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Monday, May 21, 2012

Exam Notes: MCHN - Antepartum Period PART 2


ANTEPARTUM

51. A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
A.
"Yes, it produces no adverse effects."
B.
"No, it can initiate premature uterine
contractions."
C.
"No, it can promote sodium retention."
D.
"No, it can lead to increased absorption
of fat-soluble vitamins."

Rationale:  Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn't promote sodium retention. Castor oil isn't known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.

52. Infertility in a 25-year-old couple is defined as which of the following?
A.
The couple's inability to conceive
after 6 months of unprotected
attempts
B.
The couple's inability to sustain a
pregnancy
C.
The couple's inability to conceive
after 1 year of unprotected attempts
D.
A low sperm count and decreased
motility

Rationale:  The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse.

53. When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
A.
"I'll report increased frequency of
urination."
B.
"If I have blurred or double vision,
I should call the clinic immediately."
C.
"If I feel tired after resting, I should
report it immediately."
D.
"Nausea should be reported
immediately."

Rationale:  Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.

54. The nurse is developing a plan of care for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?
A.
Encouraging ambulation
B.
Serving a nutritious diet
C.
Promoting adequate hydration
D.
Performing nipple stimulation

Rationale:  Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.

55. The nurse is assessing a client who's 6 weeks pregnant. Which findings best support a suspicion of ectopic pregnancy?
A.
Amenorrhea and adnexal fullness and
tenderness
B.
Nausea, vomiting, and slight uterine
enlargement
C.
Grapefruit-size uterine enlargement and
vaginal spotting
D.
Amenorrhea, sudden weight gain, and
audible fetal heart tones above the
symphysis pubis

Rationale:  Signs and symptoms of ectopic pregnancy include amenorrhea and adnexal fullness and tenderness. Nausea, vomiting, and vaginal spotting may occur in ectopic pregnancy, but the uterus doesn't enlarge because it remains empty. Weight gain may accompany ectopic pregnancy; however, fetal heart tones aren't audible above the symphysis pubis in clients with this disorder.

56. A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to do which of the following?
A.
Slow contractions
B.
Enhance fetal growth
C.
Prevent infection
D.
Promote fetal lung maturation

Rationale:  Betamethasone is given to promote fetal lung maturity by enhancing the production of surface-active lipoproteins. It has no effect on contractions, fetal growth, or infection.

57. A client with type 1 diabetes mellitus has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide?
A.
"Insulin requirements don't change
during pregnancy. Continue your
current regimen."
B.
"Insulin requirements usually decrease
during the last two trimesters."
C.
"Insulin requirements usually decrease
during the first trimester."
D.
"Insulin requirements increase greatly
during labor."

Rationale:  Maternal insulin requirements usually decrease during the first trimester from rapid fetal growth and maternal metabolic changes, necessitating adjustment of the insulin dosage. Maternal insulin requirements fluctuate throughout pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish from extreme maternal energy expenditure.

58. A client who's 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client isn't in labor. Which nursing intervention should the nurse perform?
A.
Allow the client to ambulate with
assistance
B.
Perform a vaginal examination to check
for cervical dilation
C.
Monitor the amount of vaginal blood loss.
D.
Notify the physician for a fetal heart rate
of 130 beats/minute.

Rationale:  Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.

59. A client tells the nurse that she suspects her amniotic membranes broke 2 hours ago. Because the goal of care for this client is to prevent infection (chorioamnionitis), the plan of care should include:
A.
assessing the fetal heart rate once
every hour.
B.
limiting vaginal examinations to once
every hour.
C.
assessing vital signs, especially temperature,
every 4 hours.
D.
confirming membrane rupture by
using a sterile speculum and
cotton-tipped applicator to assess
fluid.

Rationale:  To prevent infection, the nurse must use sterile technique to assess amniotic fluid and thus confirm membrane rupture. The nurse should assess the fetal heart rate every 30 minutes because fetal tachycardia signals chorioamnionitis. Vaginal examinations introduce bacteria into the vagina and should be performed only when necessary - for example, before narcotic administration and to assess suspected cord prolapse. The nurse should assess vital signs, especially temperature and pulse, every 2 hours to detect early signs of infection.

60. Which drug will the physician probably order to treat a pregnant client who is experiencing morning sickness?
A.
Prochlorperazine (Compazine)
B.
Diphenhydramine (Benadryl)
C.
Trimethobenzamide (Tigan)
D.
Phosphorated carbohydrate solution
(Emetrol

Rationale:  The physician will probably order phosphorated carbohydrate solution for a pregnant client who is experiencing morning sickness. Prochlorperazine, diphenhydramine, and trimethobenzamide may produce congenital anomalies and aren't recommended to treat morning sickness caused by pregnancy.

61. A pregnant client in her second trimester visits the health care practitioner for a regular prenatal checkup. During the assessment, the nurse weighs the client, then compares her current and previous weights. During the second trimester, how much weight should the client gain per week?
A.
0.5 lb (0.23 kg)
B.
1 lb (0.45 kg)
C.
1.5 lb (0.68 kg)
D.
2 lb (.91 kg)

Rationale:  During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A woman with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy.

62. The nurse is assessing a client who's 29 weeks pregnant. What is the least invasive and demanding method for assessing fetal well-being?
A.
Maternal fetal activity count
B.
Chorionic villi sampling
C.
Ultrasonography
D.
Nonstress test

Rationale:  Maternal fetal activity count is the least invasive and demanding method for assessing fetal well-being. To use this method, the client simply counts, records, and reports the number of times the fetus kicks during a designated period each day. Chorionic villi sampling is invasive and expensive and should be reserved for pregnant clients at risk for genetic defects. Ultrasonography and nonstress testing, although noninvasive, are expensive and require the use of medical facilities, which may place extra demands on the client's time.

63. A client who's 5 weeks pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:
A.
5 to 8 weeks' gestation.
B.
9 to 12 weeks' gestation.
C.
14 to 17 weeks' gestation.
D.
18 to 22 weeks' gestation.

Rationale:  Nausea, vomiting, urinary frequency, and urinary urgency normally subside between 9 and 12 weeks' gestation

64. A pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and performing a physical examination, the nurse reviews the client's laboratory test results. Which findings suggest iron deficiency anemia?
A.
Hemoglobin (Hb) 15 g/L;
hematocrit (HCT) 33%
B.
Hb 13 g/L; HCT 32%
C.
Hb 10 g/L; HCT 35%
D.
Hb 9 g/L; HCT 30

Rationale:  With iron deficiency anemia, the Hb level is below 11 g/L and HCT drops below 32%.

65. The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:
A.
the delivery may need to be induced
early.
B.
the delivery must be by cesarean.
C.
the mother will carry to term safely.
D.
it's too early to tell

Rationale:  Early induction or early cesarean are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary.

66. A woman who's 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:
A.
recognize these as normal early pregnancy
signs and symptoms.
B.
question her further about these signs and
symptoms.
C.
tell her that she'll need blood work and
urinalysis
D.
tell her that she may be excessively
worried.

Rationale:  Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.

67. What is the primary nursing diagnosis for a client with a ruptured ectopic pregnancy?
A.
Anxiety
B.
Pain
C.
Deficient fluid volume
D.
Anticipatory grieving

Rationale:  Ruptured ectopic pregnancy is associated with hemorrhage and requires immediate surgical intervention; therefore, Deficient fluid volume is the primary diagnosis. The other options are correct but aren't the primary nursing diagnosis. This client is probably experiencing anxiety because this is a surgical emergency. Pain is also present and should be addressed as warranted. The client with ruptured ectopic pregnancy may experience anticipatory grieving at the loss of her fetus.

68. A client is admitted for an amniocentesis. Initial assessment findings include the following: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 gm, hematocrit 35%, and type O-negative blood. Which of the following actions would be most important to include in the client's plan of care after the 20-minute amniocentesis has been completed?
A.
Administer RhoGAM.
B.
Check for rupture of membranes.
C.
Assess uterine activity.
D.
Provide additional fluid.

Rationale:  To prevent maternal sensitization, RhoGAM must be given after any invasive procedure on an Rh-negative client. All the other aspects are important but the administration of RhoGAM is the priority.

69. The nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect?
A.
Absent pedal pulses
B.
Bilateral dependent edema
C.
Sluggish capillary refill
D.
Unilateral calf enlargement

Rationale:  As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.

70. During her fourth clinic visit, a client who's 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond?
A.
"Yes but immunization against rubella
requires a physician's order."
B.
"No because the live viral vaccine is
contraindicated during pregnancy."
C.
"Yes and you should consider pregnancy
termination because rubella has teratogenic
effects."
D.
"No because the vaccine can be given
only during the first trimester."

Rationale:  Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus, which can have teratogenic effects on the fetus. Needing a physician's order isn't a valid reason for withholding an immunization. Recommending pregnancy termination forces the nurse's viewpoint on the client rather than allowing the client to decide for herself. Exposure to rubella virus may have teratogenic effects if the client is exposed during the first trimester.

71. The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?
A.
They're regular.
B.
They're usually felt in the abdomen.
C.
They start in the back and radiate to the
abdomen
D.
They become more intense during walking.

Rationale:  Prelabor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking.

72. A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but is concerned because she herself isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by:
A.
referring her to counseling.
B.
telling her such feelings are normal
in the beginning of pregnancy
C.
exploring her feelings.
D.
recommending she talk her feelings
over with her husband.

Rationale:  Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time.

73. The nurse is reviewing a client's prenatal history. Which finding indicates a genetic risk factor?
A.
The client is 25 years old.
B.
The client has a child with cystic
fibrosis.
C.
The client was exposed to rubella at
36 weeks' gestation.
D.
The client has a history of preterm
labor at 32 weeks' gestation.

Rationale:  Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age isn't a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history of preterm labor may place the client at risk for preterm labor, it doesn't correlate with genetic defects.

74. When should a client who's Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies receive Rh(D) human immunoglobulin (RhIg) to prevent isoimmunization?
A.
At about 28 weeks' gestation only
B.
Within 72 hours after delivery only
C.
At about 28 weeks' gestation and again
within 72 hours after delivery
D.
At about 32 weeks' gestation and again
within 24 hours after delivery

Rationale:  A client who's Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies should receive RhIg at about 28 weeks' gestation and again within 72 hours after delivery. Giving RhIg only at 28 weeks' gestation wouldn't prevent isoimmunization from occurring after placental separation, when fetal blood enters the maternal circulation. Giving RhIg only within 72 hours after delivery wouldn't prevent isoimmunization caused by passage of fetal blood into the maternal circulation during gestation. Giving RhIg at 32 weeks' gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies already have formed by then. Giving RhIg within 24 hours after delivery would be too soon because maternal sensitization occurs in approximately 72 hours.

75. At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal:
A.
edema.
B.
fever.
C.
glycosuria.
D.
vomiting.

Rationale:  Classic signs of PIH include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with various disorders.

76.  A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?
A.
Edema
B.
Pelvic adequacy
C.
Rh factor changes
D.
Hemoglobin alterations

Rationale:  At each prenatal visit, the nurse should assess the client for edema because edema, increased blood pressure, and proteinuria are cardinal signs of pregnancy-induced hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation.

77. A client is in the 8th month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?
A.
Right lateral
B.
Left lateral
C.
Supine
D.
Semi-Fowler's

Rationale:  The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

78. During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions?
A.
"I'll decrease my intake of green, leafy
vegetables."
B.
"I'll limit fluid intake to four 8-oz
glasses."
C.
"I'll increase my intake of unrefined
grains."
D.
"I'll take iron supplements regularly."

Rationale:  To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids. The use of iron supplements can cause - rather than relieve - constipation.

79. The nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask:
A.
"Do you have any cats at home?"
B.
"Do you have any birds at home?"
C.
"Have you recently had a rubeola
vaccination?"
D.
"Have you ever had osteomyelitis?"

Rationale:  TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus - agents that may infect the fetus or newborn, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.

80. The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?
A.
7 weeks
B.
11 weeks
C.
17 weeks
D.
21 weeks

Rationale:  Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation.

81. The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her baby?
A.
Encourage breast-feeding so that she can
get her rest and get healthier.
B.
Encourage breast-feeding because it's
healthier for the baby
C.
Encourage breast-feeding to facilitate
bonding.
D.
Discourage breast-feeding because HIV
can be transmitted through breast milk.

Rationale:  Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.

82. During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client?
A.
Activity intolerance related to decreased
tissue oxygenation
B.
Risk for infection related to metabolic and
vascular abnormalities
C.
Imbalanced nutrition: Less than body
requirements related to limited food intake
D.
Impaired gas exchange related to
respiratory effects of substance abuse

Rationale:  A substance abuser may spend more money on drugs than on food and other basic needs, leading to a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to limited food intake. Activity intolerance might be a relevant nursing diagnosis if the client were having trouble sleeping or getting adequate rest; however, activity intolerance wouldn't be related to decreased tissue oxygenation in this case. If the client were an I.V. drug abuser, a diagnosis of Risk for infection related to I.V. drug use might be appropriate. Because the question doesn't specify how the client is using cocaine, a diagnosis of Impaired gas exchange related to respiratory effects of substance abuse is inappropriate.

83. A 30-year-old primiparous client at 34 weeks' gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they're permanent. What should the nurse tell her?
A.
"These streaks are called linea nigra;
they'll fade after childbirth."
B.
"These streaks are called
hemangiomas; they're permanent
changes of pregnancy."
C.
"These streaks are called striae
gravidarum, or stretch marks;
they'll grow lighter after delivery."
D.
"These streaks are called nevi;
they'll fade after the postpartum
period."

Rationale:  The client's weight gain and enlarging uterus, combined with the action of adrenocorticosteroids, lead to stretching of the underlying connective tissue of the skin, creating striae gravidarum in the second and third trimesters. Better known as stretch marks, these streaks develop most often in skin covering the breasts, abdomen, buttocks, and thighs. After delivery, they typically grow lighter. Linea nigra is a dark line that extends from the umbilicus or above to the mons pubis. In the primigravid client, this line develops at approximately the 3rd month of pregnancy. In the multigravid client, linea nigra typically appears before the 3rd month. Tiny bright hemangiomas may occur during pregnancy as a result of estrogen release. They're called vascular spiders because of the branching pattern that extends from each spot. Nevi are circumscribed, benign proliferations of pigment-producing cells in the skin.

84. When teaching a group of pregnant teens about reproduction and conception, the nurse is correct when stating that fertilization occurs:
A.
in the uterus.
B.
when the ovum is released.
C.
near the fimbriated end.
D.
in the first third of the fallopian tube.

Rationale:  Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.

85. When performing a vaginal examination on a pregnant client, the nurse determines that the biparietal diameter of the fetal head has reached the pelvic inlet. Which statement best describes the position of the fetus at this time?
A.
It's at the ischial spines.
B.
It's at first station.
C.
It's engaged.
D.
It's floating.

Rationale:  The largest part of the fetus's head, the presenting part, is marked by the biparietal diameter. The largest part of the head is accommodated by the largest part of the passage - the pelvic inlet. Engagement refers to entry of the fetus's head or presenting part into the superior pelvic strait, which is marked by the pelvic inlet. When the fetus's head is at the level of the ischial spines, it's at the pelvic outlet. The ischial spines are designated as zero station. A floating fetus hasn't yet entered the pelvic inlet.

86. A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
A.
Report a heart rate greater than
120 beats/minute to the physician
B.
Take terbutaline every 4 hours,
during waking hours only.
C.
Call the physician if the fetus moves
10 times in an hour.
D.
Increase activity daily if not fatigued.

Rationale:  Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.

87. The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?
A.
On the day of discharge
B.
When the client expresses readiness
to leave the hospital.
C.
When the client's vomiting has stopped
D.
On admission to the facility

Rationale:  Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge won't be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Such factors as when the client stops vomiting and expresses readiness to learn shouldn't influence when the nurse begins discharge planning.

88. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?
A.
Make an appointment because the client
needs to be evaluated.
B.
Explain that these are expected problems
for the latter stages of pregnancy.
C.
Arrange for the client to be admitted to
the birth center for delivery.
D.
Tell the client to go to the hospital; she
may be experiencing signs of heart
failure from a 45% to 50% increase in
blood volume.

Rationale:  The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client doesn't need to be seen or admitted for delivery.

89. While caring for pregnant adolescents, the nurse should develop a plan of care that incorporates which health concern?
A.
Age of menarche
B.
Family and home life
C.
Healthy eating habits
D.
Level of emotional maturity

Rationale:  When assessing an adolescent initially, the nurse should try to determine the client's level of emotional maturity. This forms the basis for the nursing plan of care. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the client.

90. The nurse is caring for a client after evacuation of a hydatidiform molar pregnancy. The nurse should tell the woman to:
A.
wait 1 month before trying to
become pregnant again.
B.
make an appointment for follow-up
human chorionic gonadotropin (HCG)
level monitoring at the end of 1 year.
C.
discuss options for sterilization with
the physician.
D.
use birth control for at least 1 year.

Rationale:  After experiencing a hydatidiform molar pregnancy, the client should be counseled to use a reliable method of birth control for at least 1 year. Because of the risk of choriocarcinoma, her HCG levels need to be monitored monthly for 1 to 2 years. Sterilization isn't necessary after hydatidiform mole. If HCG levels remain low, a woman may try to become pregnant after 1 year. The risk of recurrence of a hydatidiform mole is low.

91. A client is in the 38th week of her first pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action?
A.
Review premonitory signs of labor with
the client.
B.
Instruct the client to go the health care
facility for a nonstress test (NST).
C.
Ask the client to bring in a urine specimen
for urinalysis
D.
Make an appointment for the client to see
the physician today.

Rationale:  Because the client is describing two premonitory signs of labor, Braxton Hicks contractions and tightening, the nurse should review these normal signs and reassure the client. An NST, used to assess fetal well-being, would be inappropriate unless the client reported changes in fetal activity. Urinalysis wouldn't be indicated unless the client reported symptoms of bladder inflammation, such as dysuria or urinary frequency or urgency. Because the client's findings are normal, she need not see the physician other than at her regular weekly appointment.

92. A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her?
A.
This symptom is abnormal during the
third trimester and may indicate a urinary
tract infection.
B.
This symptom is a normal variation and
is easily managed by limiting fluid intake.
C.
This symptom is normal and results from
the fetus exerting pressure on the bladder.
D.
This symptom is abnormal and should
subside after the presenting part of the
fetus is engaged.

Rationale:  During the first trimester, hormonal changes and uterine pressure on the bladder cause urinary frequency and urgency. During the second trimester, when the uterus rises out of the pelvis, urinary symptoms abate. However, as term approaches, pressure on the bladder by the presenting part of the fetus again causes urinary frequency and urgency. Urinary frequency isn't abnormal unless accompanied by other urinary symptoms, such as burning and pain. Fluids shouldn't be limited during pregnancy. Urinary frequency doesn't subside after the presenting part is engaged. Instead, the presenting part exerts pressure on the bladder.

93. At 15 weeks' gestation, a client is scheduled for a serum alpha-fetoprotein (AFP) test. Which maternal history finding best explains the need for this test?
A.
Family history of spina bifida in a
sister
B.
Family history of Down syndrome on
the father's side
C.
History of gestational diabetes during
a previous pregnancy
D.
History of spotting during the 1st
month of the current pregnancy

Rationale:  An abnormally high AFP level in the client's serum or amniotic fluid suggests a neural tube defect such as spina bifida. A family history of such defects increases the risk of carrying a fetus with a neural tube defect. Although a low AFP level has been correlated with Down syndrome, it isn't the most accurate indicator. No known correlation exists between gestational diabetes or early vaginal spotting and a certain AFP level at 15 to 20 weeks' gestation.

94. A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from:
A.
a neurologic disorder.
B.
inadequate nutrition.
C.
an unknown cause.
D.
hemolysis of fetal red blood cells (RBCs).

Rationale:  The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.

95. A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action?
A.
Administer amnioinfusion
B.
Prepare for cesarean delivery
C.
Reposition the client.
D.
Start I.V. oxytocin infusion as
prescribed

Rationale:  Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean delivery. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.

96. When providing health teaching to a primigravid client, the nurse tells the client that she's likely to first experience Braxton Hicks contractions. When do these contractions typically begin?
A.
Between 18 and 22 weeks' gestation
B.
Between 23 and 27 weeks' gestation
C.
Between 28 and 31 weeks' gestation
D.
Between 32 and 35 weeks' gestation

Rationale:  Braxton Hicks contractions typically begin between 23 and 27 weeks' gestation. The fetal heartbeat typically can be heard and fetal rebound is possible between 18 and 22 weeks. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks.

97. A pregnant client asks the nurse about the percentage of congenital anomalies caused by drug exposure. How should the nurse respond?
A.
1%
B.
10%
C.
20%
D.
60%

Rationale:  Drug exposure causes 1% of congenital anomalies.

98. A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:
A.
milk and ice pops.
B.
decaffeinated coffee and scrambled
eggs.
C.
tea and gelatin dessert.
D.
apple juice and oatmeal.

Rationale:  A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.

99. The nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat:
A.
grains and milk.
B.
tomatoes and fish.
C.
eggs and citrus fruit.
D.
spinach and beef.

Rationale:  Common food sources of iron include spinach, beef, liver, prunes, pork, broccoli, legumes, and whole wheat breads and cereals. Grains are good sources of carbohydrates; milk is high in vitamin D; and fish, eggs, and milk are high in protein. Tomatoes and citrus fruits are high in vitamins A and C.

100. Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which intervention by the nurse is most appropriate for this client?
A.
Provide her with the information and
teach her the skills she'll need to
understand and cope during birth.
B.
Provide her with written information
about the birthing process.
C.
Have a more experienced pregnant
woman assist her.
D.
Do nothing in hopes that she'll begin
coping as the pregnancy progresses.
Rationale:  Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs.

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