Deck 25: The Pregnant Woman

Question 1

The nurse is preparing to measure the abdomen of a client who is 24 weeks gestation. Which is the anticipated height of the fundus?

A) 22 cm.
B) 24 cm.
C) 26 cm.
D) 28 cm.

Answer 1

24 cm.

Question 2

The nurse is assessing a postpartum client and notes that the peri-pad has whitish-yellow discharge. Which term will the nurse use when documenting this finding in the medical record?

A) Postpartum bleeding.
B) Lochia rubra.
C) Lochia serosa.
D) Lochia alba.

Answer 2

Lochia alba.

Question 3

The nurse palpating a laboring client's contraction notes that it is mild. Which component of the contraction should the nurse associate the finding with?

A) Intensity.
B) Duration.
C) Frequency.
D) Length.

Answer 3

Intensity.

Question 4

A client's fundal height is slightly above the symphysis pubis. Based on this data, how many weeks gestation is the client?

A) 10-12 weeks.
B) 16 weeks.
C) 20-22 weeks.
D) 38 weeks.

Question 5

The nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odorless discharge from the vagina. Based on this data, which action by the nurse is the most appropriate?

A) Ask the client about vaginal discomfort.
B) Inquire about recent sexual intercourse.
C) Obtain a culture of the discharge.
D) Document the findings as normal.

Question 6

The nurse is examining a client who is 37 weeks pregnant. Which assessment finding would require immediate intervention by the nurse?

A) Patellar reflex 4+/0 - 4+ bilaterally.
B) Heart rate 104.
C) Trace protein in the urine.
D) Weight gain of two pounds in 2 months.

Question 7

The nurse is assisting the healthcare provider during a vaginal examination. The healthcare provider notes that the cervix has a bluish-purple change in coloration. Based on this data, which will the nurse document in the medical record?

A) Goodell sign.
B) Leukorrhea.
C) Chadwick sign.
D) Mucous plug.

Question 8

The nurse is interviewing a female client who reports no menstrual periods for 2 months and breast soreness. The nurse would document this data as which classification of signs of pregnancy?

A) Objective.
B) Probable.
C) Presumptive.
D) Positive.

Question 9

A client who is 38 weeks pregnant reports increased urinary frequency. Based on this data, which response by the nurse is indicated?

A) "Your reports are consistent with a urinary tract infection."
B) "I will need to check your blood sugar as excessive urination is associated with gestational diabetes."
C) "Reducing your fluid intake will be helpful to manage this problem."
D) "This is normal occurrence in the later stages of pregnancy."

Question 10

A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. Which information should the nurse include when addressing the client's concern? Select all that apply.

A) The stretch marks will fade but not disappear.
B) Cream will help the skin stay supple.
C) Cocoa butter lotions and creams will clear the marks completely.
D) The marks will lighten to a silvery tone after pregnancy.
E) Wearing supportive undergarments will help support the skin and reduce the appearance of the marks.

Question 11

The nurse is discussing dietary recommendations with a client who has been experiencing a larger than recommended weight gain during her pregnancy. The client reports reducing the empty calories and red meat while significantly increasing intake of fish, poultry, fresh fruits, and vegetables. Based on this data, which response by the nurse is the most appropriate?

A) "It looks like you have things under control. Do you have any other questions?"
B) "Have you considered seeing a dietitian for nutritional counseling?"
C) "Tell me more about the meat and fish you are eating each day."
D) "I think we should discuss the risky dietary choices you are making with the healthcare provider."

Question 12

The nurse examining a client notes a softening of the cervix. Which terminology should be documented to reflect the finding?

A) Goodell sign.
B) Hegar's sign.
C) Chadwick sign.
D) Ladin's sign.

Question 13

The healthcare provider is using Leopold maneuvers to assess fetal positioning. Which maneuver is used to assess the fetal back?

A) First.
B) Second.
C) Third.
D) Fourth.

Question 14

The nurse is preparing to assess the fetal heart tones for a client whose fetus is in the LOA position. Which maternal abdominal location should the nurse use to assess the fetal heart tones?

A) RUQ.
B) LUQ.
C) RLQ.
D) LLQ.

Question 15

The nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts. Which action by the nurse is the most appropriate?

A) Ask the client if she is preparing for breastfeeding.
B) Notify the healthcare provider.
C) Document the findings as normal.
D) Obtain a culture of the discharge immediately.

Question 16

The nurse is caring for a pregnant client who desires to know the estimated date of birth (EDB)for the baby. The client reports that the last menstrual period (LMP)was May 10. Using Naegele's rule, which date will the nurse share with client?

A) February 17.
B) May 17.
C) May 24.
D) January 3.

Question 17

The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require immediate intervention by the nurse?

A) "I have to get up during the night to void."
B) "I have not felt the baby move today."
C) "I am leaking a yellowish fluid from my breasts."
D) "I have been taking Tylenol (acetaminophen)for my backaches."

Question 18

The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection, the client reports she has not felt the baby move yet. Which response by the nurse is the most appropriate?

A) "We will listen for the heartbeat today."
B) "You need an ultrasound."
C) "Fetal movement may not be felt until the 18th week."
D) "Do you have reason to believe your baby is not ok?"

Question 19

A client at 33 weeks' gestation calls the healthcare provider's office and reports she was attempting to nap when she became dizzy and felt faint. Which assessment data is the priority in this situation?

A) The position the client was in during the nap period.
B) Dietary intake prior to the episode.
C) History of hyperemesis.
D) No additional data is needed as this is an isolated incident.

Question 20

While reviewing a pregnant client's medical record, the nurse notes that the cervix was soft in texture and nontender during the pelvic examination. Which is the appropriate terminology for the clinical finding?

A) Piskacek's sign.
B) Goodell sign.
C) Chadwick sign.
D) Hegar's sign.

Question 21

The nurse reviewing a client's 1 hour GTT notes that the results are 155 mg/dl. Which should the nurse interpret the findings to indicate?

A) The client needs to repeat the test.
B) The client has gestational diabetes.
C) The client does not have gestational diabetes.
D) The client should follow up with a 3 hour GTT.

Question 22

The nurse is discussing the recommended weight gain for a client with a singleton pregnancy. Which recommendation should the nurse reinforce?

A) 28 to 40 lbs.
B) 25 to 30 lbs.
C) 15 to 25 lbs.
D) 11 to 20 lbs.

Question 23

A newly pregnant client tells the nurse she takes daily herbal supplements. Which initial action should the nurse take?

A) Instruct the client to discuss the herbal supplementation with the healthcare provider.
B) Advise the client that the supplements may interfere with the prenatal
C) Instruct the client to stop taking the supplements.
D) Ask the client why she is taking supplements.

Question 24

A pregnant client with hepatitis B asks the nurse if their baby will be born with the virus. Which information should the nurse include in the discussion?

A) "Your baby is not at risk for the virus."
B) "Your baby will be tested immediately after birth."
C) "Your baby will receive an immunoglobulin after birth."
D) "The virus has been transmitted through the placenta."

Question 25

The nurse is examining a client in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?

A) Pulse of 98 beats per minute.
B) Weight gain of 1.5 pounds in a month.
C) Blood pressure of 148/94 mmHg.
D) Respiratory rate of 26 per minute.

Question 26

The nurse is preparing discuss self-care during pregnancy with a client. Which should the nurse include in this teaching session? Select all that apply.

A) Do not use soap on nipples.
B) Sleep 8-10 hours each night.
C) Eat four servings of dairy products daily.
D) Do not take iron supplements due to constipation.
E) Avoid resting in a back lying position.

Question 27

The nurse is preparing to obtain an obstetrical history from a client. Which question should the nurse include?

A) "Do you have a history of infertility?"
B) "What age did you become sexually active?"
C) "Have you ever had a sexually transmitted disease?"
D) "Have you had any spontaneous or induced abortions?"

Question 28

During a prenatal counseling session, a client tells the nurse she is concerned she may have a positive HIV test. Which statement by the nurse is indicated?

A) "I understand you are stressed about the outcome of the test."
B) "If you are HIV positive, your baby will also have HIV."
C) "Even if you do test HIV positive, preventive treatments have a good chance of providing protection for your baby."
D) "As long as you do not breastfeed and have a cesarean section, your baby will be protected."

Question 29

A client expresses concern for her unborn baby after she learns her hemoglobin level was higher before her pregnancy. Which information should the nurse be prepared to initially discuss?

A) Dietary intake.
B) Changes in physiology.
C) Supplemental iron intake.
D) Prenatal vitamin supplementation.

Question 30

A client is diagnosed with Group B Streptococcus at 37 weeks' gestation. Which prescribed treatment should the nurse be prepared to discuss?

A) A 7-day course of prescribed oral antibiotics.
B) Treatment with IV antibiotics during active labor.
C) Initiation of treatment during the postpartum period.
D) IM antibiotic treatment to facilitate a rapid treatment.

Question 31

The nurse is reviewing the risk factors of pregnancy for women over 35 yrs. Which should the nurse include? Select all that apply.

A) Hypertension.
B) Stillbirths.
C) Gestational diabetes.
D) Premature births.
E) Chromosomal abnormalities.