Question 1

The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to the health care provider?

Accepted Answer

11ecbb05_cbf6_4e9d_b433_333d27519b3e_MD0009_00 Painful genital lesions can be indicative of an outbreak of genital herpes simplex virus (HSV) and are a priority assessment finding to report to the health care provider. Herpes in pregnant women can be transmitted to the infant in utero (congenital HSV), perinatally, or postnatally as a result of direct contact with virus particles shed from the infected vulva, vagina, cervix, or perineum. Neonatal HSV infection has serious morbidity (eg, permanent neurologic sequelae) and mortality. Immediate antiviral therapy (eg, acyclovir) should be initiated to treat the active infection. Vaginal birth is not recommended in the presence of active lesions; cesarean birth helps reduce the risk of transmission to the newborn (Option C). (Option A) A systolic murmur (swooshing sound heard during S1) is a common finding in pregnancy. It results from increased total body volume (flow murmur) and usually resolves after birth. No further intervention is necessary if the client is asymptomatic. (Option B) Edema of the lower extremities is common in the third trimester, especially after long periods of standing. Pressure from the enlarged uterus slows venous return, contributing to dependent edema, which usually improves with rest and elevation of the legs. (Option D) Vaginal discharge increases at the end of pregnancy and may become mucoid and blood-tinged (pink/brownish) in the days preceding labor. This assessment finding may be a sign of approaching labor in this client at term gestation (39 weeks), but it is not the priority to report to the health care provider. Educational objective: Painful genital lesions during pregnancy are a priority assessment finding to report to the health care provider. Active herpes lesions that are present at the onset of labor indicate the need for cesarean birth.

Question 2

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply.

Accepted Answer

11ecbb05_cbf5_161a_b433_376e98ee8cf6_MD0009_00 Positive (diagnostic) signs of pregnancy represent conclusive evidence of pregnancy and cannot be attributed to any other etiology. These signs include a discernible fetal heartbeat heard by Doppler device, ultrasound visualization of the fetus, and fetal movement palpated or observed by the health care provider (HCP) (Options B and E). Presumptive (subjective) signs of pregnancy are self-reported by the client (eg, breast tenderness, nausea, amenorrhea). These signs may be related to other medical conditions and therefore cannot be considered diagnostic of pregnancy. Probable (objective) signs of pregnancy are observed by the HCP during assessment and examination (eg, cervical changes, positive pregnancy test). Combined with subjective signs, objective signs may be more indicative of pregnancy but may still have alternate causes. (Option A) Cervical softening is an objective sign of pregnancy as it may also be caused by other conditions that result in pelvic congestion (eg, use of hormonal contraceptives, uterine tumors). (Option C) A positive serum pregnancy test, which reports elevated levels of human chorionic gonadotropin, is considered an objective sign of pregnancy. Gestational trophoblastic disease can also cause positive results. (Option D) The client's perception of fetal movement, known as quickening, is a presumptive sign of pregnancy. Educational objective: Positive signs of pregnancy represent conclusive evidence of pregnancy. These signs include ultrasound visualization of the fetus, a distinguishable fetal heartbeat heard by Doppler device, and fetal movement palpated or observed by the health care provider.

Question 3

A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being "about 7-8 months." Which actions should the nurse anticipate? Select all that apply.

Accepted Answer

11ecbb05_cbf2_cc27_b433_a75d51cbd1a5_MD0009_00 Placenta previa is an abnormal implantation of the placenta resulting in partial or complete covering of the cervical os (opening). The condition is diagnosed by ultrasound. In clients reporting painless vaginal bleeding after 20 weeks gestation, placenta previa should be suspected. Placenta previa found early in pregnancy may resolve by the third trimester, but women with persistent placenta previa or hemorrhage require cesarean birth. A type and screen to determine blood type and Rh status is appropriate due to the potential for excessive blood loss and need for blood transfusion (Option A). Fetal well-being is assessed via continuous electronic fetal monitoring to help determine appropriate timing for birth (Option B). Large-bore IV access is established in anticipation of fluid resuscitation and administration of blood products (Option C). The client should also be monitored frequently for any changes in bleeding via pad counts (Option D). (Option E) Digital vaginal examinations are contraindicated in the presence of vaginal bleeding of unknown origin. When placenta previa is present, manual manipulation of the cervix can damage placental blood vessels, causing subsequent bleeding that can progress to hemorrhage. Clients with placenta previa are on pelvic rest (ie, no intercourse, nothing per vagina). Educational objective: Placenta previa is suspected in clients reporting painless vaginal bleeding after 20 weeks gestation. Clients with placenta previa are at high risk for hemorrhage. The nurse should initiate electronic fetal monitoring and pad counts, draw a type and screen, and initiate large-bore IV access. Digital vaginal examinations are contraindicated.

Question 4

The obstetric nurse is reviewing phone messages. Which client should the nurse call first?

Accepted Answer

11ecbb05_cbf4_c7f9_b433_f7936f809179_MD0009_00 Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin, naproxen) inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or to reduce fever. NSAIDs are pregnancy category C in the first and second trimesters and pregnancy category D in the third trimester. NSAIDs must be avoided during the third trimester due to the risk of causing premature closure of the ductus arteriosus in the fetus (Option D). During the first and second trimesters, NSAIDs should be taken only if benefits outweigh risks and under the supervision of a health care provider (HCP). (Option A) Beta lactam antibiotics (eg, amoxicillin, ceftriaxone [Rocephin]) are pregnancy category B. Diarrhea is a common side effect of beta lactams. Although diarrhea should be reported to the HCP, as it could indicate pseudomembranous (Clostridium difficile) colitis or lead to dehydration if prolonged, this client is not the priority. (Option B) Acetaminophen (pregnancy category B) is a common pain reliever and/or fever reducer used during pregnancy. Acetaminophen intake should not exceed 4 g per day, including any over-the-counter or prescription combination medications that contain acetaminophen. (Option C) Metronidazole (Flagyl) is an anti-infective and pregnancy category B. Dark-colored urine is an expected side effect of metronidazole and not cause for concern. Educational objective: Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in the third trimester due to risk of premature closure of the fetal ductus arteriosus. NSAIDs should be taken only under the direction and supervision of a health care provider during the first and second trimesters.

Question 5

The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning?

Accepted Answer

11ecbb05_cbf8_9890_b433_b79f2ca50f5d_MD0009_00 Symptoms of ectopic pregnancy may include lower abdominal and pelvic pain; amenorrhea, possibly followed by vaginal spotting or bleeding; and a palpable adnexal mass on pelvic examination. An ectopic pregnancy may implant in one of many locations outside the uterine cavity, including the fallopian tubes, ovaries, or abdominal cavity. As the ectopic pregnancy outgrows its environment, it may rupture, causing life-threatening maternal hemorrhage. Symptoms indicative of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain (Option D). Shoulder pain results from irritation of the diaphragm by intraabdominal blood. A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention. (Option A) Abdominal pain with an ectopic pregnancy may start out as mild, dull, and one-sided, and progress to severe and generalized as the pregnancy grows. However, a ruptured ectopic pregnancy is more dangerous than an unruptured ectopic pregnancy. (Option B) Pelvic inflammatory disease increases the risk for ectopic pregnancies. Although this important piece of the client's history raises suspicion for a diagnosis of ectopic pregnancy, it is not the most concerning finding. (Option C) Initially, a client with an ectopic pregnancy may report typical early pregnancy symptoms, such as morning sickness. Nausea and vomiting are not uncommon in ectopic pregnancies, and gastrointestinal distress may worsen after rupture. Educational objective: An ectopic pregnancy may rupture prior to diagnosis, causing life-threatening maternal hemorrhage. Symptoms of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain. Ruptured ectopic pregnancy is a surgical emergency requiring immediate intervention.

Question 6

The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider?

Accepted Answer

Anemia is a common complication of pregnancy, sometimes due to iron deficiency. During the second half of pregnancy, the fetus begins to store iron in preparation for extrauterine life and depletes maternal iron stores. Hemoglobin <11 g/dL (110 g/L) in the first or third trimester or <10.5 g/dL (105 g/L) in the second trimester is considered low. The nurse should evaluate a client with a hemoglobin of 9 g/dL (90 g/L) for symptoms of anemia (eg, fatigue, shortness of breath) and notify the health care provider because the client may require additional testing (eg, complete blood count, serum ferritin) and iron supplementation (Option A). (Option B) A 1-hour (50 g) oral glucose challenge test screens clients for gestational diabetes and is considered abnormal if blood glucose is ≥130-140 mg/dL (7.2-7.8 mmol/L). (Option C) Protein is not normally detected in the urine, but large amounts of protein in the urine (eg, ≥300 mg/24 hours, ≥1+ on urine dipstick) along with elevated blood pressure (eg, ≥140/90 mm Hg) may indicate preeclampsia. Trace protein is likely due to specimen contamination or recent illness. (Option D) During pregnancy, it is normal for the WBC count to increase, even in the absence of infection. Educational objective: Anemia during pregnancy occurs when hemoglobin is <11 g/dL (110 g/L) in the first or third trimester or <10.5 g/dL (105 g/L) in the second trimester. The nurse should evaluate clients with low hemoglobin for symptoms of anemia and anticipate additional testing and/or iron supplementation.

Question 7

The nurse is providing education to several first-trimester pregnant clients. Which client requires priority anticipatory teaching?

Accepted Answer

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus and potentially cause serious fetal harm (eg, stillbirth, malformations, blindness, mental disability). Pregnant clients should be advised to take precautions when gardening and thoroughly wash all produce to decrease exposure risk. (Option B) Weight gain recommendations vary by prepregnancy BMI. A 1.1- to 4.4-lb (0.5- to 2.0-kg) weight gain in the first trimester and approximately 1 lb (0.5 kg) per week thereafter is normal and expected for women with a healthy BMI. (Option C) Leukorrhea is a thin, milky white vaginal discharge that is normal during pregnancy and is due to increased levels of progesterone and estrogen. If discharge changes color, becomes malodorous, or causes itching/burning, further investigation is needed. (Option D) Exercise, particularly low-impact activities such as walking, swimming, and yoga, is recommended during pregnancy. Contact sports or activities with a risk for falls (eg, soccer, downhill skiing) should be avoided to prevent abdominal injuries. Educational objective: Toxoplasmosis is a parasitic infection acquired by exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis may transfer the infection to the fetus and potentially cause serious fetal harm. Pregnant clients should take precautions when gardening and thoroughly wash all produce to decrease exposure risk.

Question 8

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.

Accepted Answer

Pyrosis, or heartburn, is common during pregnancy due to an increase of the progesterone hormone and uterine enlargement that displaces the stomach. Progesterone relaxes smooth muscles, resulting in esophageal sphincter relaxation. Gastric contents are then regurgitated, usually causing a burning sensation behind the sternum. The nurse should educate the client about lifestyle changes for reducing heartburn, such as: Keep the head of the bed elevated using pillows Sit upright after meals Eat small, frequent meals (Option C) Avoid tight-fitting clothing Eliminate common dietary triggers (eg, fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint) (Option D) (Option A) Dairy products do not typically lead to heartburn and are an important source of calcium during pregnancy. (Option B) The client can minimize gastric distension, gastric acid production, and subsequent reflux by drinking small amounts of fluid while eating and avoiding overeating. The client should be instructed to cluster fluid intake between meals instead. (Option E) Lying down immediately after eating exacerbates reflux and may lead to more discomfort. Educational objective: Pyrosis is common during pregnancy due to an increase of the progesterone hormone, which causes the esophageal sphincter to relax. Lifestyle changes to reduce symptoms include eating smaller meals, avoiding trigger foods (eg, fried/fatty food), maintaining an upright position after meals, and drinking fluids mostly between meals.

Question 9

A client at 34 weeks gestation reports constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which recommendations should the nurse make for this client? Select all that apply.

Accepted Answer

Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which causes decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation. Interventions to prevent or treat constipation include: High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes High fluid intake: 10-12 cups of fluid daily Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics) Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin (Option A) Dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption. (Option D) Laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-counter stool softeners or laxatives. (Option E) Caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per cup and should therefore be consumed in moderation during pregnancy. Educational objective: Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12 cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing this with the health care provider.

Question 10

The nurse receives report on 4 first-trimester pregnant clients. Which client should the nurse assess first?

Accepted Answer

11ecbb05_cbf7_600e_b433_89bf2e9aef18_MD0009_00 An ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterine cavity, frequently in the fallopian tubes. Clients with ectopic pregnancies may report a positive pregnancy test, vaginal spotting/bleeding, and/or abdominal pain. If untreated, continued growth can lead to fallopian tube rupture, resulting in hemorrhage and hemodynamic compromise. Intra-abdominal bleeding can lead to referred shoulder pain, a classic sign of diaphragm irritation. Ruptured ectopic pregnancy requires emergency surgical intervention and hemodynamic support (eg, IV fluids, blood transfusion) (Option C). (Option A) In clients with hydatidiform mole or "molar pregnancy," the fetus is replaced by edematous, cystic chorionic villi. Clients experiencing molar pregnancy should anticipate intermittent, dark brown vaginal discharge until the pregnancy is evacuated. (Option B) Clients with hyperemesis gravidarum have excessive nausea and vomiting and weight loss, often requiring fluid replacement and antiemetic therapy. The condition is not usually life-threatening and does not take priority over ruptured ectopic pregnancy. (Option D) Clients who are Jehovah's Witnesses do not allow blood transfusions due to religious beliefs. Clients with threatened miscarriage usually report spotting but have a closed cervical os. Heavier bleeding requiring a blood transfusion may be more common with inevitable or incomplete miscarriages. Educational objective: Ectopic pregnancy occurs when a fertilized egg implants and begins to grow outside the uterus, often in the fallopian tubes. Rupture of an ectopic pregnancy results in hemorrhage and requires emergency surgery. Shoulder pain in a client with ectopic pregnancy indicates intra-abdominal bleeding from a rupture.

Question 11

The nurse is caring for a client at 30 weeks gestation who is hospitalized for preeclampsia. After reviewing the client's chart and performing an initial assessment, the nurse notes several abnormal findings. Which finding should the nurse discuss with the health care provider immediately?

Accepted Answer

11ecbb05_cbf8_235f_b433_ad6e1e6b4b07_MD0009_00 Placental abruption is a potential complication of preeclampsia related to hypertension that can be life-threatening to the client or fetus. It causes premature detachment of the placenta from the uterine wall, resulting in bleeding from uterine blood vessels. Common manifestations include abdominal pain, dark red vaginal bleeding, a rigid uterus, abnormal fetal heart rate patterns, and uterine tachysystole. Once placental abruption occurs, fetal distress and maternal hypovolemia can develop quickly. Therefore, the nurse should report vaginal bleeding to the health care provider (HCP) immediately because emergency cesarean birth is very common if the client's or fetus' condition deteriorates (Option A). (Option B) Swelling is a common feature of preeclampsia that does not require emergency action, but the nurse should report facial or hand swelling to the HCP. (Option C) Elevated liver enzymes are a severe feature of preeclampsia caused by impaired liver perfusion (end-organ damage) and are part of the diagnostic criteria for HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). HELLP syndrome requires prompt action because the definitive treatment is giving birth, but the client may be able to have labor induced. (Option D) A urine output of approximately <30 mL/hr may be an early sign of kidney damage (end-organ damage) secondary to preeclampsia; the nurse should report decreasing urine output and strictly monitor intake and output. Educational objective: Placental abruption is a severe complication of preeclampsia that can be life-threatening and requires emergency action. Manifestations include dark red vaginal bleeding, abdominal pain, a rigid uterus, abnormal fetal heart rate patterns, and uterine tachysystole.

Question 12

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment.  The client's blood type is O negative.  Which laboratory test should the nurse anticipate?

Accepted Answer

11ecbb05_cbf5_8b4b_b433_af3af41615dc_MD0009_00 During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this separation can occur at delivery or when trauma results in fetomaternal hemorrhage (eg, placental abruption after a motor vehicle collision). If an Rh-negative mother (eg, O negative blood type) is exposed to Rh-positive fetal blood (if the father is Rh positive), the pregnant client develops antibodies to the Rh antigen (ie, Rh sensitization), placing the current fetus and all future pregnancies at risk for serious complications (eg, hemolytic anemia). An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma) (Option B). Rh immune globulin (eg, RhoGAM) is administered to all Rh-negative pregnant clients at 28 weeks gestation and within 72 hours postpartum, as well as after any maternal trauma, to prevent the development of permanent Rh antibodies. RhoGAM is not effective once sensitization has occurred. (Option A) Perineal group B streptococcal cultures are routinely obtained at 35-37 weeks gestation to determine the need for antibiotics during labor to prevent neonatal infection. (Option C) Testing for rubella immunity is performed in the first trimester; nonimmune mothers receive the measles-mumps-rubella vaccine in the immediate postpartum period. (Option D) Serum alpha-fetoprotein is a blood test to screen for fetal neural tube defects. Educational objective: Indirect Coombs testing screens for Rh sensitization in Rh-negative mothers. If the test results are positive, the fetus and subsequent pregnancies are at risk for serious complications. Rh immune globulin (eg, RhoGAM) is given at 28 weeks gestation and within 72 hours postpartum as well as any time there is maternal trauma.

Question 13

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.

Accepted Answer

11ecbb05_cbf4_79d8_b433_4da70299dcb1_MD0009_00 Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic pregnancies occur in the fallopian tubes. Risk factors include recurrent sexually transmitted infections, tubal damage or scarring, intrauterine devices, and previous tubal surgeries (eg, tubal ligation for sterilization). Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed or delayed menses. Signs of subsequent hypovolemic (hemorrhagic) shock from ruptured ectopic pregnancy include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequently. (Options B and C) Distended jugular veins and lung crackles indicate volume overload. The main risk with ectopic pregnancy is hypovolemic (hemorrhagic) shock. Jugular veins would be flat in hypovolemic shock. Educational objective: The fallopian tubes are the most common site for an ectopic pregnancy. As the ectopic pregnancy grows and expands, rupture may occur, resulting in active bleeding that progresses to life-threatening hypovolemic (hemorrhagic) shock. Signs of ruptured ectopic pregnancy may include severe abdominal pain, dizziness, and referred shoulder pain.

Question 14

A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? Select all that apply.

Accepted Answer

11ecbb05_cbf2_56f6_b433_6bff5997b408_MD0009_00 In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option D). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option C). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs. As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option A). (Options B and E) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended. Educational objective: Clients with placenta previa are at risk for hemorrhage. Vaginal examinations are contraindicated, and pelvic rest is recommended to prevent disruption of placental vessels. A cesarean birth is planned prior to onset of labor.

Question 15

The nurse assesses a client at term gestation who reports having contractions for the last 2 hours. The client states, "I'm not sure, but I think my water broke." The nurse performs a nitrazine pH test, which turns blue. When documenting the results of the test, which client statement is most concerning to the nurse?

Accepted Answer

11ecbb05_cbf6_007c_b433_915934709816_MD0009_00 Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. A yellow, olive, or green color suggests that amniotic membranes are intact. A bluish color suggests probable rupture of membranes (ROM). However, the presence of blood or semen may result in a false positive, as serum and prostatic fluid are alkaline. A client history of recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen in the vagina (Option A). (Option B) Constant wetness of undergarments may indicate leaking amniotic fluid. This statement is not concerning and substantiates the positive nitrazine results and the client's history. (Option C) Occasional involuntary urine leakage is common late in the third trimester as the gravid uterus presses on the bladder. Urine is generally acidic and should not inhibit nitrazine testing or cause a false positive. (Option D) Many clients have never experienced spontaneous ROM, especially if previous labors were induced. This statement does not inhibit the nurse's ability to judge the accuracy of nitrazine results. Educational objective: A nitrazine pH test strip can differentiate between alkaline amniotic fluid and vaginal secretions or urine, which are acidic. Recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen (ie, an alkaline fluid) in the vagina.

Question 16

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention?

Accepted Answer

Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg, losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic, leading to fetal renal and cardiac abnormalities, and are contraindicated in all stages of pregnancy. (Option A) Prenatal supplements, especially folic acid and iron, are recommended during pregnancy. Although important, this is not a priority over discontinuing ACE inhibitors. (Option C) Leukorrhea, a whitish vaginal discharge, is common during the prenatal period. The client should be instructed to call the health care provider if the discharge is accompanied by other signs or symptoms, such as a foul odor, redness, or itching. (Option D) As the uterus enlarges, cramping may occur in the lower abdomen and inguinal region. This common finding can be caused by stretching of the round ligaments, and is usually not concerning in the absence of vaginal bleeding. Educational objective: Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are teratogenic and need to be discontinued when planning pregnancy.

Question 17

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum.  Which clinical manifestation should the nurse expect?

Accepted Answer

11ecbb05_cbf1_1e75_b433_2f54fb029eb4_MD0009_00 Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy that usually leads to considerable weight loss (ie, ≥5% of prepregnancy weight), fluid and electrolyte imbalances (eg, hypokalemia), and nutritional deficiencies. Clients with HG may require hospitalization for IV fluid replacement and antiemetic therapy. Routine laboratory assessment for HG includes urinalysis dipstick testing to monitor the client's health status. Expected findings include an elevated urine specific gravity and ketonuria (Option D). Urine specific gravity increases when urine is concentrated due to dehydration, and ketones are a by-product of the fat breakdown that occurs in starvation states. (Option A) Abdominal pain and fever are not expected findings with HG. Such findings, especially when associated with nausea and vomiting, should prompt further investigation for other causes (eg, gastroenteritis). (Option B) Elevated blood pressure (≥140/90 mm Hg) is not an expected finding in clients with HG due to dehydration and hypovolemia. Instead, hypotension and tachycardia are expected. (Option C) Proteinuria is not an expected finding in clients with HG but is associated with kidney disease or preeclampsia. Educational objective: Hyperemesis gravidarum (ie, excessive vomiting during pregnancy) leads to fluid and electrolyte imbalances (eg, hypokalemia, hypotension), weight loss of ≥5% of prepregnancy weight, nutritional deficiencies, and ketonuria. Urine ketones are expected because they are a by-product of fat breakdown, which occurs in starvation states.

Question 18

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago.  Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)?

Accepted Answer

Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. (Option B) Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. (Option C) Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. (Option D) A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection. Educational objective: Pica is the constant craving for and consumption of nonfood and/or nonnutritive food substances that may occur in pregnancy. It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful in these clients to screen for anemia.

Question 19

The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would best prevent neural tube defects?

Accepted Answer

Women who are planning on becoming pregnant should consume 400-800 mcg of folic acid daily. Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables (Option B). Inadequate maternal intake of folic acid during the critical first 8 weeks after conception (often before a woman knows she is pregnant) increases the risk of fetal neural tube defects (NTDs), which inhibit proper development of the brain and spinal cord. Common NTDs are spina bifida and anencephaly (lack of cerebral hemispheres and overlying skull). (Option A) Adequate calcium intake is especially important during the last trimester for mineralization of fetal bones and teeth, but it does not prevent NTDs. (Option C) Organ meats (eg, liver) may contain moderately high levels of folate but are consumed more for their high iron content, which can promote red blood cell formation and prevent maternal anemia. (Option D) A prenatal diet rich in omega-3 fatty acids is important for fetal neurologic function and is linked to a lower risk of preterm birth. Dietary sources include wild salmon, anchovies, flaxseed, and walnuts. Educational objective: Women who are planning to become pregnant should consume 400-800 mcg of folic acid daily to prevent neural tube defects (eg, spina bifida, anencephaly). Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables.

Question 20

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?

Accepted Answer

Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option A) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option B) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. (Option C) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective: HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications including placental abruption, stroke, and death may occur if HELLP syndrome is not treated immediately.

Exam 6: Maternal & Newborn Health

The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to the health care provider?

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply.

A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being "about 7-8 months." Which actions should the nurse anticipate? Select all that apply.

The obstetric nurse is reviewing phone messages. Which client should the nurse call first?

The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning?

The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider?

The nurse is providing education to several first-trimester pregnant clients. Which client requires priority anticipatory teaching?

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis) . Which of the following lifestyle changes should the nurse recommend? Select all that apply.

A client at 34 weeks gestation reports constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which recommendations should the nurse make for this client? Select all that apply.

The nurse receives report on 4 first-trimester pregnant clients. Which client should the nurse assess first?

The nurse is caring for a client at 30 weeks gestation who is hospitalized for preeclampsia. After reviewing the client's chart and performing an initial assessment, the nurse notes several abnormal findings. Which finding should the nurse discuss with the health care provider immediately?

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate?

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.

A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? Select all that apply.

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention?

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect?

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s) ?

The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would best prevent neural tube defects?

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?