Chapter 13 Antepartum Nursing Assessment My Nursing Test Banks

Olds Maternal-Newborn Nursing and Womens Health, 10e (Davidson)

Chapter 13 Antepartum Nursing Assessment

1) While completing the medical and surgical history during the initial prenatal visit, the 16-year-old primigravida interrupts with Why are you asking me all these questions? What difference does it make? Which statement would best answer the clients questions?

1. We ask these questions to detect anything that happened in your past that might affect the pregnancy.

2. We ask these questions to see whether you can have prenatal visits less often than most clients do.

3. We ask these questions to make sure that our paperwork and records are complete and up to date.

4. We ask these questions to look for any health problems in the past that might affect your parenting.

Answer: 1

Explanation: 1. The course of a pregnancy depends on a number of factors, including the past pregnancy history (if this is not a first pregnancy), prepregnancy health of the woman, presence of disease/illness states, family history, emotional status, and past health care.

Page Ref: 243

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.2.1 Perform a comprehensive prenatal assessment.

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2) During a clients initial prenatal visit, the nurse must assess and document the clients current medical history, including which information?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Body mass index

2. Infections before the last menstrual period

3. Homeopathic or herbal medication use

4. Blood type and Rh factor

5. History of previous pregnancies

Answer: 1, 3, 4

Explanation: 1. The body mass index is an important part of the current medical history to be assessed and documented.

3. Homeopathic and herbal medication use is important for the nurse to assess and document in the current medical history.

4. The blood type must be assessed and documented in the current medical history, as must the Rh factor.

Page Ref: 245

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.2.1 Perform a comprehensive prenatal assessment.

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3) During the initial prenatal visit, the nurse obtains a weight of 42 kg (92.4 lb). The nurse must further assess the client for information about which of the following?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Eating habits

2. Foods regularly eaten

3. Income limitations

4. Blood pressure and pulse rate

5. Weight loss during pregnancy

Answer: 1, 2, 3

Explanation: 1. For a client whose weight is less than 100 lb, the nurse would obtain information on eating habits.

2. For a client whose weight is less than 100 lb, the nurse would obtain information on foods regularly eaten.

3. For a client whose weight is less than 100 lb, the nurse would obtain information on income limitations.

Page Ref: 250

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.2.1 Perform a comprehensive prenatal assessment.

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4) A woman gave birth last week to a fetus at 18 weeks gestation after her first pregnancy. She is in the clinic for follow-up, and notices that her chart states she has had one abortion. The client is upset over the use of this word. How can the nurse best explain this terminology to the client?

1. Abortion is the obstetric term for all pregnancies that end before 20 weeks.

2. Abortion is the word we use when someone has miscarried.

3. Abortion is how we label babies born in the second trimester.

4. Abortion is what we call all babies who are born dead.

Answer: 1

Explanation: 1. The term abortion means a birth that occurs before 20 weeks gestation or the birth of a fetus-newborn who weighs less than 500 g. An abortion may occur spontaneously or it may be induced by medical or surgical means.

Page Ref: 244

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. C. 1. Value seeing health care situations through patients eyes. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patients dignity, uniqueness, integrity, and self-determination and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2 Define common obstetric terminology found in the history of maternity patients.

5) The clinic nurse is compiling data for a yearly report. Which client would be classified as a primigravida?

1. A client at 18 weeks gestation who had a spontaneous loss at 12 weeks

2. A client at 13 weeks gestation who had an ectopic pregnancy at 8 weeks

3. A client at 14 weeks gestation who has a 3-year-old daughter at home

4. A client at 15 weeks gestation who has never been pregnant before

Answer: 4

Explanation: 4. Primigravida means a woman who is pregnant for the first time.

Page Ref: 244

Cognitive Level: Remembering

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the health care team, including the patient and the patients support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Define common obstetric terminology found in the history of maternity patients.

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6) The client has delivered her first child at 37 weeks. The nurse would describe this to the client as what type of delivery?

1. Preterm

2. Postterm

3. Early term

4. Near term

Answer: 3

Explanation: 3. Early term births extend from 37 to 38 weeks gestation.

Page Ref: 244

Cognitive Level: Remembering

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2 Define common obstetric terminology found in the history of maternity patients.

7) The nurse in the OB-GYN clinic is working with a client who is seeking her initial prenatal visit. The nurse will use the acronym TPAL to document the clients number of which of the following?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Term infants born

2. Children living in the home

3. Pregnancies ending in abortion

4. Preterm infants born

5. Pregnancies that occurred

Answer: 1, 3, 4

Explanation: 1. T: number of term births the woman has experienced

3. A: number of pregnancies ending in either spontaneous or therapeutic abortion

4. P: number of preterm births

Page Ref: 244

Cognitive Level: Remembering

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.2.1 Perform a comprehensive prenatal assessment.

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8) The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form?

1. Where was the father of the baby born?

2. Do genetic diseases run in the family of the babys father?

3. What is the name of the babys father?

4. Are you married to the father of the baby?

Answer: 2

Explanation: 2. This question has the highest priority because it gets at the physiologic issue of inheritable genetic diseases that might directly impact the baby.

Page Ref: 245

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the value of the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.2.1 Perform a comprehensive prenatal assessment.

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9) During the initial prenatal visit, the nurse assesses the history of the father of the child for which of the following?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Stability of living conditions

2. Blood type and Rh type

3. Significant health problems

4. Nutritional history

5. Current use of tobacco

Answer: 2, 3, 5

Explanation: 2. The father of the fetus should be assessed for blood type and Rh factor.

3. The father of the fetus should be assessed for significant health problems.

5. The father of the fetus should be assessed for current alcohol intake, drug use, and tobacco use.

Page Ref: 245

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.2.1 Perform a comprehensive prenatal assessment.

10) A 25-year-old primigravida is at 20 weeks gestation. The nurse takes her vital signs and notifies the healthcare provider immediately because of which finding?

1. Pulse 88/minute

2. Rhonchi in both bases

3. Temperature 37.4 C (99.3 F)

4. Blood pressure 122/78

Answer: 2

Explanation: 2. Any abnormal breath sounds should be reported to the healthcare provider.

Page Ref: 251

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Safety and Quality: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

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MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

11) The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings?

1. Document the findings on the prenatal chart.

2. Have the physician see the client today.

3. Instruct the client to avoid direct sunlight.

4. Analyze previous thyroid hormone lab results.

Answer: 2

Explanation: 2. Mottling of the skin is indicative of possible anemia. These abnormalities must be reported to the healthcare provider immediately.

Page Ref: 250

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Safety and Quality: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

12) The nurse begins a prenatal assessment on a 25-year-old primigravida at 20 weeks gestation and immediately contacts the healthcare provider because of which finding?

1. Pulse 88/minute

2. Respirations 30/minute

3. Temperature 37.4 C (99.3 F)

4. Blood pressure 118/82

Answer: 2

Explanation: 2. Tachypnea is not a normal finding and requires medical care.

Page Ref: 250

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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13) The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings?

1. 12 weeks gestation, with fetal heart tones heard by Doppler fetoscope

2. 22 weeks gestation, client reports no fetal movement felt yet

3. 16 weeks gestation, fundus three finger breadths above umbilicus

4. Marked edema

Answer: 1

Explanation: 1. This is an expected finding because fetal heart tones should be heard by 12 weeks using a Doppler fetoscope.

Page Ref: 257

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

14) The nurse working in an outpatient obstetric clinic assesses four primigravida clients. Which client findings would the nurse tell the physician about?

1. 17 weeks gestation and client denies feeling fetal movement

2. 24 weeks gestation and fundal height is at the umbilicus

3. 4-6 weeks gestation and softening of the cervix

4. 34 weeks gestation and complains of hemorrhoidal pain

Answer: 2

Explanation: 2. The fundal height at 24 weeks should be 24 cm. The fundal height is usually at the umbilicus at 20-22 weeks.

Page Ref: 252, 256

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values preferences and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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15) What signs would indicate that a pregnant clients urinalysis culture was abnormal?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. pH 4.6-8

2. Alkaline urine

3. Cloudy appearance

4. Negative for protein and red blood cells

5. Hemoglobinuria

Answer: 2, 3, 5

Explanation: 2. Alkaline urine could indicate metabolic alkalemia, Proteus infection, or an old specimen.

3. A cloudy appearance could indicate an infection.

5. Hemoglobinuria would be indicated by an abnormal urine color.

Page Ref: 254

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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16) The nurse receives a phone call from a client who claims she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the clients estimated date of delivery (EDD) be if she is pregnant?

1. Nov. 13

2. Jan. 17

3. Jan. 10

4. Dec. 3

Answer: 2

Explanation: 2. The due date is Jan. 17. Nageles rule is to add 7 days to the last menstrual period and subtract 3 months. The last menstrual period is April 10, therefore Jan. 17 is the EDD.

Page Ref: 256

Cognitive Level: Remembering

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Calculate the estimated date of birth using the common methods.

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17) The nurse is seeing a client who asks about the accuracy of Nageles rule. The nurse explains that accuracy can be compromised under which conditions?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. There is a history of regular menses every 28 days.

2. Amenorrhea is present and ovulation occurs with breastfeeding.

3. Oral contraception was discontinued, but no regular menstruation was established.

4. There has been 1 or more months of amenorrhea.

5. There is an accurate date for the last menstrual period.

Answer: 2, 3, 4

Explanation: 2. Nageles rule is not always accurate for women who have amenorrhea but are ovulating and conceive while breastfeeding.

3. Nageles rule is not always accurate for women who conceive before regular menstruation is established following discontinuation of oral contraceptives or termination of a pregnancy.

4. Nageles rule is not always accurate for women with markedly irregular periods that include 1 or more months of amenorrhea.

Page Ref: 256

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Calculate the estimated date of birth using the common methods.

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18) The primigravida at 22 weeks gestation has a fundal height palpated slightly below the umbilicus. Which of the following statements would best describe to the client why she needs to be seen by a physician today?

1. Your baby is growing too much and getting too big.

2. Your uterus might have an abnormal shape.

3. The position of your baby cant be felt.

4. Your baby might not be growing enough.

Answer: 4

Explanation: 4. The fundal height at 20-22 weeks should be about even with the umbilicus. At 22 weeks gestation, a fundal height below the umbilicus and the size of the uterus that is inconsistent with length of gestation could indicate fetal demise.

Page Ref: 252

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

19) The nurse is explaining to a new prenatal client that the certified nurse-midwife will perform clinical pelvimetry as a part of the pelvic exam. The nurse knows that teaching has been successful when the client makes which statement about the reason for the exam?

1. It will help us know how big a baby I can deliver vaginally.

2. Doing this exam is a part of prenatal care at this clinic.

3. My sister had both of her babies by cesarean.

4. I am pregnant with my first child.

Answer: 1

Explanation: 1. By performing a series of assessments and measurements, the examiner assesses the pelvis vaginally to determine whether the size and shape are adequate for a vaginal birth; this procedure is called clinical pelvimetry.

Page Ref: 257

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

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Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

20) The nurse is explaining clinical pelvimetry to a client. The nurse explains that the anteroposterior diameters consist of which of the following?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Diagonal conjugate

2. Transverse diameter

3. Conjugata vera

4. Obstetric conjugate

5. Oblique diameter

Answer: 1, 3, 4

Explanation: 1. The diagonal conjugate is a part of the anteroposterior diameter measurement.

3. The conjugata vera is a part of the anteroposterior diameter measurement.

4. The obstetric conjugate is a part of the anteroposterior diameter measurement.

Page Ref: 258, 259

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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21) The nurse is assessing a newly pregnant client. Which finding does the nurse note as a normal psychosocial adjustment in this clients first trimester?

1. An unlisted telephone number

2. Reluctance to tell the partner of the pregnancy

3. Parental disapproval of the womans partner

4. Ambivalence about the pregnancy

Answer: 4

Explanation: 4. Ambivalence toward a pregnancy is a common psychosocial adjustment in early pregnancy.

Page Ref: 255

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.1.4 Assess the childbearing familys psychosocial adaptation to pregnancy.

22) The nurse is assessing a primiparous client who indicates that her religion is Judaism. Why is this information is pertinent for the nurse to assess?

1. Religious and cultural background can impact what a client eats during pregnancy.

2. It provides a baseline from which to ask questions about the clients religious and cultural background.

3. Knowing the clients beliefs and behaviors regarding pregnancy is not important.

4. Clients sometimes encounter problems in their pregnancies based on what religion they practice.

Answer: 2

Explanation: 2. Nurses have an obligation to be aware of other cultures and develop a culturally sensitive plan of care to meet the needs of the childbearing woman and her family.

Page Ref: 246

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Respect the patients dignity, uniqueness, integrity, and self-determination and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Summarize the essential components of a prenatal history.

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MNL LO: 2.2.3 Recognize maternal cultural and spirituality factors that affect pregnancy.

23) What would the nurse include as part of a routine physical assessment for a second-trimester primiparous patient whose prenatal care began in the first trimester and is ongoing?

1. Pap smear

2. Hepatitis B screening (HBsAg)

3. Fundal height measurement

4. Complete blood count

Answer: 3

Explanation: 3. At each prenatal visit, the blood pressure, pulse, and weight are assessed, and the size of the fundus is measured. Fundal height should be increasing with each prenatal visit.

Page Ref: 250, 252

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.1.2 Explain the expected maternal physiologic adaptations to pregnancy.

24) If a woman has the pre-existing condition of diabetes, the nurse knows that she would be prone to what high-risk factor when pregnant?

1. Vasospasm

2. Postpartum hemorrhage

3. Episodes of hypoglycemia and hyperglycemia

4. Cerebrovascular accident (CVA)

Answer: 3

Explanation: 3. Episodes of hypoglycemia and hyperglycemia would be a high-risk factor for a client with pre-existing diabetes.

Page Ref: 247

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

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Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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25) Which third-trimester client would the nurse suspect might be having difficulty with psychological adjustments to her pregnancy?

1. A woman who says, Either a boy or a girl will be fine with me

2. A woman who puts her feet up and listens to some music for 15 minutes when she is feeling too stressed

3. A woman who was a smoker but who has quit at least for the duration of her pregnancy

4. A woman who has not investigated the kind of clothing or feeding methods the baby will need

Answer: 4

Explanation: 4. By the third trimester, the client should be planning and preparing for the baby (for example, living arrangements, clothing, feeding methods).

Page Ref: 265

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal patient.

MNL LO: 2.1.4 Assess the childbearing familys psychosocial adaptation to pregnancy.

26) A client comes into the prenatal clinic accompanied by her boyfriend. When asked by the nurse why she is there, the client looks down, and the boyfriend states, She says she is pregnant. She constantly complains of feeling tired, and her vomiting is disgusting. What is a priority for the nurse to do at this point?

1. Ask the client what time of the day her fatigue is more common.

2. Recommend that the woman have a pregnancy test done as soon as possible.

3. Continue the interview of the client in private.

4. Give the woman suggestions on ways to decrease the vomiting.

Answer: 3

Explanation: 3. The nurse should suspect that the client is in an abusive relationship. The priority is for the nurse to get the client away from the boyfriend and continue the interview.

Page Ref: 245, 265

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: QSEN Competencies: I. C. 1. Value seeing health care situations through patients eyes. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Respect the patients dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Assessment

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Learning Outcome: 1 Summarize the essential components of a prenatal history.

MNL LO: 2.1.1 Perform a comprehensive prenatal assessment.

27) A pregnant client calls the clinic nurse to say she is worried about symptoms she is experiencing. The nurse advises the client to come immediately to the clinic because of which reported symptoms?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Vaginal bleeding

2. Abdominal pain

3. Constipation

4. Epigastric pain

5. Blurring of vision

Answer: 1, 2, 4, 5

Explanation: 1. Vaginal bleeding can indicate abruptio placentae, placenta previa, or lesions of cervix or vagina, or it can be bloody show, and requires that the client be seen.

2. Abdominal pain can signal premature labor or abruptio placentae, and requires that the client be seen.

4. Epigastric pain must be evaluated, as it can indicate preeclampsia or ischemia in a major abdominal vessel.

5. Dizziness, blurring of vision, double vision, or spots before the eyes can indicate either hypertension and/or preeclampsia and requires the client be seen.

Page Ref: 263

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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28) A nurse examining a prenatal client recognizes that a lag in progression of measurements of fundal height from week to week and month to month could signal what condition?

1. Twin pregnancy

2. Intrauterine growth restriction

3. Hydramnios

4. Breech position

Answer: 2

Explanation: 2. A lag in progression of measurements of fundal height from month to month could signal intrauterine growth restriction (IUGR).

Page Ref: 257

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally, and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

29) The nurse at the prenatal clinic has four calls to return. Which phone call should the nurse return first?

1. Client at 32 weeks, reports headache and blurred vision.

2. Client at 18 weeks, reports no fetal movement in this pregnancy.

3. Client at 16 weeks, reports increased urinary frequency.

4. Client at 40 weeks, reports sudden gush of fluid and contractions.

Answer: 1

Explanation: 1. Headache and blurred vision are signs of preeclampsia, which is potentially life-threatening for both mother and fetus. This client has top priority.

Page Ref: 263

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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30) The nurse is providing guidance for a woman in her second trimester of pregnancy and telling her about some of the signs and symptoms that she might experience. Which statement by the client indicates that further teaching is necessary?

1. During the third trimester, I might have frequent urination.

2. During the third trimester, I might have heartburn.

3. During the third trimester, I might have back pain.

4. During the third trimester, I might have a persistent headache.

Answer: 4

Explanation: 4. A persistent headache is not normal or expected. This could be related to the complication of preeclampsia.

Page Ref: 263

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

31) The nurse in the prenatal clinic is seeing a pregnant 16-year-old for the first time. What comment by the young client is the most critical for the nurse to address first?

1. My favorite lunch is burger and fries.

2. Ive been dating my new boyfriend for 2 weeks.

3. On weekends, we go out and drink a few beers.

4. I dropped out of school about 3 months ago.

Answer: 3

Explanation: 3. The nurse responds to this most critical statement because of the danger of fetal alcohol syndrome.

Page Ref: 247

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. C. 3. Value the patients expertise with own health and symptoms. | AACN Essentials Competencies: IX. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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32) The nurse is providing health teaching to a group of women of childbearing age. One woman states that she is a smoker, and asks about the effect of smoking on her fetus. The nurse tells her that which fetal complication can occur when the mother smokes?

1. Genetic changes in the fetal reproductive system

2. Extensive central nervous system damage

3. Addiction to the nicotine inhaled from the cigarette

4. Low birth rate

Answer: 4

Explanation: 4. Smoking can cause low birth rate.

Page Ref: 247

Cognitive Level: Remembering

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

33) A pregnant client has a hemoglobin of 10 g/dL and a Hct of 30%. The clinic nurse recognizes the fetus is at risk for which of the following?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Macrosomia

2. Respiratory distress syndrome

3. Low birth weight

4. Prematurity

5. Fetal death

Answer: 3, 4, 5

Explanation: 3. Anemia places the fetus at risk for a low birth weight.

4. Anemia places the fetus at risk for premature birth.

5. Anemia places the fetus at risk for fetal death.

Page Ref: 247

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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34) Screening for gestational diabetes mellitus (GDM) is typically completed between which of the following weeks of gestation?

1. 36 and 40 weeks

2. Before 20 weeks

3. 24 and 28 weeks

4. 30 and 34 weeks

Answer: 3

Explanation: 3. Screening for gestational diabetes mellitus (GDM) is typically completed between 24 and 28 weeks gestation.

Page Ref: 260

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the prenatal patient.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

35) A pregnant client at 30 weeks gestation has had a steady rise in blood pressure. She is now 20 mmHg above her systolic baseline. The nurse advises her to immediately report which symptoms?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Dizziness

2. Even a small amount of dependent edema

3. Spots before her eyes

4. Persistent nausea and vomiting

5. Vaginal spotting

Answer: 1, 3

Explanation: 1. Dizziness can be a sign of hypertension or preeclampsia, and should be reported immediately.

3. Spots before the eyes can be a sign of hypertension or preeclampsia, and should be reported immediately.

Page Ref: 263

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

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Copyright 2016 Pearson Education, Inc.

Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes.

MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors.

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