Exam (elaborations)
Chapter 25 (Prenatal) & 31 (Newborn Care) (1).
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- Nursing 2024
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- Nursing 2024
Chapter 25 (Prenatal) & 31 (Newborn Care) (1).
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Chapter 25 (Prenatal) & 31 (Newborn Care)The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis.
What instruction should the nurse provide?
1. Strict bed rest required after procedure
2. Hospitalization necessary for 24 hours after procedure
3. Informed consent needs to be signed before procedure
4. A fever is expected after procedure because of the trauma to the abdomen - CORRECT
ANSWER-3
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she
has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the
client?
1. "Come to the clinic immediately"
2. "The vaginal discharge may be bothersome, but is a normal occurrence."
3. "Report to the ED at the maternity center immediately"
4. "Use tampons if the discharge is bothersome, but be sure to change them every 2 hours" -
CORRECT ANSWER-2
A nonstress test is performed on a pregnant client and the results indicate nonreactive findings.
The HCP prescribes a contraction stress test and the results are documented as negative. How
should the nurse document this finding?
1. A normal test result
2. An abnormal test result
3. A high risk for fetal demise
4. The need for a c-section - CORRECT ANSWER-1
A rubella titer result of a 1 day postpartum client is less than 1:8, and a rubella virus vaccine is
prescribed to be administered before discharge. The nurse provides which information to the client
about the vaccine? Select all that apply.
1. Breastfeeding (BF) needs to be stopped for 3 months
2. Pregnancy needs to be avoided for 1 - 3 months
3. The vaccine is administered by the subcutaneous route
4. Exposure to immunosuppressed individuals needs to be avoided
5. A hypersensitivity reaction can occur if the client has an allergy to eggs
6. The area of the injection needs to be covered with a sterile gauze for 1 week - CORRECT
ANSWER-2, 3, 4, 5
The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts".
Which statement by the client indicates need for further instruction?
1. "I will record the # of movements or kicks"
2. "I need to lie flat on my back to perform this procedure"
3. "If I count fewer than 10 kicks in a 2 hour period I should count the kicks again over the next 2
hours"
, 4. "I should place my hands on the largest part of my abdomen and concentrate of the fetal
movements to count the kicks" - CORRECT ANSWER-2
The nurse is performing an assessment of a pregnant client who is 28 weeks of gestation. The
nurse measures the fundal height in cm, and notes it is approximately 30 cm. How should the
nurse interpret this finding?
1. The client is measuring large for gestational age
2. The client is measuring small for gestational age
3. The client is measuring normal for gestational age
4. More evidence is needed to determine size for gestational age - CORRECT ANSWER-3
The nurse is performing an assessment on a client who suspects that she is pregnant and is
checking the client for probably signs of pregnancy. The nurse should assess for which probable
signs of pregnancy? Select all that apply.
1. Ballotment
2. Chadwick's sign
3. Uterine enlargement
4. Positive pregnancy test
5. Fetal heart rate detected by nonelectronic device
6. Outline of fetus via radiography or ultrasonography - CORRECT ANSWER-1, 2, 3, 4
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing
irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions.
On the basis of the finding, which nursing action is appropriate?
1. Contact HCP
2. Instruct client to maintain bed rest for the remainder of the pregnancy
3. Inform the client that these contractions are common and may occur throughout the pregnancy
4. Call the maternity unit and inform them that the client will be admitted in a preterm labor
condition - CORRECT ANSWER-3
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day
of her last normal menstrual period was October 19, 2018. Using Nagele's rule, which expected
date of delivery should the nurse document in the client's chart?
1. July 12, 2019
2. July 26, 2019
3. August 12, 2019
4, August 26, 2019 - CORRECT ANSWER-2
The nurse is collecting data during an 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 tells the nurse
that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what
should the nurse document in the client's chart?
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 - CORRECT ANSWER-2
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