Pregnancy, Labor, Childbirth, Postpartum -At Risk Test with
Answers Rated A
While auscultating the lungs of a client admitted adjustment does this statement most closely
with severe preeclampsia, the nurse identifies typify?
crackles. What inference does the nurse make 1. Taking-in
when considering the presence of crackles in the 2. Letting-go
lungs? 3. Taking-hold
1. Seizure activity is imminent. 4. Working-through - ANSWER -1. Taking-
2. Pulmonary edema has developed. in
3. Bronchial constriction was precipitated by the
stress of pregnancy. **By discussing the experience, the client is
4. Impaired diaphragmatic function was caused bringing it into reality; this is characteristic of the
by the enlarged uterus. - ANSWER -2. taking-in phase .
Pulmonary edema has developed.
A pregnant client with a history of preterm labor is
A client at term is admitted in active labor. She at home on bedrest. What instructions should a
has tested positive for HIV. Which intervention in teaching plan for this client include?
the standard orders should the nurse question as 1. Place blocks under the foot of the bed.
a risk to the fetus? 2. Sit upright with several pillows behind the
1. Sonogram back.
2. Nonstress test 3. Lie on the side with the head raised on a small
3. Sterile vaginal examination pillow.
4. Internal fetal scalp electrode - 4. Assume the knee-chest position at regular
ANSWER -4. Internal fetal scalp electrode intervals throughout the day. - ANSWER -3.
Lie on the side with the head raised on a small
**The electrode used for internal fetal monitoring pillow.
pierces the fetal scalp; fetal exposure to maternal
blood increases the risk of the fetus' contracting
HIV. A nurse is caring for a client who has severe
preeclampsia. For which characteristic of
eclampsia should the nurse monitor the client?
The nurse is counseling a pregnant client with 1. Seizures
type 1 diabetes about medication changes as 2. Anasarca
pregnancy progresses. Which medication will be 3. Excessive weight gain
needed in increased dosages during the second 4. Increased blood pressure - ANSWER -1.
half of her pregnancy? Seizures
1. Insulin
2. Antihypertensives
3. Pancreatic enzymes A nurse is assessing a postpartum client for signs
4. Estrogenic hormones - ANSWER -1. of an impending hemorrhage resulting from
Insulin laceration of the cervix. Besides monitoring the
client for a firm uterus, what other assessment is
important?
After an unexpected emergency cesarean birth 1. Slowed pulse rate
the client tells the nurse, "I failed natural 2. Increased blood pressure
childbirth." Which postpartum phase of 3. Persistent muscular twitching
1/8
, Pregnancy, Labor, Childbirth, Postpartum -At Risk Test with
Answers Rated A
4. Continuous trickling of blood - ANSWER -1. Fundal height
ANSWER -4. Continuous trickling of blood
**It is vital that a baseline measurement be
obtained, because increasing fundal height is a
A nurse is planning for the discharge of a crack- sign of concealed hemorrhage.
addicted 17-year-old mother and her newborn.
What is the most appropriate referral to meet the
mother's and infant's needs? What should be included in the plan of care for a
1. Legal aid client with class I cardiac disease during the last
2. Family court weeks of pregnancy?
3. Foster parent care 1. Administering penicillin, promoting periods of
4. Home health nurse - ANSWER -4. Home rest, and daily testing of urine for protein
health nurse 2. Maintaining bedrest, administering oxygen and
penicillin, and monitoring for cardiac
decompensation
A client is to undergo amniocentesis at 38 weeks' 3. Instituting seizure precautions and instructing
gestation to determine fetal lung maturity. What the client to report dyspnea, coughing,
lecithin/sphingomyelin ratio (L/S ratio) is palpitations, and increased fatigue
adequate for the nurse to conclude that the fetus' 4. Advising the client to limit stress, promoting
lungs are mature enough to sustain extrauterine rest after meals, and educating the client about
life? the analgesia and anesthesia used during labor -
1. 2:1 ANSWER -4. Advising the client to limit
2. 1:1 stress, promoting rest after meals, and educating
3. 1:4 the client about the analgesia and anesthesia
4. 3:4 - ANSWER -1. 2:1 used during labor
**The lecithin concentration increases abruptly at
35 weeks, reaching a level that is twice the When working with a client who has
amount of sphingomyelin, which decreases spontaneously aborted a pregnancy, it is
concurrently. At 30 to 32 weeks' gestation, the important for the nurse to first deal with his or her
amounts of lecithin and sphingomyelin are equal, own feelings about abortion, death, and loss so
indicating lung immaturity. A ratio of 1:4 does not that he or she may :
reflect fetal lung maturity; nor does a ratio of 3:4.1. Maintain control of the situation
2. Share personal grief with the clients
3. Allow the clients to express their grief
A client is admitted to the birthing unit with 4. Teach the clients how to cope effectively -
uterine tenderness and minimal dark-red vaginal ANSWER -3. Allow the clients to express
bleeding. She has a marginal abruptio placentae. their grief
The priority evaluation includes fetal status, vital
signs, skin color, and urine output. What **The nurse can be more sensitive to the needs
additional information is essential? of the client by addressing personal emotions
1. Fundal height first. Control is not, and should not be, the goal of
2. Obstetric history the nurse. The client's feelings, not the nurse's,
3. Time of the last meal should be the focus. A time of crisis is not the
4. Family history of bleeding disorders - time to teach; the client is not ready to learn.
2/8
Answers Rated A
While auscultating the lungs of a client admitted adjustment does this statement most closely
with severe preeclampsia, the nurse identifies typify?
crackles. What inference does the nurse make 1. Taking-in
when considering the presence of crackles in the 2. Letting-go
lungs? 3. Taking-hold
1. Seizure activity is imminent. 4. Working-through - ANSWER -1. Taking-
2. Pulmonary edema has developed. in
3. Bronchial constriction was precipitated by the
stress of pregnancy. **By discussing the experience, the client is
4. Impaired diaphragmatic function was caused bringing it into reality; this is characteristic of the
by the enlarged uterus. - ANSWER -2. taking-in phase .
Pulmonary edema has developed.
A pregnant client with a history of preterm labor is
A client at term is admitted in active labor. She at home on bedrest. What instructions should a
has tested positive for HIV. Which intervention in teaching plan for this client include?
the standard orders should the nurse question as 1. Place blocks under the foot of the bed.
a risk to the fetus? 2. Sit upright with several pillows behind the
1. Sonogram back.
2. Nonstress test 3. Lie on the side with the head raised on a small
3. Sterile vaginal examination pillow.
4. Internal fetal scalp electrode - 4. Assume the knee-chest position at regular
ANSWER -4. Internal fetal scalp electrode intervals throughout the day. - ANSWER -3.
Lie on the side with the head raised on a small
**The electrode used for internal fetal monitoring pillow.
pierces the fetal scalp; fetal exposure to maternal
blood increases the risk of the fetus' contracting
HIV. A nurse is caring for a client who has severe
preeclampsia. For which characteristic of
eclampsia should the nurse monitor the client?
The nurse is counseling a pregnant client with 1. Seizures
type 1 diabetes about medication changes as 2. Anasarca
pregnancy progresses. Which medication will be 3. Excessive weight gain
needed in increased dosages during the second 4. Increased blood pressure - ANSWER -1.
half of her pregnancy? Seizures
1. Insulin
2. Antihypertensives
3. Pancreatic enzymes A nurse is assessing a postpartum client for signs
4. Estrogenic hormones - ANSWER -1. of an impending hemorrhage resulting from
Insulin laceration of the cervix. Besides monitoring the
client for a firm uterus, what other assessment is
important?
After an unexpected emergency cesarean birth 1. Slowed pulse rate
the client tells the nurse, "I failed natural 2. Increased blood pressure
childbirth." Which postpartum phase of 3. Persistent muscular twitching
1/8
, Pregnancy, Labor, Childbirth, Postpartum -At Risk Test with
Answers Rated A
4. Continuous trickling of blood - ANSWER -1. Fundal height
ANSWER -4. Continuous trickling of blood
**It is vital that a baseline measurement be
obtained, because increasing fundal height is a
A nurse is planning for the discharge of a crack- sign of concealed hemorrhage.
addicted 17-year-old mother and her newborn.
What is the most appropriate referral to meet the
mother's and infant's needs? What should be included in the plan of care for a
1. Legal aid client with class I cardiac disease during the last
2. Family court weeks of pregnancy?
3. Foster parent care 1. Administering penicillin, promoting periods of
4. Home health nurse - ANSWER -4. Home rest, and daily testing of urine for protein
health nurse 2. Maintaining bedrest, administering oxygen and
penicillin, and monitoring for cardiac
decompensation
A client is to undergo amniocentesis at 38 weeks' 3. Instituting seizure precautions and instructing
gestation to determine fetal lung maturity. What the client to report dyspnea, coughing,
lecithin/sphingomyelin ratio (L/S ratio) is palpitations, and increased fatigue
adequate for the nurse to conclude that the fetus' 4. Advising the client to limit stress, promoting
lungs are mature enough to sustain extrauterine rest after meals, and educating the client about
life? the analgesia and anesthesia used during labor -
1. 2:1 ANSWER -4. Advising the client to limit
2. 1:1 stress, promoting rest after meals, and educating
3. 1:4 the client about the analgesia and anesthesia
4. 3:4 - ANSWER -1. 2:1 used during labor
**The lecithin concentration increases abruptly at
35 weeks, reaching a level that is twice the When working with a client who has
amount of sphingomyelin, which decreases spontaneously aborted a pregnancy, it is
concurrently. At 30 to 32 weeks' gestation, the important for the nurse to first deal with his or her
amounts of lecithin and sphingomyelin are equal, own feelings about abortion, death, and loss so
indicating lung immaturity. A ratio of 1:4 does not that he or she may :
reflect fetal lung maturity; nor does a ratio of 3:4.1. Maintain control of the situation
2. Share personal grief with the clients
3. Allow the clients to express their grief
A client is admitted to the birthing unit with 4. Teach the clients how to cope effectively -
uterine tenderness and minimal dark-red vaginal ANSWER -3. Allow the clients to express
bleeding. She has a marginal abruptio placentae. their grief
The priority evaluation includes fetal status, vital
signs, skin color, and urine output. What **The nurse can be more sensitive to the needs
additional information is essential? of the client by addressing personal emotions
1. Fundal height first. Control is not, and should not be, the goal of
2. Obstetric history the nurse. The client's feelings, not the nurse's,
3. Time of the last meal should be the focus. A time of crisis is not the
4. Family history of bleeding disorders - time to teach; the client is not ready to learn.
2/8
