MATERNAL FINAL
A home health nurse is teaching a client who is breastfeeding about managing breast
engorgement. Which of the following client statements indicates understanding of the
teaching?
"I'll let my baby drain one breast at each feeding."
"I'll try drinking herbal tea to reduce the engorgement."
"I'll apply cold compresses 20 minutes before each feeding."
"I'll feed my baby every 2 hours." - ANS-"I'll feed my baby every 2 hours."
\A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured
membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F).
Besides notifying the provider, which of the following is an appropriate nursing action?
Recheck the client's temperature in 4 hr.
Administer glucocorticoids intramuscularly.
Assess the odor of the amniotic fluid.
Prepare the client for emergency cesarean section. - ANS-Assess the odor of the amniotic
fluid.
\A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a
healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting
to cry. Which of the following is a priority action by the nurse?
Assist the family to identify prior use of positive coping skills in family crises.
Ask the client if she has considered harming her newborn.
Anticipate a prescription by the provider for an antidepressant.
Reinforce postpartum and newborn care discharge teaching. - ANS-Ask the client if she has
considered harming her newborn.
\A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she
has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination
by the provider, the client is told that the fetus has died and that the placenta, fetus, and
tissues remain in the uterus. How should the nurse document these findings?
Incomplete miscarriage
Missed miscarriage
Inevitable miscarriage
Complete miscarriage - ANS-Missed miscarriage
,\A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant.
The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein
(MSAFP) screening for which of the following clients?
A client who has mitral valve prolapse
A client who has been exposed to AIDS
All of the clients
A client who has a history of preterm labor - ANS-All of the clients
\A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what
to do when her newborn cries persistently. Which of the following strategies should the nurse
suggest? (Select all that apply.)
Take the newborn for a ride in the car.
Keep the newborn in the center of a large crib.
Carry the newborn in a front or back pack.
Swaddle the newborn in a receiving blanket.
Allow the newborn to continue crying. - ANS-Take the newborn for a ride in the car.
Carry the newborn in a front or back pack.
Swaddle the newborn in a receiving blanket.
\A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and
undergoing a contraction stress test. The test results are negative. Which of the following
interpretations of this finding should the nurse make?
There is evidence of cervical incompetence.
There is no evidence of two or more accelerations in fetal heart rate in 20 min.
There is no evidence of uteroplacental insufficiency.
There are less than 3 uterine contractions in a 10-min period. - ANS-There is no evidence of
uteroplacental insufficiency.
\A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who
asks about the signs that precede the onset of labor. Which of the following should the nurse
identify as a sign that precedes labor?
Decreased vaginal discharge
A surge of energy
Urinary retention
Weight gain of 0.5 to 1.5 kg - ANS-A surge of energy
, \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?
"It's a minor inconvenience, which you should ignore."
"In most cases it only lasts until the 12th week, but it will continue if you have poor bladder
tone."
"There is no way to predict how long it will last in each individual client."
"It occurs during the first trimester and near the end of the pregnancy." - ANS-"It occurs
during the first trimester and near the end of the pregnancy."
\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? (Select all that apply.)
Eczema
Psoriasis
Linea nigra
Chloasma
Striae gravidarum - ANS-Linea nigra
Chloasma
Striae gravidarum
\A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of
gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks;
the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the
GTPAL system, which of the following describes the client's current status?
4-0-1-2-2
3-0-2-0-2
2-0-0-2-0
4-2-0-2-2 - ANS-4-0-1-2-2
\A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new
diagnosis of gestational diabetes. Which of the following statements by the client indicates a
need for further teaching?
"I should limit my carbohydrates to 50% of caloric intake."
"I will reduce my exercise schedule to 3 days a week."
"I will take my glyburide daily with breakfast."
"I know I am at increased risk to develop type 2 diabetes." - ANS-"I will reduce my exercise
schedule to 3 days a week."
A home health nurse is teaching a client who is breastfeeding about managing breast
engorgement. Which of the following client statements indicates understanding of the
teaching?
"I'll let my baby drain one breast at each feeding."
"I'll try drinking herbal tea to reduce the engorgement."
"I'll apply cold compresses 20 minutes before each feeding."
"I'll feed my baby every 2 hours." - ANS-"I'll feed my baby every 2 hours."
\A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured
membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F).
Besides notifying the provider, which of the following is an appropriate nursing action?
Recheck the client's temperature in 4 hr.
Administer glucocorticoids intramuscularly.
Assess the odor of the amniotic fluid.
Prepare the client for emergency cesarean section. - ANS-Assess the odor of the amniotic
fluid.
\A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a
healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting
to cry. Which of the following is a priority action by the nurse?
Assist the family to identify prior use of positive coping skills in family crises.
Ask the client if she has considered harming her newborn.
Anticipate a prescription by the provider for an antidepressant.
Reinforce postpartum and newborn care discharge teaching. - ANS-Ask the client if she has
considered harming her newborn.
\A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she
has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination
by the provider, the client is told that the fetus has died and that the placenta, fetus, and
tissues remain in the uterus. How should the nurse document these findings?
Incomplete miscarriage
Missed miscarriage
Inevitable miscarriage
Complete miscarriage - ANS-Missed miscarriage
,\A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant.
The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein
(MSAFP) screening for which of the following clients?
A client who has mitral valve prolapse
A client who has been exposed to AIDS
All of the clients
A client who has a history of preterm labor - ANS-All of the clients
\A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what
to do when her newborn cries persistently. Which of the following strategies should the nurse
suggest? (Select all that apply.)
Take the newborn for a ride in the car.
Keep the newborn in the center of a large crib.
Carry the newborn in a front or back pack.
Swaddle the newborn in a receiving blanket.
Allow the newborn to continue crying. - ANS-Take the newborn for a ride in the car.
Carry the newborn in a front or back pack.
Swaddle the newborn in a receiving blanket.
\A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and
undergoing a contraction stress test. The test results are negative. Which of the following
interpretations of this finding should the nurse make?
There is evidence of cervical incompetence.
There is no evidence of two or more accelerations in fetal heart rate in 20 min.
There is no evidence of uteroplacental insufficiency.
There are less than 3 uterine contractions in a 10-min period. - ANS-There is no evidence of
uteroplacental insufficiency.
\A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who
asks about the signs that precede the onset of labor. Which of the following should the nurse
identify as a sign that precedes labor?
Decreased vaginal discharge
A surge of energy
Urinary retention
Weight gain of 0.5 to 1.5 kg - ANS-A surge of energy
, \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?
"It's a minor inconvenience, which you should ignore."
"In most cases it only lasts until the 12th week, but it will continue if you have poor bladder
tone."
"There is no way to predict how long it will last in each individual client."
"It occurs during the first trimester and near the end of the pregnancy." - ANS-"It occurs
during the first trimester and near the end of the pregnancy."
\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? (Select all that apply.)
Eczema
Psoriasis
Linea nigra
Chloasma
Striae gravidarum - ANS-Linea nigra
Chloasma
Striae gravidarum
\A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of
gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks;
the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the
GTPAL system, which of the following describes the client's current status?
4-0-1-2-2
3-0-2-0-2
2-0-0-2-0
4-2-0-2-2 - ANS-4-0-1-2-2
\A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new
diagnosis of gestational diabetes. Which of the following statements by the client indicates a
need for further teaching?
"I should limit my carbohydrates to 50% of caloric intake."
"I will reduce my exercise schedule to 3 days a week."
"I will take my glyburide daily with breakfast."
"I know I am at increased risk to develop type 2 diabetes." - ANS-"I will reduce my exercise
schedule to 3 days a week."
