Antepartum: NCLEX Exam Questions with Answers. 2022/2023. Rated A

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Antepartum: NCLEX Exam Questions with Answers A nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months'... gestation. The student describes the procedure correctly if the student states to: -Ans- Place a rolled blanket under the right abdominal flank and hip area. (To relieve an airway obstruction on an unconscious woman in an advanced stage of pregnancy, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. ) The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes: -Ans- Are where fertilization occurs (Each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization. Fertilization typically occurs near the boundary between the ampulla and the isthmus of the tube. The vagina is the organ of copulation, and the fetus develops in the uterus. Estrogen is a hormone that is produced by the ovarian follicles, the corpus luteum, the adrenal cortex, and the placenta during pregnancy. Progesterone is a hormone that is secreted by the corpus luteum of the ovary, the adrenal glands, and the placenta during pregnancy. ) A nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of folliclestimulating hormone (FSH) and luteinizing hormone (LH) if the student states: -Ans- "FSH and LH are released from the anterior pituitary gland." (FSH and LH are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the Graafian follicle, and production of progesterone. ) The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is: -Ans- The most favorable for labor and birth (A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. An android pelvis would not be favorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. The platypelloid pelvis has a wide transverse diameter, but the anteroposterior diameter is short, thus making the outlet inadequate.)The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta: -Ans- Provides an exchange of nutrients and waste products between the mother and the fetus (The placenta provides an exchange of nutrients and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and allows for fetal movement. The amniotic fluid also maintains the body temperature of the fetus.) The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of: -Ans- Two umbilical arteries and one umbilical vein (Blood pumped by the fetus' heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then 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.) A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states that it: -Ans- Connects the umbilical vein to the inferior vena cava (The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.) During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted? -Ans- 150 beats per minute (Fetal heart rate depends on gestational age. It is normally 160 to 170 beats per minute during the first trimester, but it slows with fetal growth to 110 or 120 (low end) to 160 (high end) beats per minute near or at term.) The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen? -Ans- It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation. (Estrogen stimulates uterine development to provide an environment for the fetus, and it stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionicgonadotropin prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.) A nursing student is asked to describe the size of the uterus in a nonpregnant client. Which of the following responses, if made by the student, indicates an understanding of the anatomy of this structure? -Ans- "The uterus weighs about 2 ounces." (Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz), and it has a capacity of about 10 mL (1/3 oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb), and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.) The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. -Ans- 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2012. Using Nägele's rule, the nurse determines the estimated date of birth to be: -Ans- July 27, 2013 (The accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20, 2012. When you subtract 3 months, you get July 20, 2012. If you add 7 days, you get July 27, 2012. Add 1 year to this, and you get the estimated date of birth: July 27, 2013.) A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between: -Ans- 16 and 20 weeks' gestation (Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity)The nurse is collecting data during the admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as: -Ans- G = 2, T = 1, P = 0, A = 0, L = 1 (Pregnancy outcomes can be described with the GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.) The nurse is collecting data during the admission assessment of a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse would document which gravida and para status on this client? - Ans- Gravida II, para I (Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants. ) The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of: -Ans- A softening of the cervix (During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin is noted in maternal urine with a positive urine pregnancy test. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; it is the result of blood circulating through the placenta. ) A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing? -Ans- Fetal heart rate of 180 beats per minute (The fetal heart rate depends on the gestational age. It is 160 to 170 beats per minute during the first trimester, and it slows with fetal growth to approximately 120 to 160 beats per minute. Options 1, 2, and 3 are normal expected findings.)The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following? -Ans- 28 cm (During the second and third trimesters (18 to 30 weeks' gestation), the fundal height in centimeters approximately equals the fetus' age in weeks plus or minus 2 cm. At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and, at term, the fundus is at the xiphoid process.) A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? -Ans- Tell the client that these are common and they 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) The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term? -Ans- "It is the fetal movement that is felt by the mother." (Quickening is fetal movement that appears usually at week 16 to 20, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. A compressibility of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; this is known as uterine souffle. This sound is the result of blood circulation to the placenta, and it corresponds with the maternal pulse. ) The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign(s) of pregnancy that the nurse should recognize? Select all that apply. -Ans- 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions(The probable signs of pregnancy include uterine enlargement, Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy), Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (the rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.) The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client: -Ans- That the bladder must be full during the exam (Before 20 weeks' gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks' gestation, the bladder should be emptied to minimize the chance of puncturing the placenta or fetus. Rho(D) immune globulin (RhoGAM) is administered to Rh-negative woman because of the risk of contact with the fetal blood during the exam. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the exam is an important intervention.) The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client states: -Ans- "I will tell the nurse at the hospital that I had RhoGAM during pregnancy." (As described in the question, it is accepted practice to administer Rho(D) immune globulin (RhoGAM) to an Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated, because the immunity is passive.) While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of: -Ans- Compression of the vena cava (Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem.)A contraction stress test is scheduled for the client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following? -Ans- "The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation." (A contraction stress test assesses placental oxygenation and function and determines the fetus' ability to tolerate labor as well as its well-being. The test is performed if the non stress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30- minute baseline strip is recorded. The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40 seconds or more during a 10-minute period have occurred. Frequent maternal blood pressure readings are performed, and the client is monitored closely while increasing doses of oxytocin are given. Leopold's maneuvers are performed to locate the position of the fetus.) The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following? -Ans- A diet that is high in fluids and fiber to decrease constipation (Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system. The absence of weight gain is not recommended during pregnancy. Diets that are low in fluid and fiber cause a decrease in blood volume, which in turn deprives the fetus of nutrients. Too much sodium could cause an overload to the circulating blood volume and contribute to the cardiac condition.) The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes: -Ans- Petechiae, oozing from injection sites, and hematuria (DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.) The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning? -Ans- "The iron is needed for the red blood cells." (A nutritional supplement that is commonly needed during pregnancy for the red blood cells is iron. Anemia of pregnancy is primarily caused by iron deficiency. Ironsupplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal serum.) During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states: -Ans- "I need to increase the fiber in my diet to control my blood glucose and prevent constipation." (An increase in calories is needed during pregnancy, but concentrated sugars should be avoided, because they may cause hyperglycemia. The fat intake should be 20% to 30% of the total calories. The client with diabetes needs about 50% to 60% of her caloric intake from carbohydrates and about 12% to 20% from protein. High-fiber foods will control blood glucose levels and prevent constipation.) The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse recommends which measure to help relieve both discomforts? -Ans- Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle. (The position described in option 4 will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities.) The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and tells the partner to: -AnsDorsiflex the client's foot while extending the knee. (Leg cramps often occur when the pregnant woman stretches her leg and plantarflexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. ) The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to: -Ans- Drink decaffeinated coffee and tea. (Spices tend to trigger heartburn. Caffeine, like spices, may cause heartburn and needs to be avoided. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.) The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving? - Ans- The client complains of a headache and blurred vision. (Option 3 is a symptom of the worsening of the GH.)The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? Select all that apply. -Ans- 1. Proteinuria 2. Hypertension 4. Generalized edema (The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria.) A nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination will not be performed on the client primarily because it could do which of the following? -Ans- Cause profound hemorrhage (Because the placenta is implanted low in the uterus, cervical examination could cause the disruption of the placenta and initiate profound hemorrhage. The other options are also correct, but the profound hemorrhage is of the greatest concern in this case.) The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process? -Ans- "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, thus inhibiting the release of follicle-stimulating hormone and luteinizing hormone, which are necessary for ovulation.) The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which of the following areas? -Ans- Midway between the symphysis pubis and the umbilicus (At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.) A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately: -Ans- 18 weeks of gestation(The first recognition of fetal movements, or "feeling life," by the multiparous woman may occur as early as the 14th to 16th week of gestation. The nulliparous woman may not notice these sensations until the 18th week of gestation or later. The first recognition of fetal movement is called "quickening." ) A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present? -Ans- Abdominal pain (Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and localized over one region of the uterus, or diffuse over 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.) A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse teaches the client about the signs that need to be reported to the health care provider (HCP) and tells the client to call the HCP if: -Ans- Weight increases by more than 1 pound in a week. (The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported.) A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, the nurse should first: -AnsCheck for signs of thrombophlebitis. (Leg cramps may be a result of compression of the nerves supplying the legs because of the enlarging uterus, a reduced level of diffusible serum calcium, an increase in serum phosphorus, or the presence of thrombophlebitis. In the pregnant client who complains of leg cramps, the nurse would first check for signs of thrombophlebitis and notify the registered nurse. If thrombophlebitis is not present, the nurse may be instructed to massage and place heat on the affected area, dorsiflex the foot until the spasm relaxes, or have the client stand on a cold surface. 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. Although the nurse may check for edema and assess the pedal pulses, these would not be the first actions.)A nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse tells the client that she will: -Ans- Feel some pressure when the vaginal probe is moved (Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound exam is well tolerated by most clients because it alleviates the need for a full bladder. The client is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.) A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week? -Ans- 5 (The fetal heart is beating and has developed four chambers by gestational week 5.) A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is: -Ans- Oxytocin (Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Prolactin stimulates the secretion of milk, called lactogenesis. Progesterone stimulates the secretions of the endometrial glands and causes the endometrial vessels to become dilated and tortuous in preparation for possible embryo implantation. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.) A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which of the following, if identified by the student, indicates an understanding of this process? -Ans- Fallopian tube (Fallopian tubes, also called oviducts, are 8 to 14 cm long and are quite narrow. The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube.) A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which of the following responses, if made by the student, indicates an understanding of the function of this hormone? -Ans- "It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus." (Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus. Relaxin is the hormone that softens the muscles and joints of the pelvis during labor. Thyroxine increases during pregnancy to stimulate basal metabolic rates, and prolactin is the primary hormone of milk production.)A maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phase, if stated by the nursing student, indicates a need to further research this area? -Ans- Proliferative phase (The ovarian cycle consists of three phases: preovulatory, ovulatory, and luteal. The proliferative phase is a phase of the endometrial cycle.) A nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. The nurse tells the client that: -Ans- A cesarean section will be necessary if vaginal lesions are present at the time of labor. (For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy and should be used only for a life-threatening infection. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, they should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry will promote healing) The plan of care for a pregnant teen should include teaching regarding which of the following concerning dental care? -Ans- Tell the dental office staff that she is pregnant. (Baking soda may irritate the gums, which are more likely to bleed because of hormonal changes of pregnancy. Local anesthetics for minor dental work should not have adverse effects on the fetus. Option 4 is inaccurate information. The dental staff needs to know about the pregnancy so that care is taken during examinations and x-ray studies are avoided.) A nurse is providing information to a pregnant woman about food items high in folic acid. Which of the following mid-afternoon snacks should be recommended to supply folic acid? -Ans- Nuts and green, leafy vegetables (Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four daily servings of foods rich in folic acid. The food items in option 3 contain folic acid.) A client beginning week 30 of gestation comes to the clinic for a routine visit. Which of the following observations by the nurse indicates a need for teaching? -Ans- The client is wearing knee-high hose. (Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing, such as knee-high hose, impedes venous return from the lowerlegs and thus places the client at higher risk for developing varicosities. Clients should be encouraged to wear support hose (pantyhose). Flat, nonslip shoes with proper support are important to help the pregnant woman maintain proper posture and balance and minimize fall risks.) A nurse is collecting data from a prenatal client. The nurse determines that which of the following places the client in the high-risk category for contracting human immunodeficiency virus (HIV)? -Ans- A history of intravenous (IV) drug use in the past year (HIV is transmitted by intimate sexual contact and by the exchange of body fluids, exposure to infected blood, and the transmission from an infected woman to her fetus. Women who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases or a history of multiple sexual partners and those who use or have used IV drugs) A perinatal client is at risk for toxoplasmosis. The nurse should teach the client which of the following to prevent exposure to this disease? -Ans- Avoid exposure to litter boxes used by cats. (Infected house cats transmit toxoplasmosis through feces. Handling litter boxes can transmit the disease to the maternity client. Meats that are undercooked can harbor microorganisms that can cause infection. Hands should be washed throughout the day when items that could be contaminated are handled. Topical corticosteroid treatment is not the pharmacological treatment of choice for toxoplasmosis.) A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client? -Ans- Client exhibits no signs of fetal distress. (Option 1 clearly identifies a physiological need.) A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone? -Ans- "It increases during pregnancy to stimulate basal metabolic rate." (Thyroxine increases during pregnancy to stimulate basal metabolic rates. Relaxin is the hormone that softens the muscles and joints of the pelvis. Prolactin is the primary hormone of milk production. Progesterone maintains uterine lining for implantation and relaxes all smooth muscle including the uterus.) A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is: -Ans- Wedge-shaped and narrow and nonfavorable for a vaginal birth(The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is a nonfavorable shape for a vaginal birth.) A nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should: -Ans- Turn the client onto her left side. (When measuring fundal height, the client lies in a supine position, and the nurse instructs the woman to turn onto her left side. The nurse then elevates the left buttock by placing a pillow under the area. This position will assist in preventing supine hypotension) A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by: -Ans- Massaging the abdomen during contractions using both hands in a circular motion (Effleurage 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. 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 then concentrates on letting tension goes from the rest of the body. Touch relaxation helps the women to learn to loosen taut muscles when they are touched by her partner.) A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs? -AnsProviding the mother with pamphlets and booklets to read about the pregnancy (The woman's emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse should also discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Option 4 will least likely assist in meeting the emotional needs of the woman.) A pregnant client asks a nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following? -Ans- Swimming(Non-weight-bearing exercises are preferable to weight-bearing exercises. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non-weight-bearing exercise such as swimming is allowable.) A nurse is teaching a pregnant client about the warning signs in pregnancy that require the need to notify the health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the health care provider if which of the following occurs? -Ans- Irregular, painless contractions (Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout the 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.) A pregnant woman visiting a health care clinic for the first prenatal visit hears the health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the preembryonic period is the: -Ans- First 2 weeks of fetal development following conception (The preembryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period. The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form.) A nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. The nurse tells the woman that the purpose of progesterone is to: -AnsMaintain the uterine lining for implantation. (Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.)A nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which of the following? - Ans- Estrogen (The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish tinge that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy.) A nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client: -Ans- In a sitting position (Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. The blood pressure should be obtained in the sitting position with the arm supported in a horizontal position at heart level.) A nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in this area? -Ans- Vulva (Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion.) A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate? -Ans- Instruct the client that these are common and may occur throughout the pregnancy. (Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. ) A pregnant client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the sex of the fetus can usually be determined by: -Ans- Weeks 12 to 16 (By the end of the 12th week, the fetal sex can be determined by the appearance of the external genitalia on ultrasound. )A nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is: -Ans- Flat and nonfavorable for a vaginal birth (The platypelloid pelvic shape is flattened with a wide, short oval shape and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth.) A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to: -Ans- St [Show More]

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