospitalized for
the duration of pregnancy to relieve
stress."
D.
"Client will exhibit uterine growth
within the expected norms for
gestational age."

Rationale:  For a client with hyperemesis gravidarum, the goal of nursing care is to achieve optimal fetal growth, which can be evaluated by monitoring uterine growth through fundal height assessment. The nurse shouldn't assume that excessive vomiting signifies the client doesn't accept the pregnancy. Clients with hyperemesis gravidarum rarely gain weight according to the expected pattern. They may be hospitalized briefly to regulate fluid and electrolyte status, but they don't require hospitalization for the duration of pregnancy. In fact, hospitalization may add to the stress of pregnancy by causing family separation and financial concerns.

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.
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
A.
Amenorrhea and quickening
B.
Uterine enlargement and Chadwick's sign
C.
A positive pregnancy test and a fetal
outline
D.
Braxton Hicks contractions and Hegar's
sign
Rationale:  Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators - for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators such as fetal outline on ultrasound confirm pregnancy

148. At what gestational age would a primigravida expect to feel quickening?
A.
12 weeks
B.
16 to 18 weeks
C.
20 to 22 weeks
D.
By the end of the 26th week

Rationale:  It's important for the nurse to distinguish between a client who's having her first baby and one who has already had a baby. For the client who's pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations.

149. A pregnant client who's diabetic is at risk for having a large-for-gestational-age infant because of which of the following?
A.
Excess sugar causing reduced
placental functioning
B.
Insulin acting as a growth hormone
on the fetus
C.
Maternal dietary intake of high
calories
D.
Excess insulin reducing placental
functioning

Rationale:  Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.

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?
A.
"It's contraindicated for you to breast-feed
following this type of surgery."
B.
"I support your commitment; however,
you may have to supplement each feeding
with formula."
C.
"You should check with your surgeon to
determine whether breast-feeding would be
possible."
D.
"You should be able to breast-feed without
difficulty."

Rationale:  Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so 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?
A.
Temperature elevation
B.
Vaginal bleeding
C.
Nausea and vomiting
D.
Abdominal pain

Rationale:  Abdominal pain is the most common finding in ectopic pregnancy, occurring in over 90% of women with this antepartum complication. Temperature elevation, vaginal bleeding, and nausea and vomiting are less commonly associated with ectopic pregnancy.

152. Which of the following is the approximate time that the blastocyst spends traveling to the uterus for implantation?
A.
2 days
B.
7 days
C.
10 days
D.
14 weeks

Rationale:  The blastocyst takes approximately 1 week to travel to the uterus for implantation. The other options are incorrect. 

153. When evaluating a pregnant client's fundal height, the nurse should measure in which way?
A.
Across the abdomen laterally
B.
From the symphysis pubis notch to
the umbilicus
C.
With a pelvimeter designed to measure
fundal height
D.
From the symphysis pubis notch to
the highest level of the fundus

Rationale:  To measure fundal height, the nurse should stretch a measuring tape over the client's enlarged abdomen and measure from the symphysis pubis notch to the highest level of the fundus, determined by palpation. Measuring across the abdomen and measuring from the symphysis pubis to the umbilicus are incorrect procedures for measuring fundal height. A pelvimeter is used to evaluate the size of the maternal pelvis for delivery, not fundal height.

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:
A.
may not take care of herself.
B.
may not be fit to take care of a child.
C.
needs to take up a second job.
D.
should be referred to community
resources available for pregnant women.

Rationale:  The client needs to know that resources are available to her, and the nurse should help her to find those resources. Health care can be costly but it doesn't necessarily mean that the client has no interest in caring for herself or her child. Taking up a second job doesn't necessarily solve this situation.

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?
A.
Abruptio placentae
B.
Preterm labor
C.
Placenta previa
D.
Threatened abortion

Rationale:  Placenta previa is associated with painless vaginal bleeding that occurs when the placenta or a portion of the placenta covers the cervical os. In abruptio placentae, the placenta tears away from the wall of the uterus before delivery; the client usually has pain and a boardlike uterus. Preterm labor is associated with contractions and shouldn't involve bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks' gestation.

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?
A.
At the beginning of each fetal
movement
B.
At the beginning of each contraction
C.
After every three fetal movements
D.
At the end of fetal movement

Rationale:  An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn't allow accurate comparison of fetal movement and FHR changes.

157. The nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole?
A.
Rapid fetal heart tones
B.
Abnormally high human chorionic
gonadotropin (HCG) levels
C.
Slow uterine growth
D.
Lack of symptoms of pregnancy

Rationale:  In a pregnant woman with a hydatidiform mole, the trophoblast villi proliferate and then degenerate. Proliferating trophoblast cells produce abnormally high HCG levels. No fetal heart tones are heard because there is no viable fetus. Because there is rapid proliferation of the trophoblast cells, the uterus grows fast and is larger than expected for a given gestational date. Because of the greatly elevated HCG levels, a woman with hydatidiform mole often has marked nausea and vomiting.

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?
A.
Both estrogen and progesterone levels
are rising
B.
The estrogen level is much higher than
the progesterone level.
C.
Both estrogen and progesterone levels
are declining.
D.
The estrogen level is much lower than
the progesterone level.

Rationale:  Until the 7th month of pregnancy, both estrogen and progesterone are secreted in progressively greater amounts. Between the 7th and 9th months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio promotes the onset of uterine contractions.

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:
A.
switch brands.
B.
take the vitamin on a full stomach.
C.
take the vitamin with orange juice
for better absorption.
D.
take the vitamin first thing in the
morning.

Rationale:  Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.

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?
A.
Examine the vagina to determine
whether her client is in labor.
B.
Assess the location and consistency
of the uterus
C.
Perform an ultrasound to determine
placental placement.
D.
Prepare for immediate delivery.

Rationale:  The nurse must determine whether placenta previa or abruptio placentae is the problem. (Fifty percent of all clients with hypertension will develop abruptio placenta.) In this case, the presenting symptoms are highly suggestive of an abruption, so the nurse must determine the level of the uterus and mark that level on the client's abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because the placenta has detached early is rigid. Bleeding from a placental previa is usually painless. A vaginal examination is contraindicated in the presence of bleeding. Most nurses haven't been taught how to perform an ultrasound. If the client has a placental abruption, birth will most likely be by cesarean section.

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?
A.
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?
A.
"8 days after conception"
B.
"When the woman misses a menstrual
period"
C.
"2 to 3 weeks after fertilization"
D.
"As soon as hormone levels decline"

Rationale:  Based on human chorionic gonadotropin (hCG) levels in the blood and urine, pregnancy can be diagnosed as early as 8 days after conception, when the syncytiotrophoblast produces hCG. Sensitive and specific pregnancy tests can detect hCG in the blood and urine even before the first missed menstrual period. A missed period may also be related to other factors, such as poor nutrition, strenuous athletic activity, and certain drugs. Levels of hCG rise rapidly until about the 20th week of gestation. By the 20th week, they decline gradually and stay low for the remainder of gestation. Other hormones, such as human placental lactogen, estrogen, and progesterone, increase during pregnancy.

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:
A.
be able to suck and swallow
B.
open the eyes.
C.
have audible heart sounds.
D.
have open nostrils.

Rationale:  Fetal heart tones are usually audible with a fetoscope between 16 and 20 weeks' gestation. The fetus can suck and swallow at about 20 weeks' gestation. The eyes are open at approximately 28 weeks' gestation. The nostrils are open at about 21 to 28 weeks' gestation.

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?
A.
7 days after fertilization
B.
14 days after fertilization
C.
21 days after fertilization
D.
28 days after fertilization

Rationale:  Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium. During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the 3rd week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures - the primitive streak, notochord, and allantois - form. Early during the 4th week (28 days after implantation), cellular differentiation and organization occur.

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?
A.
"Tell your son about the childbirth about
1 month before your due date."
B.
"Reassure your son that nothing is going
to change."
C.
"Reprimand your son if he displays
immature behavior."
D.
"Involve your son in planning and
preparing for a sibling."

Rationale:  Being involved in the pregnancy helps reinforce a child's position in the family and minimizes feelings of neglect and abandonment. Telling the child about the childbirth only 1 month before the due date wouldn't allow enough time to prepare him for the sibling and would prevent him from conceptualizing the passage of time. Reassuring him that nothing will change would be misleading; instead, the parents should discuss which aspects of family life will be changed by the upcoming birth and which will remain the same. Parents should reward mature behavior and ignore immature behavior.

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?
A.
"Return to the clinic for a checkup
in 6 weeks."
B.
"Abstain from sexual intercourse
unless you use a condom."
C.
"You can return to your job as a
hairdresser in 2 weeks."
D.
"Take the medication as needed
whenever contractions occur."

Rationale:  A client who's predisposed to preterm labor should abstain from sexual intercourse unless she uses a condom because semen contains prostaglandins that stimulate uterine contractions. A client receiving ritodrine should return to the clinic in 1 to 2 weeks for a regular checkup and evaluation for preterm labor. Returning to work - especially to a job that involves much standing - is contraindicated immediately after preterm labor. Ritodrine must be taken regularly to prevent recurrence of preterm labor.

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?
A.
12 weeks
B.
19 weeks
C.
24 weeks
D.
28 weeks

Rationale:  The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.

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?
A.
Hemorrhoids
B.
Blurred vision
C.
Dyspnea on exertion
D.
Increased vaginal mucus

Rationale:  During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they don't require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

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?
A.
Signs and symptoms of labor
B.
Quickening and fetal movements
C.
Warning signs of complications
D.
False labor and true labor

Rationale:  In early childbirth education classes, instruction on the physiologic aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development. Signs and symptoms of labor, quickening and fetal movements, and false and true labor are discussed in later classes.

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