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Ante/Intra Partum NCLEX

Terms in this set (364)

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:

1. Place the hands in the pelvis to perform the thrusts.
2. Perform abdominal thrusts until the object is dislodged.
3. Perform left lateral abdominal thrusts until the object is dislodged.
4. Place a rolled blanket under the right abdominal flank and hip area.
Rationale: 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. Options 1, 2, and 3 are incorrect and can cause harm to the woman and the fetus.

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:

1. Are the organ of copulation
2. Are where the fetus develops
3. Are where fertilization occurs
4. Secrete estrogen and progesterone
Rationale: 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 follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student states:

1. "FSH and LH are secreted by the adrenal glands."
2. "FSH and LH are released from the anterior pituitary gland."
3. "FSH and LH are secreted by the corpus luteum of the ovary."
4. "FSH and LH stimulate the formation of milk during pregnancy."
Rationale: 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. Options 1, 3, and 4 are incorrect.

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:

1. Not favorable for labor
2. Not normally a female pelvis type
3. A wide pelvis with a short diameter
4. The most favorable for labor and birth
Rationale: 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:

1. Cushions and protects the fetus
2. Maintains the body temperature of the fetus
3. Surrounds the fetus and allows for fetal movement
4. Provides an exchange of nutrients and waste products between the mother and the fetus
Rationale: 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:

1. Two umbilical veins and one umbilical artery
2. Two umbilical arteries and one umbilical vein
3. Arteries that carry oxygenated blood to the fetus
4. Veins that carry deoxygenated blood to the fetus
Rationale: 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:

1. Connects the pulmonary artery to the aorta
2. Is an opening between the right and left atria
3. Connects the umbilical vein to the inferior vena cava
4. Connects the umbilical artery to the inferior vena cava
Rationale: 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?

1. 80 beats per minute
2. 100 beats per minute
3. 150 beats per minute
4. 180 beats per minute
Rationale: 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?

1. It maintains the uterine lining for implantation.
2. It stimulates the metabolism of glucose, and converts glucose to fat.
3. It prevents the involution of the corpus luteum, and maintains the production of progesterone until the placenta is formed.
4. It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.
Rationale: 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 chorionic gonadotropin 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?

1. "The uterus weighs about 2 ounces."
2. "The uterus weighs about 2.2 pounds."
3. "The uterus has a capacity of about 50 milliliters."
4. "The uterus is round in shape and weighs approximately 1000 grams."
Rationale: 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.

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
5. Prevents large particles such as bacteria from passing to the fetus
6. Provides an exchange of nutrients and waste products between the mother and the fetus
Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, it maintains the body temperature of the fetus, and it helps to measure kidney function, because the amount of fluid is based on the amount of urination from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus, and it provides an exchange of nutrients and waste products between the mother and 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:

1. July 12, 2013
2. July 27, 2013
3. August 12, 2013
4. August 27, 2013
Rationale: 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:

1. 6 and 8 weeks' gestation
2. 8 and 10 weeks' gestation
3. 10 and 12 weeks' gestation
4. 16 and 20 weeks' gestation
Rationale: 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. Options 1, 2, and 3 are incorrect; these gestational time frames are too early for quickening.

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:

1. G = 3, T = 2, P = 0, A = 0, L = 1
2. G = 2, T = 1, P = 0, A = 0, L = 1
3. G = 1, T = 1, P = 1, A = 0, L = 1
4. G = 2, T = 0, P = 0, A = 0, L = 1
Rationale: 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?

1. Gravida I, para I
2. Gravida II, para I
3. Gravida II, para II
4. Gravida III, para II
Rationale: 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. Options 1, 3, and 4 are incorrect on the basis of these definitions.

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:

1. A softening of the cervix
2. The presence of fetal movement
3. The presence of human chorionic gonadotropin in the urine
4. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus
Rationale: 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?

1. Quickening
2. Braxton Hicks contractions
3. Consistent increase in fundal height
4. Fetal heart rate of 180 beats per minute
Rationale: 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?

1. 22 cm
2. 28 cm
3. 36 cm
4. 40 cm
Rationale: 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?

1. Contact the health care provider.
2. Instruct the client to maintain bedrest for the remainder of the pregnancy.
3. Tell the client that these are common and they may occur throughout the pregnancy.
4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.
Rationale: 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.

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?

1. "It is the fetal movement that is felt by the mother."
2. "It is the compressibility of the lower uterine segment."
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."
Rationale: 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.

1. Ballottement
2. Chadwick's sign
3.Uterine enlargement
4. Braxton Hicks contractions
5. Outline of fetus via radiography or ultrasound
6. Fetal heart rate detected by a non electronic device
Rationale: 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:

1. That the bladder must be full during the exam
2. That the bladder must be empty during the exam
3. She will be given RhoGAM because she is Rh positive
4. Not to eat or drink anything 4 to 6 hours before the exam
Rationale: 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:

1. "I know I can never have another child."
2. "I am glad I won't have to have these shots if I have another child."
3. "I will have to have an injection once a month until the baby is born."
4. "I will tell the nurse at the hospital that I had RhoGAM during pregnancy."
Rationale: 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. Options 1, 2, and 3 are inaccurate information.

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:

1. A full bladder
2. Emotional instability
3. Insufficient iron intake
4. Compression of the vena cava
Rationale: 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. Options 1, 2, and 3 are not the cause of the problem described in the question.

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?

1. "Uterine contractions are stimulated by Leopold's maneuvers."
2. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin."
3. "The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."
4. "Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions."
Rationale: 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 client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client?

1. Measuring the fundal height
2. Attaching electronic fetal monitoring
3. Preparing the client for a possible cesarean section
4. Gathering equipment for starting an intravenous line
Rationale: Option 1 is a low priority, because fundal height should be measured at each antepartal clinic visit; it is not a priority of care during the intrapartum period. Options 2, 3, and 4 are all high priorities. The twins should be monitored by dual electronic fetal monitoring, and any signs of distress should be reported. Many health care providers choose to perform a cesarean birth if either of the twins is breech. The mother should have an intravenous line in place in case fluid or blood replacement is required.

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?

1. A low-calorie diet to ensure the absence of weight gain
2. A diet that is high in fluids and fiber to decrease constipation
3. A diet that is low in fluids and fiber to decrease blood volume
4. Unlimited sodium intake to increase the circulating blood volume
Rationale: 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:

1. Rapid clotting times
2. Pain and swelling of the calf of one leg
3. Laboratory values that indicate increased platelets
4. Petechiae, oozing from injection sites, and hematuria
Rationale: 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?

1. "Iron supplements will give me diarrhea."
2. "The iron is needed for the red blood cells."
3. "Meat does not provide iron and should be avoided."
4. "My body has all the iron it needs, and I don't need to take supplements."
Rationale: 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. Iron supplements 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:

1. "I can eat more sweets now, because I need more calories."
2. "I need more fat in my diet so that the baby can gain enough weight."
3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose."
4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."
Rationale: 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?

1. Lie on the left side with the feet dorsiflexed.
2. Soak the feet in hot water after performing 10 pelvic tilt exercises.
3. Lie on the right side with the feet elevated on a pillow and a heating pad on the back.
4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.
Rationale: 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. Although the other options may seem useful, options 2 and 3 identify heat, which should be prescribed by the health care provider (HCP). Option 1 will not relieve back pain and ankle edema.

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:

1. Dorsiflex the client's foot while flexing the knee.
2.Plantarflex the client's foot while flexing the knee.
3. Dorsiflex the client's foot while extending the knee.
4. Plantarflex the client's foot while extending the knee.
Rationale: 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. Therefore, the remaining options are incorrect.

The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to:

1. Eliminate between-meal snacks.
2. Drink decaffeinated coffee and tea.
3. Lie down for 30 minutes after eating.
4. Substitute salt in cooking for other spices.
Rationale: 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?

1. Urinary output has increased.
2. There is no evidence of dependent edema.
3. The client complains of a headache and blurred vision.
4. The blood pressure reading has returned to the prenatal baseline.
Rationale: Options 1, 2, and 4 are all signs that the GH is being resolved. 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.

1. Proteinuria
2. Hypertension
3. Low-grade fever
4. Generalized edema
5. Increased pulse rate
6. Increased respiratory rate
Rationale: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?

1. Baseline fetal heart rate
2. Intensity of contractions
3. Maternal blood pressure
4. Frequency of contractions
Rationale: The nurse should first determine the baseline fetal heart rate. Although options 2, 3, and 4 are components of the data collection process, the fetal heart rate is the priority.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:

1. Measures the height of the maternal fundus
2. Determines the "lie" and "attitude" of the fetus
3. Is a systematic method for palpating the fetus through the maternal back
4. Is a systematic method for palpating the fetus through the maternal abdominal wall
Rationale: Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 3 are incorrect.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

1. Squatting
2. Left lateral
3. Tailor sitting
4. Semi-Fowler's
Rationale: Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her left side. Options 1, 3, and 4 are incorrect because they would not prevent hypotension.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened?

1. Encourage the mother to breast-feed soon after birth.
2. Support the mother in her reaction to the newborn infant.
3. Tell the mother that it is important to hold the newborn infant.
4. Document a complete account of the mother's reaction in the birth record.
Rationale: Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the mother's feelings.

A primigravida's membranes rupture spontaneously. The nurse's first action is to:

1. Determine the fetal heart rate.
2. Prepare for immediate delivery.
3. Monitor the contraction pattern.
4. Note the amount, color, and odor of the amniotic fluid.
Rationale: When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the contraction pattern and noting the amount, color, and odor of the amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery.

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of:

1. Uterine atony
2. Placenta previa
3. Abruptio placentae
4. Placental separation
Rationale: As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The clinical manifestations identified in the question are not related to options 1, 2, and 3.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to:

1. Prepare for an oxytocin infusion.
2. Keep the client in a side-lying position.
3. Prepare the client for epidural anesthesia.
4. Encourage the client to start pushing with the contractions.
Rationale: Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is:

1. Leopold's maneuvers
2. A manual pelvic examination
3. Hemoglobin and hematocrit evaluation
4. External electronic fetal heart rate monitoring
Rationale: Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia. Options 1, 3, and 4 are procedures that would not place the client at further risk.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?

1. Soft abdomen on palpation
2. Uterine tenderness on palpation
3. No complaints of abdominal pain
4. Lack of uterine irritability or tetanic contractions
Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated?

1. A change in the uterine contour
2. Sudden and sharp abdominal pain
3. A shortening of the umbilical cord
4. A decrease in blood loss from the introits
Rationale: Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness but not sudden and sharp abdominal pain.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the:

1. Prone position
2. Semi-Fowler's position
3. Trendelenburg's position
4. Supine position with a wedge under the right hip
Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides for the displacement of the uterus. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, thus decreasing respiratory capacity and oxygenation.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:

1. Monitor the maternal vital signs.
2. Notify the registered nurse (RN) immediately.
3. Continue monitoring labor and the fetal heart rate.
4. Encourage relaxation and breathing techniques between contractions.
Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse would immediately contact the RN, who would then contact the health care provider. Options 1, 3, and 4 will delay necessary and immediate interventions.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:

1. Estimate the fetal size.
2. Check pelvic adequacy.
3. Administer an analgesic.
4. Determine the maternal and fetal vital signs.
Rationale: To evaluate a woman's physical well-being, her temperature, pulse, respirations, and blood pressure (as well as the fetal heartbeat) are checked. Option 3 is incorrect, because it would be too premature for an analgesic; medication given too early tends to slow or stop labor contractions. Options 1 and 2 are incorrect. These assessments should be performed by the health care provider during prenatal visits.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. Select all that apply.

1. Uterine rigidity
2. Uterine tenderness
3. Severe abdominal pain
4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
Rationale: Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abruptio placentae, the abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client?

1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Early decelerations of the fetal heart rate
Rationale: Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Fatigue and drowsiness may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection?

1. Proteinuria of 3+
2. Presence of deep tendon reflexes
3. Serum magnesium level of 6 mEq/L
4. Respirations of 10 breaths per minute
Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium sulfate therapy is effective if:

1. Scotomas are present.
2. Seizures do not occur.
3. Ankle clonus is noted.
4. The blood pressure decreases.
Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Ankle clonus indicates hyperreflexia and may precede the onset of eclampsia.

A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?

1. Betamethasone
2. Nalbuphine (Nubain)
3. Misoprostol (Cytotec)
4. Rho(D) immune globulin (RhoGAM)
Rationale: Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. Nalbuphine (Nubain) is an opioid analgesic. Misoprostol (Cytotec) is a prostaglandin that is given to ripen and soften the cervix and to stimulate uterine contractions. Rho(D) immune globulin (RhoGAM) is given to RH-negative clients to prevent sensitization.

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply.

1. Flushing
2. Hypertension
3. Increased urine output
4. Depressed respirations
5. Extreme muscle weakness
6. Hyperactive deep tendon reflexes
Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

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?

1. Initiate premature labor
2. Cause profound hemorrhage
3. Rupture the fetal membranes
4. Increase the chance of infection
Rationale: 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?

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 follicle-stimulating hormone and luteinizing hormone."
4. "The high levels of estrogen and progesterone promote the release of follicle-stimulating hormone and luteinizing hormone."
Rationale: Because the placenta is implanted low 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. Options 2, 3, and 4 are incorrect.

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?

1. At the umbilicus
2. Just above the symphysis pubis
3. At the level of the xiphoid process
4. Midway between the symphysis pubis and the umbilicus
Rationale: 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:

1. 10 weeks of gestation
2. 12 weeks of gestation
3. 14 weeks of gestation
4. 18 weeks of gestation
Rationale: 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?

1. Soft uterus
2. Abdominal pain
3. Nontender uterus
4. Painless vaginal bleeding
Rationale: 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 nurse in the labor room is caring for a client in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

1. Notify the registered nurse.
2. Administer oxygen via face mask.
3. Place the mother in Trendelenburg's position.
4. Document the findings and continue to monitor the fetal patterns.
Rationale: Early deceleration of the FHR is a gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Options 1, 2, and 3 are unnecessary.

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:

1. Urine output increases.
2. Fetal movements are more than four per hour.
3. Weight increases by more than 1 pound in a week.
4. The blood pressure reading is between 122/80 and 138/88 mm Hg.
Rationale: 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:

1. Check for pedal edema.
2. Assess the dorsalis pedis pulses.
3. Check for signs of thrombophlebitis.
4. Tell the client to apply heat to the affected area when cramps occur.
Rationale: 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:

1. Be placed in a supine position
2. Feel some pain during the procedure
3. Feel some pressure when the vaginal probe is moved
4. Need to drink 2 quarts of water to attain a full bladder
Rationale: 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 nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse would first:

1. Stop the oxytocin infusion.
2. Check the client's blood pressure.
3. Check the client for bladder distention.
4. Place the client in a knee-chest position.
Rationale: Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse would intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped. In addition, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The registered nurse is immediately notified and will then contact the health care provider. The nurse would monitor the client's blood pressure and monitor intake and output. However, the nurse would first stop the infusion.

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?

5
Rationale: 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:

1. Prolactin
2. Oxytocin
3. Progesterone
4. Testosterone
Rationale: 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?

1. In the ovary
2. Fallopian tube
3. Fundus of the uterus
4. In the corpus of the uterus
Rationale: 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. Options 1, 3, and 4 are incorrect.

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?

1. "It softens the muscles and joints of the pelvis."
2. "It is the primary hormone of milk production."
3. "It increases during pregnancy to stimulate the basal metabolic rate."
4. "It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."
Rationale: 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?

1. Luteal phase
2. Ovulatory phase
3. Proliferative phase
4. Preovulatory phase
Rationale: 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:

1. Total abstinence from sexual intercourse is necessary during the entire pregnancy.
2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present.
3. A cesarean section will be necessary if vaginal lesions are present at the time of labor.
4. Daily administration of acyclovir (Zovirax) is necessary during the first trimester of the pregnancy.
Rationale: 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?

1. Tell the dental office staff that she is pregnant.
2. Avoid the use of local anesthetics during dental work.
3. Use toothpaste with baking soda to decrease plaque buildup.
4. Expect to lose at least one tooth because of calcium and phosphorus leaving the teeth to nourish the fetus.
Rationale: 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?

1. 1½ cup of yogurt
2. One medium banana
3. Nuts and green, leafy vegetables
4. 1 cup milk with two graham crackers
Rationale: 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. Milk and yogurt supply calcium. Bananas provide potassium.

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?

1. The client is wearing pantyhose.
2. The client is wearing nonslip shoes.
3. The client is wearing knee-high hose.
4. The client is wearing shoes with arch supports.
Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing, such as knee-high hose, impedes venous return from the lower legs 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)?

1. A history of intravenous (IV) drug use in the past year
2. Living in an area where HIV infections are minimal
3. A history of one sexual partner within the past 10 years
4. A spouse who is heterosexual and has had only one sexual partner in the past 10 years
Rationale: 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. Options 2, 3, and 4 are not situations that contribute to contracting HIV infection.

A perinatal client is at risk for toxoplasmosis. The nurse should teach the client which of the following to prevent exposure to this disease?

1. Eat raw meats.
2. Wash hands only before meals.
3. Avoid exposure to litter boxes used by cats.
4. Use topical corticosteroid treatments prophylactically.
Rationale: 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 asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

1. Locate fetal heart tones.
2. Warm the sonogram gel.
3. Have the client empty her bladder.
4. Have the client drink 8 ounces of water.
Rationale: An empty bladder contributes to a woman's comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram (ultrasound). Often, Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.

The advantages of using spinal anesthesia for delivery of a fetus include which of the following? Select all that apply.

1. Ease of administration
2. Absence of fetal hypoxia
3. Immediate onset of anesthesia
4. Blockade of sympathetic fibers
5. Increased voluntary expulsive efforts
6. Decreased incidence of bladder atony
Rationale: Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include onset of anesthesia in 1 to 3 minutes, ease of administration, and absence of fetal hypoxia. A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

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?

1. Client exhibits no signs of fetal distress.
2. Client expresses an understanding of her condition.
3. Client identifies and uses available support systems.
4. Client demonstrates compliance with activity limitations.
Rationale: Option 1 clearly identifies a physiological need. Options 2, 3, and 4 may be a component of the plan of care, but the physiological integrity and safety of the mother newborn dyad are the priorities.

A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

1. Hemoglobin of 11.5 g/dL
2. White blood cell count of 35,000 mm3
3. Fetal heart rate of 154 beats per minute
4. Maternal pulse rate of 90 beats per minute
Rationale: White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 mm3 to 15,000 mm3 up to 18,000 mm3. A count of 35,000 mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of hemodilution caused by an increase in plasma volume during pregnancy. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. A normal fetal heart rate is 120 to 160 beats per minute.

A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client's feelings of anxiety by:

1. Emphasizing the technical aspects of this type of delivery
2. Deciding how soon the client should see the baby after delivery
3. Decreasing the partner's anxiety by keeping him or her in the waiting area
4. Encouraging the client to discuss her concerns and desires regarding anesthesia options
Rationale: Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse, which do not involve client input. A woman undergoing cesarean delivery often feels disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help to alleviate these feelings. Too much technical information may increase the client's anxiety. The presence of a support person is helpful.

A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted?

1. Fetal tachycardia
2. Increased urinary output
3. Contractions occurring every 3 minutes
4. Soft uterine tone palpated between contractions
Rationale: Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia because of excessive uterine activity. The nurse should also ensure that the uterus maintains an adequate resting tone between contractions. Options 2, 3, and 4 are not indications of a problem.

A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse includes which of the following in the plan of care?

1. Administer antibiotics.
2. Maintain complete bedrest.
3. Notify the neonatal resuscitation team.
4. Maintain continuous electronic fetal monitoring.
Rationale: Maternal and fetal well-being is monitored before and during oxytocin administration and includes monitoring fetal heart rate, uterine contractions and tone, and maternal blood pressure. No data in the question indicate the presence of maternal or fetal complications that would require antibiotics, complete bedrest, or notifying the neonatal resuscitation team.

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will likely have:

1. Less pressure on her cervix
2. Increased efficiency of contractions
3. Decreased number of contractions
4. The need for increased blood pressure (BP) monitoring
Rationale: Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not create the need for increased monitoring of the BP.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs:

1. General anesthesia
2. To be left totally alone
3. To push with her contractions
4. To regain her breathing pattern
Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated. The client may be terrified of being left alone during this phase of labor.

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." The appropriate response by the nurse is which of the following?

1. "The health care provider is all set to go and cannot change plans now."
2. "You need to listen to your health care provider; he knows what he is doing."
3. "Tell me what you mean when you say that your baby has moved."
4. "That would be impossible because babies don't move around this late."
Rationale: Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 3 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 1, 2, and 4 do not and are blocks to communication.

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?

1. "I'm getting tired of lying flat on my back."
2. "I shut the machine off when I talk on the telephone."
3. "What an efficient way to record my baby's heart rate."
4. "How many volts of electricity are going through my body?"
Rationale: EFM is a method of recording the fetal heart rate. The woman is asked to assume a semi-sitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface; in this case, the fetal heart and valves. No electricity or voltage goes through the body. EFM does not need to be shut off when talking on the telephone.

A nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which of the following is the most important information for the nurse to document on the strip?

1. Age of client
2. Maternal vital signs
3. Last menstrual period
4. A temporary interruption in recording
Rationale: Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 1 and 3 are irrelevant.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Considering the client's behavior, the nurse suspects she is dilated:

1. 1 to 2 cm
2. 3 to 4 cm
3. 5 to 7 cm
4. 8 to 10 cm
Rationale: During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

A nurse is assisting in performing Leopold's maneuvers. When the client asks what these are for, the nurse's best response is that these maneuvers help to determine:

1. Fetal position
2. Fetal heart rate
3. Duration of contractions
4. Frequency of contractions
Rationale: Leopold's maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal position and presentation. Options 2, 3, and 4 are incorrect.

A nurse assists the nurse-midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (−) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity for the client?

1. Up in chair
2. Ambulation
3. Complete bedrest
4. Bathroom privileges
Rationale: Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions.

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?

1. "It softens the muscles and joints of the pelvis."
2. "It is the primary hormone of milk production."
3. "It increases during pregnancy to stimulate basal metabolic rate."
4. "It maintains the uterine lining for implantation."
Rationale: 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:

1. Rounded and most favorable for a vaginal birth
2. Narrow and oval and not the most favorable for a vaginal birth
3. Wedge-shaped and narrow and nonfavorable for a vaginal birth
4. Flat and nonfavorable for a vaginal birth
Rationale: 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:

1. Turn the client onto her left side.
2. Instruct the client to lie in a prone position.
3. Place the client in a prone position with the head of the bed elevated.
4. Have the client stand for the procedure.
Rationale: 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. Options 2, 3, and 4 are incorrect client positions for measuring fundal height.

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:

1. Contracting and then consciously relaxing different muscle groups
2. 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
3. Massaging the abdomen during contractions using both hands in a circular motion
4. Instructing the significant other to stroke or massage a tightened muscle by the use of touch
Rationale: 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?

1. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy
2. Using a caring and supportive approach when dealing with the pregnant woman
3. Offering praise and reinforcement for compliance with treatment therapies
4. Providing the mother with pamphlets and booklets to read about the pregnancy
Rationale: 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?

1. Bicycling with the legs in the air
2. Swimming
3. Scuba diving
4. Low-weight gymnastics
Rationale: 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?

1. Visual disturbances
2. Rapid weight gain
3. Facial edema
4. Irregular, painless contractions
Rationale: 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:

1. Period of time before conception
2. First 2 weeks of fetal development following conception
3. Fetal development period from the beginning of the third week through the eighth week after conception
4. Longest period of fetal development
Rationale: 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:

1. Maintain the uterine lining for implantation.
2. Stimulate metabolism of glucose and convert the glucose to fat.
3. Prevent the involution of the corpus luteum and maintain the production of progesterone until the placenta is formed.
4. Stimulate uterine development to provide an environment for the fetus, and stimulate the breasts to prepare for lactation.
Rationale: 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?

1. Human chorionic gonadotropin (hCG)
2. Estrogen
3. Progesterone
4. Prolactin
Rationale: 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:

1. Lying down
2. In a sitting position
3. On the right side
4. On the left side
Rationale: 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. Options 1, 3, and 4 are incorrect, and these positions may cause physiological stress that will affect the blood pressure.

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?

1. Vulva
2. Fingers
3. Around the eyes
4. Around the abdomen
Rationale: 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?

1. Instruct the client to maintain bedrest for the remainder of the pregnancy.
2. Instruct the client that these are common and may occur throughout the pregnancy.
3. Contact the health care provider.
4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.
Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some women during pregnancy, options 1, 3, and 4 are unnecessary and inaccurate.

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:

1. Weeks 6 to 8
2. Weeks 8 to 10
3. Weeks 12 to 16
4. Weeks 20 to 22
Rationale: 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:

1. Rounded and most favorable for a vaginal birth
2. Narrow and oval and not the most favorable for a vaginal birth
3. Wedge-shaped and narrow and nonfavorable for a vaginal birth
4. Flat and nonfavorable for a vaginal birth
Rationale: 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:

1. Strengthen the pelvic floor in preparation for delivery.
2. Prevent urinary tract infections.
3. Reduce a backache.
4. Prevent ankle edema.
Rationale: Kegel exercises will assist to strengthen the pelvic floor. Pelvic tilt exercises will help reduce backaches. Instructing a client to drink 8 ounces of fluids six times a day will help prevent urinary tract infections. Leg elevation will assist in preventing ankle edema.

A nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
2. "I should drink 8 to 12 glasses of liquid a day, and I can count the tea, fruit juices, or milk that I drink."
3. "I should drink 8 to 12 glasses of liquid a day, and I can count the carbonated soft drinks that I consume."
4. "I should drink 8 to 12 glasses of liquid a day, and I can count the coffee that I drink."
Rationale: The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation: 8 to 12 glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.

A nurse is instructing a pregnant client on dietary sources of iron. Which of the following food selections made by the client demonstrates an understanding of teaching?

1. Milk
2. Fresh spinach
3. Potatoes
4. Cantaloupe
Rationale: Dietary sources of iron include lean meats, liver, shellfish, dark green, leafy vegetables, such as spinach, legumes, whole grains and enriched grains, cereals, and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C.

A nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to:

1. Help the mother prepare for labor and delivery.
2. Reduce excessive maternal stress and fatigue.
3. Prepare the 18-month-old child for maternal separation during hospitalization.
4. Avoid exposure to potential pathogens and resulting infections.
Rationale: A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. Use of appropriate resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Options 1, 3, and 4 are not primary purposes for use of resources with the pregnant cardiac client.

A nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:

1. Stimulate the labor process.
2. Avoid the necessity of a cesarean delivery.
3. Prevent dehydration and hypoxemia.
4. Eliminate the need for analgesic administration.
Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:

1. Schedule the counting periods in the morning when the fetal movement is highest.
2. Lie on the stomach when preparing to count the fetal movement.
3. Expect the baby to move at least 35 times in 3 hours.
4. Contact the health care provider if the baby's movements are fewer than 10 times in 2 hours.
Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

A nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to:

1. Avoid further stress on the maternal immune system.
2. Reduce the risks of anemia during pregnancy.
3. Minimize the possibility of preterm labor.
4. Minimize the risk of premature rupture of membranes.
Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 1 identifies the primary nursing management subject for the HIV-infected client.

A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed?

1. Oral intake of 15 mg of warfarin (Coumadin) daily
2. Intravenous infusion of heparin sodium 5000 units daily
3. Subcutaneous administration of heparin sodium 5000 units daily
4. Subcutaneous administration of terbutaline
Rationale: Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antepartum, intrapartum, and postpartum periods. Warfarin is contraindicated during pregnancy because it crosses the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not cross the placental barrier, is safe to use during pregnancy and would be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only.

A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

1. A 33-year-old gravida III
2. An adolescent with multiple heterosexual contacts
3. A 25-year-old client with a history of spontaneous abortions
4. A multigravida with a history of repeat cesarean deliveries
Rationale: Although all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors. The client profiles in options 1, 3, and 4 identify at-risk situations for a variety of obstetric risk factors but not necessarily HIV infection.

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in the:

1. Trendelenburg's position with the legs in stirrups
2. Semi-Fowler's position with a pillow under the knees
3. Prone position with the legs separated and elevated
4. Supine position with a wedge under the right hip
Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's, prone, or Trendelenburg's position with the legs in stirrups is not practical for this type of abdominal surgery.

A nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following most appropriately describes the mother's problem at this time?

1. Fear about what is happening
2. Lack of control over the situation
3. Inability to cope
4. Deficient sensory perception
Rationale: The mother is anxious and frightened and the most appropriate problem for the client at this time is fear about what is happening. No data in the question support the problems noted in the other options; although they may be a consideration for this client at some point during the hospitalized experience.

A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:

1. Placing the external fetal monitor over the fetus that is most anterior to the mother's abdomen
2. Placing the external fetal monitor over the fetus that is most posterior to the mother's abdomen
3. Placing external fetal monitors so that each fetal heart rate is monitored separately
4. Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus
Rationale: In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 1, 2, and 4 are incorrect because these actions would not provide information regarding the status of each fetus.

A nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

1. The umbilical cord shortens in length and changes in color
2. A soft and boggy uterus
3. Maternal complaints of severe uterine cramping
4. Changes in the shape of the uterus
Rationale: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness but not sudden uterine cramping.

A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage:

1. Is a form of biofeedback to enhance bearing-down efforts during delivery
2. Is light stroking of the abdomen to facilitate relaxation during labor
3. Is the application of pressure to the sacrum to relieve a backache
4. Stimulates uterine activity by contracting a specific muscle group while other parts of the body rest
Rationale: Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used prior to transition to promote relaxation and relieve mild to moderate pain. Options 1, 3, and 4 are incorrect descriptions.

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is isolated:

1. 1 cm above the ischial spines
2. 1 fingerbreadth below the symphysis pubis
3. 1 inch below the coccyx
4. 1 inch below the iliac crest
Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and noted as a negative number above the line and a positive number below the line. Options 2, 3, and 4 are incorrect.

A nurse assisting to monitor a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client to reflect an attitude of:

1. Excitement
2. Helplessness
3. Irritability
4. Seriousness
Rationale: In early labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth. Options 2, 3, and 4 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

A woman at 20 weeks of gestation calls the health care provider's office and speaks to a nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which of the following is the least helpful response to the client?

1. "This is an emergency; you should come to the clinic within the hour."
2. "Drink three glasses of water and lie on your left side for 1 hour."
3. "Palpate for contractions and if four or more are felt within 1 hour, you need to be seen by the health care provider."
4. "Tell me about your activity, food, fluid, and medication intake for the past 24 hours."
Rationale: The woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation. Option 4 addresses the process of data collection and is an important initial component of care.

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which priority action to assist in preventing a crisis from occurring during labor?

1. Reassure the client.
2. Administer oxygen as prescribed throughout labor.
3. Maintain strict asepsis.
4. Prevent bearing-down.
Rationale: During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. An intervention to prevent sickle cell crisis during labor includes administering oxygen as needed. Options 1, 3, and 4 are accurate information but not for the situation described in the question.

A nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is a cephalic presentation. The nurse understands that this is:

1. An abnormal presentation
2. The least favorable presentation
3. A presentation associated with prolonged labor
4. The common presentation
Rationale: The cephalic presentation is more favorable than others and is the most common. Abnormal presentations result in prolonged labor and are likely to necessitate a cesarean birth.

A nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which of the following at the client's bedside?

1. Code cart
2. Suction machine
3. Intravenous (IV) supplies
4. Nasogastric tube
Rationale: The client who is a gravida VI is at risk for possible uterine atony. An IV access is needed so that blood and medication can be administered if necessary. Options 1, 2, and 4 are unnecessary items.

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

1. "There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."
2. "There is no risk to the newborn of an HIV-infected mother during delivery."
3. "Newborns who contract HIV during delivery will show immediate symptoms."
4. "A newborn cannot contract HIV during delivery."
Rationale: There is a risk of transmission of HIV to a newborn at the time of delivery if the pregnant woman is HIV positive. Newborns may not exhibit symptoms for 18 months or more. Therefore the remaining options are incorrect.

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be appropriate?

1. "There is no need to be concerned if you don't have a fever or rash within the next 2 days."
2. "Be sure to tell the doctor on your next prenatal visit, but there is little risk in the second trimester."
3. "You should avoid all school-age children during pregnancy."
4. "You were wise to call. I will check your rubella titer screening results and we can identify immediately if interventions are needed."
Rationale: Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. Rubella titer screening is a standard antenatal test for women during their initial screening. The results of this screening test need to be checked to determine if interventions are necessary. Options 1, 2, and 3 are inappropriate statements and do not address the subject of the question.

A client calls the health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which of the following in the urine?

1. Estrogen
2. Progesterone
3. Human chorionic gonadotropin (hCG)
4. Follicle-stimulating hormone (FSH)
Rationale: In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests. Options 1, 2, and 4 are incorrect.

A pregnant client 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 bases the response on which of the following?

1. The breast changes are a result of the secretion of estrogen and progesterone.
2. The breasts become stretched because of weight gain.
3. The increased metabolic rate causes the breasts to become larger.
4. Cortisol secreted by the adrenals plays a factor in increasing the size and appearance of the breasts.
Rationale: During pregnancy the breasts change in both size and appearance. The increase in size is a result 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. Options 2, 3, and 4 are incorrect.

A nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as:

1. Exhaustion
2. Fear of losing control
3. Involuntary grunting
4. Valsalva's maneuver
Rationale: Pains, helplessness, and fear of losing control are possible client responses in the transition stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, and low-pitched grunting sounds usually indicate a woman is working effectively with contractions.

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines that the client's primary physiological need at this time is:

1. Change in position
2. Intravenous analgesia
3. Oral food and fluids
4. Rest between contractions
Rationale: The birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy and facilitates voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which improves fetal tolerance of the stress of labor. No data in the question indicate that option 1 is necessary. Option 2 is incorrect because this action would likely cause central nervous system depression in the infant. Option 3 is incorrect because food and fluids are likely withheld at this time, except for ice chips.

A nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client says:

1. "I'm having bloody show."
2. "My cervix is completely dilated."
3. "My membranes are now ruptured."
4. "The contractions are intense."
Rationale: The second stage of labor begins when the cervix is completely dilated and ends with the birth of the infant. Options 1, 3, and 4 can occur any time in labor.

A client delivers a viable male neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be:

1. Critical
2. Poor
3. Fair
4. Good
Rationale: The APGAR scoring system was designed to evaluate the physical condition of the newborn at birth and determine the immediate need for resuscitation. Scores range from 0 to 10. A score of 8 to 10 indicates a newborn in good condition.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is to:

1. Complete routine newborn care measures quickly.
2. Determine the parents' desires for contact with the newborn.
3. Encourage immediate breast-feeding.
4. Suggest the mother hold the newborn after the placenta is delivered.
Rationale: Although immediate contact may be important for attachment or breast-feeding, the parents' wishes concerning contact with their newborn must be supported and determined first. The remaining options would follow the initial intervention.

In providing initial care to the newborn following delivery, the priority action of the nurse is to:

1. Identify gestational age.
2. Identify the infant and mother.
3. Turn the infant's head to the side.
4. Record the number of umbilical vessels.
Rationale: The priority is to maintain an open airway. Turning the infant's head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.

A nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse responds to the client, knowing that the sex of the fetus can be visually recognizable as early as week:

1. 4
2. 6
3. 8
4. 12
Rationale: By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Options 1, 2, and 3 are incorrect.

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week?

1. Week 12
2. Week 18
3. Week 28
4. Week 32
Rationale: Surfactant, a substance needed to facilitate neonatal breathing, begins to be produced at approximately week 28. Therefore the remaining options are incorrect.

A nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at gestational week:

1. 5
2. 10
3. 16
4. 20
Rationale: The fetal heart rate can first be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound device is used, the fetal heart rate can be detected as early as 10 weeks of gestation.

A maternity nurse is providing an inservice educational session to nursing students regarding the process of conception. The nurse determines that a nursing student understands this process if the student states that fertilization of a mature ovum occurs in which of the following areas?

1. In the uterus
2. In the ovary
3. In the distal third of the fallopian tube
4. In the wall of the myometrium
Rationale: The mature ovum is transported through the fallopian tube by the muscular action of the tube and the movement of the cilia within the tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovary. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovum. The other options are incorrect.

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands about this infection when the client says:

1. "I know my baby will be immune from hepatitis for the first 2 months of life."
2. "I feel sad that my baby is going to be isolated in the nursery after my delivery."
3. "Hepatitis B will cause a severe eye infection in my baby."
4. "I am so glad that I can breast-feed my baby after she has been vaccinated."
Rationale: Although HBV is transmitted in breast milk, once serum immune globulin has been administered, the mother may breast-feed without risk to the newborn. Option 1 is incorrect. To reduce the possibility of hepatitis B virus being spread to the newborn, neonates routinely are vaccinated at birth. Options 2 and 3 are incorrect.

In the prenatal clinic, a nurse is gathering data from a new client for the health history information. What is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

1. Establish a therapeutic relationship between the nurse and pregnant client.
2. Use specific closed-ended questions.
3. Omit this area of questions because they are highly personal.
4. Apologize for the embarrassment that these questions may cause the client.
Rationale: The initial data collection interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned, purposeful communication that focuses on specific content. Options 2, 3, and 4 are incorrect and would not elicit correct client responses.

A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse determines that:

1. The client has the herpes simplex virus.
2. HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.
3. The newborn infant will have this disease at birth.
4. This client has contracted an airborne disease.
Rationale: Diagnosis depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA test. Options 1 and 4 are incorrect because HIV occurs primarily through the exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk of developing this infection.

A nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement by the client indicates an immediate need for further investigation?

1. "I don't like my face anymore. I always look like I have been crying."
2. "I don't like my breasts anymore. These silver lines are ugly."
3. "I don't like my stomach anymore. That brown line is disgusting."
4. "I don't like my figure anymore. My clothes are all too tight."
Rationale: Options 2, 3, and 4 are dealing with body image. Although these comments should not be ignored, the need for follow-up is not urgent. Option 1 is an implication of periorbital and facial edema, which could be indicative of gestational hypertension (GH). Because this is an adolescent who has not sought early prenatal care, she is at higher risk for the development of GH.

A nurse is collecting data from a client with placenta previa during an office visit. The nurse checks which of the following items as first priority?

1. Availability of support systems
2. Compliance with activity limitations
3. Signs of fetal distress
4. Client's understanding of her condition
Rationale: Although all of the options may be assessed, the safety of the mother-infant dyad is the priority. Signs of fetal distress is a primary concern, although the information gained through the other assessments may ultimately affect the well-being of the fetus.

A nurse is preparing to instruct a pregnant client about nutrition. The nurse plans to include which of the following in this client's teaching plan?

1. The nutritional status of the mother significantly influences fetal growth and development.
2. All mothers are at high risk for nutritional deficiencies.
3. Calcium is not important until the third trimester.
4. Iron supplements are not necessary unless the mother has iron deficiency anemia.
Rationale: Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements are prescribed routinely.

A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. The nurse immediately:

1. Places a gloved hand into the vagina and holds the presenting part off of the umbilical cord
2. Transports the client to the delivery room
3. Gently pushes the cord into the vagina
4. Summons for help from other staff members
Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should also place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. The nurse should summon for help, and other staff members should contact the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is also administered to the mother to increase fetal oxygenation.

A nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?

1. High-Fowler's
2. Upright
3. With the hips elevated
4. Semi-Fowler's
Rationale: When cord compression is suspected, the woman is immediately repositioned. The client may be turned from side to side or the hips elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hand-and-knees position may also reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves. Options 1, 2, and 4 are inappropriate positions and may cause further cord compression.

A nurse is monitoring a client who is in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, the nurse immediately:

1. Administers oxygen via face mask to the mother
2. Documents the findings
3. Transports the client to the delivery room
4. Increases the rate of an oxytocin (Pitocin) infusion
Rationale: Late decelerations are caused by uteroplacental insufficiency that occurs as a result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the immediate action in this situation.

A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately:

1. Monitors the contraction pattern
2. Checks the fetal heart rate
3. Notes the amount, color, and odor of the amniotic fluid
4. Prepares the client for immediate delivery
Rationale: When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 1 and 3 may also be a component of care but are not the immediate actions. There are no data to indicate that option 4 is necessary at this time.

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?

1. Pelvic exam
2. Chorionic villus sampling
3. Amniocentesis
4. Contraction stress test
Rationale: A client with painless vaginal bleeding is at risk for going into labor, and a contraction stress test is indicated. The concern is that if fetal oxygenation is only marginally adequate when the uterus is at rest, it may be decreased further during uterine contractions. Options 2 and 3 are not appropriate at this time. A pelvic examination is contraindicated when there is vaginal bleeding.

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client would indicate that the client understands her needs?

1. "There is no restriction on people who visit me."
2. "I should avoid stressful situations."
3. "My weight gain is not important."
4. "I should rest on my back."
Rationale: To avoid infections, visitors with active infections should not be allowed to visit the client. Stress causes increased heart workload. Too much weight gain causes an increase in body requirements and stress on the heart. Resting should be on the side to prevent vena cava syndrome (hypotensive syndrome) and to promote blood return.

A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?

1. Pain level is "0" and experiences a period of rest from labor contractions.
2. Pain level is "4" while a progressive labor pattern continues.
3. Pain level is "5" with increased amounts of bloody show.
4. Contractions are longer, stronger, and closer together.
Rationale: Effective pain management during labor does not interrupt the labor process but does provide relaxation and moderate pain relief to the mother. The increased bloody show and intensity of the contractions are not measures of effective pain management.

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted?

1. Decreased fetal heart rate variability
2. Presence of late decelerations
3. Presence of accelerations
4. Evidence of fetal bradycardia
Rationale: Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system. Decreased variability, late decelerations, and bradycardia are representative of decreased oxygenation of the fetus.

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client states:

1. "Breast-feeding after delivery is best for my baby."
2. "I can continue to hug and hold my other children."
3. "It may be 2 years before I know if my baby has HIV."
4. "My husband and I can still sleep together in the same bed."
Rationale: Breast-feeding is contraindicated if the mother is positive for HIV because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertain that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV.

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, the nurse determines that the best response would be which of the following?

1. "If you do not eat regular meals, you will hurt your baby."
2. "Can you tell me more about what you are eating?"
3. "I'll have the health care provider review your diet history."
4. "It does not matter anymore how much weight you gain."
Rationale: It is important for the nurse to obtain additional information from the client. In option 2, the nurse is using the therapeutic communication tool of validation and clarification in order to obtain more information. The other options will block communication. Option 1 devalues the client and shows disapproval. Option 3 is avoiding the subject, and option 4 provides false reassurance.

A 38-week gestational pregnant woman arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing:

1. The passage of the mucous plug
2. Abruptio placentae
3. Rupture of the amniotic sac
4. Placenta previa
Rationale: The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucous plug appears pink or as blood-tinged mucus. A ruptured amniotic sac would include findings such as a watery vaginal drainage. Findings of abruptio placentae include dark red vaginal bleeding and abdominal pain.

A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of:

1. Emotional immaturity
2. An undiagnosed psychiatric disorder
3. Acute anxiety and the need for support
4. A stubborn personality
Rationale: Any of the situations identified in the options may contribute to the reason for the client's behavior, but the most likely reason is anxiety. Option 3 is the only option that supports the information identified in the question. The client may be anxious about the unknown effects of complications, and the presence of a support person while dealing with a crisis is crucial. There are no data in the question to support options 1, 2, and 4.

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

1. "Urinary infections during pregnancy are common. Your baby will be fine."
2. "Your developing baby cannot acquire an infection from you during pregnancy."
3. "Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."
4. "You shouldn't worry about this because you received early prenatal care and are taking your prenatal vitamins."
Rationale: Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery. Appropriate antenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up repeat urine cultures. Option 3 is the only therapeutic response and is the response that identifies accurate information.

A nurse is collecting data on a pregnant woman who is human immunodeficiency virus (HIV) positive during the 32nd gestational week. The nurse reviews the data and determines that which finding requires further follow up?

1. Slight lower extremity edema
2. Increased shortness of breath and bilateral rales
3. Active fetal movement
4. Weight gain of 22 pounds
Rationale: HIV infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The finding in option 2 can be indicative of an opportunistic infection and requires followup.

A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. The nurse analyzes this data as indicative of:

1. Increased intracranial pressure
2. Dehydration
3. Decreased intracranial pressure
4. A normal finding
Rationale: The anterior fontanel is normally 2.5 to 5 cm in width and diamond shaped. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.

A nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client?

1. How to test for proteinuria
2. How to check for and manage preterm bleeding
3. How to manage the discomfort of early labor
4. How to check for signs of hypoglycemia and the required treatment
Rationale: In diabetes mellitus, the pancreas does not produce enough insulin for necessary carbohydrate metabolism. The physiological changes of pregnancy drastically alter insulin requirements. Pregnant diabetic clients should be taught to monitor themselves for hypoglycemia to minimize potential maternal and fetal effects that result from hypoglycemia. Testing for proteinuria is important for the mother with gestational hypertension. Management of preterm bleeding is taught to the mother with placenta previa. Managing the discomforts of early labor is important for all pregnant women.

A 15-year-old client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which of the following treatments for acne will likely be avoided with this client?

1. Topical erythromycin
2. Exfoliation
3. Cleansing with antibacterial soap
4. Oral tetracycline hydrochloride
Rationale: Tetracycline is avoided during pregnancy because it may cause discoloration of the child's teeth when they erupt. Options 1, 2, and 3 are acceptable measures to treat acne during pregnancy.

A nurse is providing instructions to a pregnant woman regarding measures that will strengthen the perineal floor muscles. The nurse instructs the client to:

1. Drink 8 ounces of fluid six times per day.
2. Wipe the perineal area anterior to posterior after toileting.
3. Perform Kegel exercises in 10 repetitions, three times per day.
4. Perform pelvic tilt exercises in 10 repetitions, three times per day.
Rationale: Kegel exercises strengthen the pelvic floor. Option 1 relates to hydration that is important for normal physiological body functioning. Option 2 will help prevent urinary tract infections. Pelvic tilt exercises will reduce backache.

A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which of the following statements by the nurse indicates an understanding of the problem?

1. "You feel you are having difficulty fulfilling your role as a wife."
2. "You are afraid your husband will go to dinner without you."
3. "You are not physically able to go to dinner and should stay at home."
4. "You should go to dinner. Others will understand if you don't feel well."
Rationale: There are no data to support the fear that the wife will be left at home. Options 3 and 4 are examples of giving advice and do not lead to open communication with the pregnant woman. Option 1 reflects a feeling that the woman may be having. By identifying this feeling, the nurse provides the opportunity for further discussion.

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which of the following statements by the client would identify the need for further teaching regarding the hemorrhoids?

1. "Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born."
2. "Hemorrhoids are aggravated by standing for long periods. I need to lie down periodically during the day to relieve the pressure."
3. "Hemorrhoids can be gently pushed back inside my body using a lubricant."
4. "Diet is very important in the treatment of hemorrhoids. Plenty of liquids and a balance of bulk in the diet are needed."
Rationale: Hemorrhoids are varicosities and are most likely to be precipitated during pregnancy by the pressure of the growing fetus inside the abdominal cavity. Standing aggravates the problem. Dietary factors such as fluids and roughage, and the technique of manual reduction should be included in the plan of care. Hormonal changes are not a factor.

A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which of the following is appropriate to suggest to the client?

1. Perform Kegel exercises during the play.
2. Limit fluid intake to 500 mL on the day of the play.
3. Wear a perineal pad to the play.
4. Have a friend videotape the play for her.
Rationale: Kegel exercises are useful to promote long-term bladder tone but will not be effective with one day's use. Limiting fluid intake can be harmful. A videotape will not satisfy the client's need to be present at the play. Wearing a perineal pad will give the client the security that she needs. The client should be instructed to remove a damp pad as soon as possible to decrease the incidence of infection.

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that goal achievement has occurred when the client states which of the following?

1. "I am eating three servings of cracked-wheat bread each day."
2. "I am eating fresh fruits and vegetables for snacks and for dessert each day."
3. "I am drinking 8 ounces of water with each meal."
4. "I eat two saltine crackers before I get up each morning."
Rationale: Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Cracked-wheat bread may abrade the tender gums; drinking water with meals has no direct effect on gums; saltine crackers before arising helps decrease nausea.

A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which of the following problems should receive highest priority?

1. Inability to perform activities
2. Expressing concern about appearance
3. Verbalizing fear about delivery
4. Dehydration
Rationale: For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, such as an interruption of blood flow to the respiratory system and placenta. Although options 1, 2, and 3 may be components of the plan of care at some point, fluid volume deficit is the priority.

A nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which of the following actions will the nurse take before the procedure to ensure the maintenance of fetal safety during the procedure?

1. Require that the client empty her bladder.
2. Test the ultrasound equipment to ensure proper functioning.
3. Teach the client the signs and symptoms of labor.
4. Prepare a local anesthetic to be used during the insertion of the spinal needle.
Rationale: Before 20 weeks of gestation, it is recommended to perform an amniocentesis with the bladder full. This pushes the uterus upward for better visualization. After week 20, the bladder is emptied before the test to minimize the risk of puncturing it during the test. The client does need to be taught about the signs and symptoms of labor because this action does not ensure fetal safety. The local anesthetic makes the insertion of the needle less painful but does not protect the fetus. The use of ultrasound to guide the procedure has greatly decreased the risk of fetal and placental damage during the procedure.

A pregnant client is a gravida III, para 0, abortus II. She is placed on bedrest at home because of preterm labor. The nurse provides information to the husband, knowing that which of the following will assist to promote family adaptation?

1. Teaching the husband to administer and titrate tocolytic agents
2. Teaching the husband to instruct the wife how to perform Kegel exercises
3. Teaching the husband to perform passive range of motion and provide back rubs for his wife
4. Telling the husband that sexual intercourse has probably caused the preterm labor
Rationale: Range-of-motion exercises will help maintain muscle tone during bedrest, and back rubs provide skin-to-skin contact and are comforting. The inclusion of the significant other promotes adaptation and decreases the sense of isolation. Option 4 will lead to guilt and maladaptation. The husband should not be expected to titrate medications. Kegel exercises are beneficial but will not provide the human-to-human contact that promotes family adaptation.

A client age 23 develops melasma during pregnancy. The nurse notes that the client has started wearing very heavy makeup. The client tells the nurse that she is fearful that her mate will reject her, and that she has decreased her social engagements drastically because of this change. The nurse determines that the client is experiencing which problem?

1. Concern about her appearance
2. Anxiety about the pregnancy
3. Need to isolate self from others
4. Inability to carry out expected roles
Rationale: Although the nurse might consider all of these problems initially, the information described in the question most clearly relates to concern about appearance. Anxiety is inaccurate because there is a physical focus for the problem: melasma. The client has decreased social engagements, but there is no indication that she has excluded all activities. There are insufficient data to support the inability to carry out expected roles.

A nurse employed in a health care provider's office is collecting information from a pregnant client. Which of the following statements made by the client likely indicates the need for psychological referral?

1. "I will never be able to lose my weight and regain a great figure. I feel ugly."
2. "I don't like the way I look. My husband could never find me attractive again."
3. "I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."
4. "I have terrible mood swings. I will be glad when this is all over."
Rationale: Options 1, 2, and 4 are feelings about self and body image that many women express during pregnancy. The statement in option 3 is much stronger and places blame on the fetus. The direction of anger to the fetus should be explored. The nurse may find that a psychological referral is appropriate.

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which of the following laboratory results indicates a physiological consequence of a result of this practice?

1. Hematocrit 37%
2. Hemoglobin 9.1 g/dL
3. Glucose 86 mg/dL
4. White blood cell count 12,400/mm3
Rationale: Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin. The other three laboratory values are within normal limits for the pregnant woman.

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding would indicate a serious nutritional disorder of pregnancy?

1. Ketone bodies in urine are negative.
2. Weight compared to last visit is a loss of 2.3 pounds.
3. Patellar reflex is 2+.
4. Chadwick's sign is positive.
Rationale: Weight loss along with the symptoms described in the question could indicate hyperemesis gravidarum. Ketone bodies, if present, would indicate protein wasting. Patellar reflexes would be used during magnesium sulfate administration. Chadwick's sign may be an indicator of pregnancy.

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. The nurse interprets these findings as indicating:

1. A negative test
2. A positive test
3. A suspicious test
4. An unsatisfactory test
Rationale: A reactive nonstress test (normal/negative) indicates a healthy fetus. A nonreactive nonstress test is an abnormal test and requires further followup. A suspicious test result also requires further followup. An unsatisfactory test cannot be interpreted because of the poor quality of the fetal heart rate findings.

A nurse is collecting data from a client who is pregnant with twins. The nurse understands that which of the following complications is likely associated with a twin pregnancy?

1. Maternal anemia
2. Postterm labor
3. Oligohydramnios
4. Gestational diabetes
Rationale: Maternal anemia occurs in a client pregnant with twins because the maternal system is nurturing more than one fetus. Preterm labor, rather than postterm labor is likely to occur. Hydramnios may be associated with a twin pregnancy as a result of increased renal perfusion from cross-vessel anastomosis with monozygotic twins. Option 4 is not a complication of a twin pregnancy.

A nurse is providing instructions to a client about preterm labor. The nurse would do which of the following as the effective method for teaching the client to monitor for preterm uterine contractions?

1. Palpate for uterine contractions at the same time as the client.
2. Provide a simple pamphlet with multiple illustrations.
3. Ask about contractions at each visit.
4. Attach the monitor to the client's abdomen and have her palpate at the same time.
Rationale: Option 1 uses teaching and learning principles. It includes the most direct way to determine the level of client understanding. The client may not be able to read well. The client may not understand what to feel for with contractions and may answer only to please the nurse. A monitor would be cost prohibitive and does not give human feedback.

A nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status to detect complications caused by:

1. Hypertrophy and increased contractility
2. The increase in circulating volume
3. Fetal cardiomegaly
4. Rh incompatibility
Rationale: Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase. This is especially important to monitor in the client whose heart may not tolerate this normal increase. Hypertrophy may result in cardiac disease, but the outcome would be a decrease in contractility, not an increase. Options 3 and 4 are related to the fetus, not the prenatal client.

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection the client questions everything the nurse does and behaves in an anxious manner. The appropriate nursing response or action at this time would be to:

1. Tell her not to worry.
2. Ignore her unfounded concerns, and continue.
3. Explain the purpose of the nurse's actions, and answer all questions.
4. Refer the client to a counselor.
Rationale: For the prenatal cardiac client, stress should be reduced as much as possible. It is important to be certain the woman understands the purpose of any procedures so she does not worry unnecessarily. Options 1, 2, and 4 are nontherapeutic at this time. Explaining the purpose of nursing actions will assist in decreasing the stress level of the client.

A perinatal client with a history of heart disease has been instructed on care at home. Which of the following statements if made by the client would indicate the need for further instructions?

1. "I need to avoid people with infections."
2. "I should avoid stressful situations."
3. "I need to watch for weight gain."
4. "It is best to rest on my right side."
Rationale: Stress causes increased cardiac workload. Too much weight gain causes an increase in body requirements and stress on the heart. To avoid infections, visitors with active infections should not be allowed to visit the client. It is best to rest on the left side to promote blood return.

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which of the following client problems does the nurse identify as important at this time?

1. Pain associated with the infection
2. Altered tissue integrity
3. Urinary tract infection
4. Fear about the safety of the fetus
Rationale: The primary concern for this client is safety of her fetus, not herself. Therefore the priority problem at this time is option 4. Option 3 is the client's diagnosis. Pain and altered tissue integrity may be seen in clients experiencing urinary tract infections, but the question includes no data to support either of the options.

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which of the following treatments would the nurse consider to be safe for this maternity client?