ANTEPARTUM
51. A pregnant client asks the nurse whether she
can take castor oil for her constipation. How should the nurse respond?
"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?
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?
"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?
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?
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?
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?
"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?
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:
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?
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?
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?
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:
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?
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:
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:
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?
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?
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?
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?
"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?
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:
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?
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?
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:
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?
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?
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?
"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:
"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?
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?
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?
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?
"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:
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?
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?
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?
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?
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?
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:
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?
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?
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?
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
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?
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?
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?
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:
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:
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?
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.