Antepartum NCLEX Test Bank Questions with Answers and Rationales. 100% proven pass rate, 2022/2023

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Antepartum NCLEX Test Bank Questions with Answers and Rationales A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client th... at fetal circulation consists of: 1.Two umbilical veins and one umbilical artery 2.Two umbilical arteries and one umbilical vein 3.Arteries carrying oxygenated blood to the fetus 4.Veins carrying deoxygenated blood to the fetus - 2. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus. The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida 2. The client has a history of cardiac disease 3. The client's hemoglobin level is 13.5 g/dL 4. The client is a 20-year-old primigravida of average weight and height - 2. The client has a history of cardiac disease Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years. A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present? 1. Soft uterus 2. Abdominal pain 3. Nontender uterus4. Painless vaginal bleeding - 2. Abdominal pain Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa. The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2. "Meat does not provide iron and should be avoided." 3. "The iron is best absorbed if taken on an empty stomach." 4. "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement." - 3. "The iron is best absorbed if taken on an empty stomach." Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach with water or a vitamin C containing juice. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake. A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action? 1. Instruct the client to avoid walking. 2. Assess for signs of venous thrombosis. 3. Instruct to elevate the legs throughout the day. 4. Tell the client that this is normal during pregnancy. - 2. Assess for signs of venous thrombosis. If a woman complains of calf pain during walking, it could be an indication of venous thrombosis of the lower extremities. The most appropriate nursing action would be to check for the presence of additional signs of venous thrombosis. It is not appropriate to tell the mother that this is normal during pregnancy. Ambulation is a necessary exercise,and the woman should be encouraged to ambulate during pregnancy. Although it is important to elevate the legs during pregnancy, elevating the legs consistently is not the most appropriate nursing action. The prenatal clinic nurse asks a coassigned nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if he or she makes which statement? 1. "An increase in pulse rate occurs." 2. "A decrease in blood volume occurs." 3. "A decrease in cardiac output occurs." 4. "The systolic and diastolic blood pressures increase by 20 mm Hg." - 1. "An increase in pulse rate occurs." Between 14 and 20 weeks' gestation, the maternal pulse rate increases slowly, up to 10 to 15 beats/min, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy. The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. What is the best response by the nurse? 1. "It causes the cessation of menstruation." 2. "It is pain that occurs during ovulation." 3. "It is the presence of tissue outside the uterus that resembles the endometrium." 4. "It is also known as primary dysmenorrhea and causes lower abdominal discomfort." - 3. "It is the presence of tissue outside the uterus that resembles the endometrium." Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods, and amenorrhea is the cessation of menstruation for at least three cycles or 6 months in a woman who has an established a pattern of menstruation. Amenorrhea can be caused by a variety of factors.The nurse in the prenatal clinic is conducting a session about nutrition to a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? 1. Eat only when hungry. 2. Eliminate snacks during the day. 3. Avoid meals in fast-food restaurants. 4. Monitor for appropriate weight gain patterns. - 4. Monitor for appropriate weight gain patterns. The nurse should appropriately teach the adolescent about appropriate weight patterns and how to monitor these patterns. The adolescent is more likely to follow suggestions and adhere to the appropriate dietary patterns if the nurse explains why the weight gain is important for the fetus as well as the mother. Advising an adolescent to eat only when hungry could lead to a deficit in nutrients. Telling an adolescent to avoid fast-food restaurants and eliminate snacks may cause the adolescent to rebel. The nurse in a health care clinic is instructing a client how to perform kick counts. Which statement made by the client indicates a need for further teaching? 1. "I should lie on my back to perform the procedure." 2. "I will use a clock or a timer and record the number of movements or kicks." 3. "I should count the fetal movements for 30 to 60 minutes three times a day." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks." - 1. "I should lie on my back to perform the procedure." In general, a client is advised to count the fetal movements for 30 to 60 minutes three times a day. The client should lie on her side. The client is instructed to place her hands on the largest part of her abdomen and concentrate on the fetal movements. The client should use a timer or a clock, and should record the number of movements felt during that time. The clinic nurse is teaching a pregnant woman about the warning signs in pregnancy. Which, if identified as a warning sign by the woman, would indicate a need for further education? 1. Rapid weight gain 2. Visual disturbances3. Generalized or facial edema 4. Presence of irregular painless contractions - 4. Presence of irregular painless contractions Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout pregnancy. Rapid weight gain, visual disturbances, and generalized or facial edema are warning signs in pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection. The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks of gestation. Which information should the nurse discuss with the client? Select all that apply. 1. Plan induction at 35 weeks. 2. Plan amniocentesis at this time. 3. Schedule biophysical profile immediately. 4. Plan for weekly non-stress test at 32 weeks. 5. Obtain nutritional counseling with a dietitian. - 4. Plan for weekly non-stress test at 32 weeks. 5. Obtain nutritional counseling with a dietitian. Gestational diabetes can result in delayed lung maturity and complications. The nurse should discuss non-stress testing procedures, the plan for nutritional counseling, and the plan for delivery. Amniocentesis is not indicated at this time. Biophysical profile is done at 32 to 36 weeks of gestation. The nurse is performing an assessment on a pregnant client at 16 weeks of gestation. On assessment, the nurse expects the fundus of the uterus to be located at which area? 1. At the umbilicus 2. Just above the symphysis pubis 3. At the level of the xiphoid process4. Midway between the symphysis pubis and the umbilicus - 4. Midway between the symphysis pubis and the umbilicus At 16 weeks' gestation, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks' gestation, the fundus is located at the umbilicus. At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process. A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging in the 130/90 mm Hg range. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1. "My vision the past 2 days has been really fuzzy." 2. "The swelling in my hands and ankles has gone down." 3."I had heartburn yesterday after I ate some spicy foods." 4. "I had a headache yesterday, but I took some acetaminophen (Tylenol) and it went away." - 1. "My vision the past 2 days has been really fuzzy." Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia. The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action? 1. Contracting and then consciously relaxing different muscle groups 2. Massaging the abdomen during contractions, using both hands in a circular motion 3. Instructing her partner to stroke or massage a tightened muscle by the use of touch 4. Contracting an area of the body, such as an arm or leg, and then concentrating on letting tension go from the rest of the body - 2. Massaging the abdomen during contractions, using both hands in a circular motionEffleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Touch relaxation helps the woman learn to loosen taut muscles when she is touched by her partner. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body. A nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid? 1. Rice 2. Cheese 3. Chicken 4. Green leafy vegetables - 4. Green leafy vegetables Of the choices available, green leafy vegetables are highest in folic acid. Other sources of folic acid include whole grains, fruits, liver, dried peas, and beans. Chicken, rice, and cheese are not high in folic acid. Cheese is high in calcium, and rice and chicken are good sources of iron. The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. "I should wear panty hose." 2. "I should wear support hose." 3. "I should wear flat nonslip shoes that have good support." 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours." - 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours." Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize falls.The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding - 2. Uterine tenderness Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client? 1. "The test is an invasive procedure and requires that you sign an informed consent." 2. "The fetus is challenged by uterine contractions to obtain the necessary information." 3. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." - 4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." The nonstress test takes about 30 to 40 minutes. The test is termed nonstress because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded.A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent - 1. The appearance of the fetal external genitalia By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the gender of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eighth week. Internal differences in the male and female occur at the end of the seventh week. Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby. - 1. It cushions and protects the baby. The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP).4. Tell the client that the fetal heart rate is normal. - 2. Check the mother's heart rate. The fetal heart rate (FHR) depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified. A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, would indicate that she understands her needs? 1. "My weight gain is not important." 2. "I should avoid stressful situations." 3. "I should rest by lying on my back." 4. "There is no restriction on people who visit me." - 2. "I should avoid stressful situations." Stress causes increased heart workload, and the client should be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return. To avoid infections, individuals with active infections should not be allowed to visit the client. Otherwise restrictions are not required. The nurse reviews the laboratory results for a client with a suspected ectopic pregnancy. The nurse would expect which result of the beta subunit of human chorionic gonadotropin (β-hCG) if the client had an ectopic pregnancy? 1. Not present 2. Present in low levels 3. Present in high levels 4. Within normal limits - 2. Present in low levels An abnormal pregnancy (ectopic) is suspected if β-hCG is present but at lower levels than expected. The absence of β-hCG would indicate no pregnancy, whereas normal limits could indicate a normal pregnancy. High levels could indicate a molar pregnancy.The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? 1. A client who has a history of intravenous drug use 2. A client who has a significant other who is heterosexual 3. A client who has a history of sexually transmitted infections 4. A client who has had one sexual partner for the past 10 years - 1. A client who has a history of intravenous drug use Human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals with persistent and recurrent sexually transmitted infections, individuals who have a history of multiple sexual partners, and individuals who have used intravenous drugs. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV. A nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. What should the nurse determine that this sign indicates? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus - 1. A softening of the cervix In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, causing Goodell's sign. Cervical softening is noted by the examiner during pelvic examination. Goodell's sign does not indicate the presence of fetal movement. The presence of hCG is noted in the maternal urine in a urine pregnancy test. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulation through the placenta. A nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What is the nurse's best response? 1. "Prolactin stimulates the secretion of milk, which is called lactogenesis."2. "Oxytocin stimulates the secretion of milk, which is called lactogenesis." 3. "Progesterone stimulates the secretion of milk, which is called lactogenesis." 4. "Testosterone stimulates the secretion of milk, which is called lactogenesis." - 1. "Prolactin stimulates the secretion of milk, which is called lactogenesis." Prolactin stimulates the secretion of milk, which is called lactogenesis. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 1. "The procedure takes about 2 hours." 2. "It will be necessary to drink 1 to 2 quarts of water before the examination." 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." 4. "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture." - 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 4 identify components of abdominal ultrasound. The nurse is reviewing fetal development with a client who is at 36 weeks gestation. Which statements describe the characteristics that develop in a fetus at this time? Select all that apply. 1. Eyelids begin to fuse. 2. Fetal heart begins to beat.3. The fetal skin is transparent. 4. The fetus weighs approximately 1200 g. 5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1 - 5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1 At gestational week 36, the fetus weighs 2500 g and is approximately 42 to 48 cm long. The skin is pink and the body is rounded. Lanugo is disappearing, and the L/S ratio is greater than 2:1. At gestational week 8, the eyelids begin to fuse. The fetal heart begins to beat at week 5. The fetal skin is transparent at week 16. At 28 weeks of gestation, the fetus weighs approximately 1200 g. The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding, which nursing action is most appropriate? 1. Document the temperature. 2. Notify the health care provider. 3. Retake the temperature by the rectal route. 4. Inform the client that the temperature is elevated and antibiotics may be required. - 1. Document the temperature. The normal temperature during pregnancy is 36.2° C to 37.6° C (98° F to 99.6° F). This slight elevation occurs because of the increased metabolic effect that occurs as a result of pregnancy. A temperature greater than this may suggest infection that might require medical management. The remaining options are unnecessary. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately."4. "Use tampons if the discharge is bothersome, but to be sure to change the tampons every 2 hours." - 2. "The vaginal discharge may be bothersome, but is a normal occurrence." Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently. The nurse is caring for a client with preeclampsia. The client is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1. Tongue blade 2. Percussion hammer 3. Potassium chloride injection 4. Calcium gluconate injection - 4. Calcium gluconate injection Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest-priority item. Potassium chloride is not related to the administration of magnesium sulfate. The nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant woman to describe the process of quickening. Which statement if made by the student indicates an understanding of this term? 1. "It is the thinning of the lower uterine segment." 2. "It is the fetal movement that is felt by the mother." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." - 2. "It is the fetal movement that is felt by the mother." Quickening is fetal movement and may occur as early as the 14th to 16th week of gestation. The expectant mother first notices subtle fetal movements that gradually increase in intensity. Thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegar's sign. Braxton Hicks contractions are irregular,painless contractions that may occur throughout pregnancy. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, and this is known as uterine souffle. This sound is caused by the blood circulation to the placenta and corresponds to the maternal pulse. A client reports to the health care clinic and says that it has been 6 weeks since her last menstrual period. The nurse performs a pregnancy test and should expect to note the presence of which hormone in the blood test results if the client is pregnant? 1. Estrogen 2. Progesterone 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) - 4. Human chorionic gonadotropin (hCG) hCG can be detected in the blood as early as 6 days after conception or 20 days after the last menstrual period. Options 1, 2, and 3 are unrelated to determining the presence of a pregnant state. The clinic nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to the risk of abruptio placentae if which information is obtained on assessment? 1. The client is 28 years of age. 2. This is the second pregnancy. 3. The client has a history of hypertension. 4. The client performs moderate exercise on a regular daily schedule. - 3. The client has a history of hypertension. Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors. A pregnant client in the prenatal clinic is scheduled for a biophysical profile. The client asks the nurse what this test involves. The nurse should make which appropriate response?1. "This test measures your ability to tolerate the pregnancy." 2. "This test measures amniotic fluid volume and fetal activity." 3. "This test measures your cardiac status and ability to tolerate labor." 4. "This test only measures the amount of amniotic fluid present in the uterus." - 2. "This test measures amniotic fluid volume and fetal activity." The biophysical profile assesses five parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points, with a score of 8 considered normal and a score of 10 perfect. Results are available immediately. Options 1, 3, and 4 are incorrect. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching? 1. "I need to stay on the diabetic diet." 2. "I will perform glucose monitoring at home." 3. "I cannot exercise because of the negative effects on insulin production." 4. "I will report signs of infection immediately to my health care provider." - 3. "I cannot exercise because of the negative effects on insulin production." Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many women are taught to perform blood glucose monitoring. If the woman is not performing the blood glucose monitoring at home, then it will be performed at the clinic or health care provider's office. Signs of infection need to be reported to the health care provider. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy.3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition. - 3. Inform the client that these contractions are common and may occur throughout the pregnancy. Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions. A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2015, and ended the menses on March 14, 2015. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is which date? 1. January 14, 2014 2. January 21, 2014 3. December 21, 2015 4. December 14, 2015 - 4. December 14, 2015 Nägele's rule is a noninvasive method for estimating the date of birth and is based on the assumption that the menstrual cycle is 28 days. The rule states the following: subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year. March 7, 2015, minus 3 months is December 7, 2014. December 7, 2014, plus 7 days is December 14, 2014. Adding 1 year brings the date of delivery to December 14, 2015. A pregnant woman is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? 1. The breasts become stretched because of the weight gain. 2. The increased metabolic rate causes the breasts to become larger. 3. The breast changes occur because of the secretion of estrogen and progesterone. 4. Cortisol secreted by the adrenal glands plays a role in increasing the size and appearance of the breasts. - 3. The breast changes occur because of the secretion of estrogen and progesterone.During pregnancy, the breasts change in size and appearance. The increase in size occurs because of the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin. The remaining options are unrelated to breast changes during pregnancy. The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? 1. Consume a low-fiber diet. 2. Drink 8 glasses of water per day. 3. Use a Fleet enema when the episodes occur. 4. Take a mild stool softener daily in the evening. - 2. Drink 8 glasses of water per day. The nurse should instruct the client to drink at least 8 to 10 (8-oz) glasses of fluid each day, of which 4 to 6 glasses are water, and to consume a diet that includes fiber to prevent constipation. The client should not take stool softeners, laxatives, mineral oil, other medications, or enemas without first consulting with the health care provider or nurse-midwife. A clinic nurse is explaining the changes in the integumentary system that occur during pregnancy to a client and should tell the client that which change may persist after she gives birth? 1. Epulis 2. Chloasma 3. Telangiectasia 4. Striae gravidarum - 4. Striae gravidarum Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. After birth they usually fade, although they never disappear completely. Options 1, 2, and 3 are incorrect. An epulis is a red, raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and forehead and is especially noticed in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasias, or vascular "spiders," are tiny star-shaped or branch-shaped, slightly raised, and pulsating end arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders usually disappear after delivery.A nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data should alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? 1. The client's last baby weighed 10 lb at birth. 2. The client has a family history of type 1 diabetes. 3. The client is 5 feet, 3 inches tall and weighs 165 lb. 4. The client's previous deliveries were by cesarean section. - 1. The client's last baby weighed 10 lb at birth. Known risk factors that increase the risk of developing gestational diabetes include obesity (over 198 lb), chronic hypertension, family history of type 2 diabetes, previous birth of a large infant (over 4000 g), and gestational diabetes in a previous pregnancy. The other options are not risk factors associated with the development of gestational diabetes. The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk? 1. Presence of cats in the home 2. Number of sexual partners during pregnancy 3. Exposure to children with rashes or gastrointestinal symptoms 4. History of high fevers or unusual rashes during the first 6 weeks of pregnancy - 1. Presence of cats in the home Toxoplasmosis is a systemic (and usually asymptomatic) illness caused by a protozoan parasite. Approximately one third of all women in the United States have positive antibody titers for toxoplasmosis, thus confirming prior exposure. Humans acquire the infection by consuming inadequately cooked meat, eggs, or milk; by ingesting or inhaling the oocyst stage excreted in feline feces or contaminated soil; or from receiving contaminated blood products. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection in the developing embryo or fetus. The other options are questions unrelated to toxoplasmosis. The clinic nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instructions?1. "It is best that I rest lying on my side to promote blood return to the heart." 2. "I need to avoid excessive weight gain to prevent increased demands on my heart." 3. "I need to try to avoid stressful situations because stress increases the workload on the heart." 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." - 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Resting should be done by lying on the side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased heart workload, and the client should be instructed to avoid stress. During a prenatal visit, a nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? 1. "Diet and insulin needs change during pregnancy." 2. "I will plan my diet based on the results of urine glucose testing." 3. "I will need to eat 600 more calories every day because I am pregnant." 4. "I can continue with the same diet as before pregnancy, as long as it is well balanced." - 1. "Diet and insulin needs change during pregnancy." The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. An increase of 600 additional calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the second and third trimesters, insulin needs increase. The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. 1. Viruses2. Bacteria 3. Nutrients 4. Medications 5. Antibodies - 1. Viruses 3. Nutrients 4. Medications 5. Antibodies Large particles such as bacteria cannot pass through the placenta, but viruses, nutrients, medications, antibodies, and recreational drugs can pass through the placenta and potentially affect the fetus. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery - 1. A normal test result Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations. The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 2. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low."3. "The low levels of estrogen and progesterone increase the release of the folliclestimulating hormone and luteinizing hormone." 4. "The high levels of estrogen and progesterone promote the release of the folliclestimulating hormone and luteinizing hormone." - 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation. All other options are incorrect. The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion? 1. Age of 35 years 2. History of syphilis 3. History of genital herpes 4. History of diabetes mellitus - 2. History of syphilis Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion, although the presence of active lesions at the time of birth presents concerns. Maternal age greater than 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations, not abortions. During a woman's prenatal visit, the nurse is measuring fundal height. The nurse knows that the woman is at 20 weeks' gestation. Based on this information, the nurse expects the fundus to be found at what area of the abdomen? 1. At the umbilicus 2. At the xiphoid process 3. Midway between the umbilicus and the xiphoid process 4. Midway between the symphysis pubis and the umbilicus - 1. At the umbilicus The fundus can be palpated above the symphysis pubis between 12 and 14 weeks' gestation. At 20 weeks' gestation, the fundus can be palpated at the umbilicus. At approximately 28 weeks' gestation, the fundus can be palpated midway between theumbilicus and the xiphoid process. At 36 weeks, the fundus can be palpated at the level of the xiphoid process. The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? 1. Checking for edema 2. Monitoring daily weight 3. Monitoring the apical pulse 4. Monitoring the temperature - 3. Monitoring the apical pulse Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Weight and edema are priority interventions for the client with preeclampsia, and an elevated temperature is an indicator of infection. In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to do to elicit the most accurate responses to the questions that refer to sexually transmitted infections? 1. Establish a therapeutic relationship. 2. Use specific closed-ended questions. 3. Omit these types of questions because they are highly personal. 4. Apologize for the embarrassment that these questions will cause the client. - 1. Establish a therapeutic relationship. The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned purposeful communication that focuses on specific content. The remaining options are incorrect and would not lend themselves to eliciting accurate information from the client. The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? 1. "Most children do not receive the vaccine until they are 5 years of age." 2. "You are still susceptible to rubella, so your toddler should receive the vaccine."3. "It is not advised for children of pregnant women to be vaccinated during their mother's pregnancy." 4. "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." - 4. "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." All pregnant women should be screened for prior rubella exposure during pregnancy. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to rubella. All children of pregnant women should receive their immunizations according to schedule. Additionally, no definitive evidence suggests that the rubella vaccine virus is transmitted from client to client. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding? 1. 22 cm 2. 30 cm 3. 36 cm 4. 40 cm - 2. 30 cm During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus' age in weeks ± 2 cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process. A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? 1. Apply heat to the affected area. 2. Take acetaminophen (Tylenol) every 4 hours. 3. Self-administer calcium carbonate tablets three times daily. 4. Purchase a chewable antacid that contains calcium and take a tablet with each meal. - 1. Apply heat to the affected area. Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serumphosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications. The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? 1. A full bladder 2. Emotional instability 3. Insufficient iron intake 4. Compression of the vena cava - 4. Compression of the vena cava Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the left buttock during fundal height measurement will correct or prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome. A pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. Which activity should the nurse tell the client to perform when the cramps occur? 1. Dorsiflex the foot while flexing 2. Dorsiflex the foot while extending 3. Plantar flex the foot while flexing 4. Plantar flex the foot while extending - 2. Dorsiflex the foot while extending Leg cramps occur when the pregnant client stretches the leg and plantar flexes the foot. Dorsiflexing the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Therefore the other activities are incorrect.The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and folliclestimulating hormone." - 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. L [Show More]

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