N3610 Quiz 1 | Questions, Answers and Rationales

N3610 Quiz 1 | Questions, Answers and Rationales A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? A. Expulsion of a blood-tinged mucous plug B. Continuous contraction lasting 2 min C. Pressure on the perineum causing the client to bear down D. Expulsion of clear fluid from the vagina Rationale: A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately. A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching? A. "You will need to increase your calcium intake during breastfeeding." B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy." C. "Vitamin E requirements decline during pregnancy due to the increase in body fat." D. "You will need to double your intake of iron during pregnancy." Rationale: During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client's red blood cell volume. A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching? A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." B. "The sex of the baby is determined by week 8 of pregnancy." C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy." D. "You will first feel your baby move in week 24 of pregnancy." Rationale: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation. A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? A. The presenting part is 1cm above the ischial spines. B. The presenting art is 1cm below the ischial spines. C. The cervix is 1cm dilated. D. The cervix is effaced 1cm. Rationale: Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus 1, then the presenting part is 1cm above the ischial spines. A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? A. "This will determine is there is more than one fetus." B. "It is useful for estimating fetal age." C. "It assists in identifying the location of the placenta and fetus." D. "This is a screening tool for spina bifida." Rationale: Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a durtiong of 1min and a frequency of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54mmHg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Have the client void. Rationale: Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess. A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately? A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions. B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors. C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes. D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache. Rationale: These findings indicate that the client's condition is worsening and are signs of severe preeclampsia. They should be reported to the provider immediately. Other manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant pain. A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse perform? A. Prepare for a cesarean birth. B. Assist the client to an upright position. C. Prepare for an immediate vaginal delivery. D. Assist the client to turn onto her side. Rationale: Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range. A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate is 130 to 150/min, but there has been no fetal movement for 15min. Which of the following actions should the nurse perform? A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Encourage the client to walk around without the monitoring unit for 10min, then resume monitoring. C. Offer the client a snack of orange juice and crackers. D. Turn the client onto her left side. Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? A. Shortly after giving birth B. In the third trimester C. Immediately D. During her next attempt to get pregnant Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome. A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (SATA) A. Eczema B. Psoriasis C. Linea nigra D. Chloasma E. Striae gravidarum Rationale: Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy. A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? A. Vertex B. Shoulder C. Breech D. Mentum Rationale: An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation. A nurse is caring for a client who is at 18 weeks gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? A. Ballottement B. Lightening C. Quickening D. Chloasma Rationale: Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement. A nurse in a prenatal clinic is caring for a client who is at 38 weeks gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? A. There is no evidence of cervical incompetence. B. There is no evidence of two or more accelerations in fetal heart rate in 20 min. C. There is no evidence of uteroplacental insufficiency. D. There are less than 3 uterine contractions in a 10 min period. Rationale: A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations. A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? A. 3cm above the umbilicus B. Slightly above the umbilicus C. Slightly below the umbilicus D. 3cm below the umbilicus Rationale: At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation. A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15weeks of gestation. Which of the following should be included in the teaching? A. "The test will be performed if your baby's heart beat is heard." B. "This test will determine if your baby's lungs are mature." C. "This test requires the presence of amniotic fluid." D. "After the test, you will be given Rh0 immune globulin since you are Rh positive." Rationale: Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation. A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? A. "These exercises help prevent constipation." B. "These exercises help pelvic muscles to stretch during birth." C. "They can help reduce back aches." D. "They can prevent further stretch marks." Rationale: Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A. "It's a minor inconvenience, which you should ignore." B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." C. "There is no way to predict how long it will last in each individual client." D. "It occurs during the first trimester and near the end of the pregnancy." Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder. A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? A. "You should not receive the rubella vaccine while breastfeeding." B. "You should receive a varicella vaccine before you deliver." C. "You can receive an influenza vaccination during pregnancy." D. "You cannot receive the Tdap vaccine until after you deliver." Rationale: It is recommended that pregnant women receive annual influenza vaccinations. A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A. Left lower B. Right lower C. Left upper D. Right upper Rationale: Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant. A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? A. "Ambivalent feelings are quite common for women early in pregnancy." B. "Perhaps you should see a counselor to discuss these feelings further." C. "Have you spoken to your mother about these feelings?" D. "Don't worry. You'll be fine once the baby is born." Rationale: This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy. A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A. "This will occur during the last trimester of pregnancy." B. "This will happen by the end of the first trimester of pregnancy." C. "This will occur between the fourth and fifth months of pregnancy." D. "This will happen once the uterus begins to rise out of the pelvis." Rationale: Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks. A nurse is caring for a client who is scheduled for a amternal serum-alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? A. This test assesses fetal lung maturity. B. It assesses various markers of fetal well-being. C. This test identifies an Rh incompatibility between the mother and fetus. D. It is a screening test for spinal defects in the fetus. Rationale: The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected neural tube defects (NTDs) and abdominal wall defects. These include spina bifida, microcephaly, and anencephaly. This tool is the basis for further testing, such as amniocentesis and specialized ultrasounds. A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she in in labor. Which of the following findings confirm to the nurse that the client is in labor? A. Cervical dilation B. Reports of pain above the umbilicus C. Brownish vaginal discharge D. Amniotic fluid in the vaginal vault Rationale: Cervical dilation and effacement are indications of true labor. A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? A. Apply fundal pressure. B. Observe for the presence of a nuchal cord. C. Observe for crowning. D. Prepare to administer oxytocin. Rationale: In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent. A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? A. "I should drink about 2 liters of fluid each day." B. "I should not drink alcoholic beverages during my pregnancy." C. "I can have a moderate amount of caffeine daily." D. "I should increase my calcium intake to 1,500mg per day." Rationale: A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass. A nurse is providing teaching to a client who is planning on becoming pregnant about the changes she should expect. Identify the sequence of maternal changes. A. Quickening B. Lightening C. Goodell's sign D. Amenorrhea D C A B Rationale: Amenorrhea, a presumptive sign of pregnancy, is one of the first physiological indications of pregnancy that occurs by 4 weeks of gestation. Goodell's sign, a probable sign of pregnancy, is the next of physiological indications to occur. Goodell's sign is the softening of the cervix that typically occurs at 5 to 6 weeks of gestation. Quickening, the mother's perception of the first fetal movement, is a presumptive sign of pregnancy that typically occurs between 16 and 20 weeks of gestation. Lightening is the last of these physiological signs of pregnancy to occur. As the fetus descends into the pelvic cavity the fundal height decreases, which typically occurs between 38 and 40 weeks of gestation. A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? 0504 - May 4th Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. B. The client is immune to the rubella virus. C. The client requires a rubella vaccination at this time. D. The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. A nurse is caring for a client who is primigravida, at term, and having contractions but is statins that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membranes B. Changes in the cervix