Question 5331)
The nurse is assessing a woman who thinks she may be pregnant. Which
information from the client is most significant in confirming the diagnosis of pregnancy?
A. . The client is experiencing nausea before bedtime and after meals.
B. The client says she has gained six pounds and her slacks are tight.
C. The client has noticed it is difficult to sleep on her “stomach” because her breasts are tender.
D. The client has a history of regular menstrual periods since age 13, and she has missed her second period.
Answer: D
Explanation: Amenorrhea in an otherwise healthy woman of childbearing age is strongly suggestive of pregnancy.
Nausea, weight gain, and tender breasts are all presumptive signs but are not as significant as amenorrhea.
Question 5332)
After her examination by the physician, the antepartal client tells the nurse that
the doctor said she had positive Chadwick’s and Goodell’s signs. She asks the nurse what this
means. What is the best response for the nurse to make?
A. “Chadwick’s sign is a dark blue coloring of the vagina and cervix. Goodell’s sign is softening of the cervix of the
uterus.”
B. “These help to confirm pregnancy. They refer to color changes and changes in the uterus caused by increased
hormones of pregnancy.”
C. “Those are medical terms. You don’t need to be concerned about them.”
D. “It refers to changes that occasionally happen in pregnancy but are unlikely to cause problems.”
Answer: B
Explanation: This answer is most appropriate to give the client. Answer 1 is a true statement but uses vocabulary
that is inappropriate for the client. These changes are normal changes and occur in most pregnancies. Answer 3 is
a real put-down to the client. Answer 4 is not correct. These are normal findings that help to confirm the diagnosis
of pregnancy.
Question 5333)
An antepartal client asks when her baby is due. Her last menstrual period was
August 28. Using Naegele’s rule, calculate the estimated date of delivery.
A. May 21
B. May 28
C. June 4
D. June 28
Answer: C
Explanation: Add nine months or take away three months and then add seven days. August 28 minus three months
is May 28. Adding seven days would make it May 35. Since there are only 31 days in May, the days are carried into
June—making June 4 the expected delivery date. Answer 1 subtracts seven days instead of adding seven days.
Answer 2 does not add seven days. Answer 4 subtracts only 2 months instead of 3 months and does not add seven
days.
Question 5334)
In establishing a teaching plan for a client who is in the first trimester of
pregnancy, the nurse identifies a long list of topics to discuss. Which is most appropriate for the
first visit?
A. Preparation for labor and delivery
B. Asking the woman what questions and concerns she has about parenting
C. Nutrition and activity during pregnancy
D. Dealing with heartburn and abdominal discomfort
Answer: C
Explanation: Nutrition and activity are important concerns from the first trimester onward. Labor and delivery is a
third trimester concern, and parenting is of most concern in either the third trimester or after delivery. Heartburn
and abdominal discomfort do not usually occur until the third trimester.
Question 5335)
When a woman in early pregnancy is leaving the clinic, she blushes and asks the
nurse if it is true that sex during pregnancy is bad for the baby, What is the best response from
the Nurse to make?
A. “The baby is protected by his sac. Sex is perfectly alright.”
B. “It is unlikely to harm the baby. What you do with your personal life is your concern.”
C. “In a normal pregnancy, intercourse will not harm the baby. However, many women experience a change in
desire. How are you feeling?”
D. “Intercourse during pregnancy is usually alright, but you need to ask the doctor if it is acceptable for you.”
Answer: C
Explanation: Intercourse is not harmful during a normal pregnancy. This response recognizes the changes in libido
that may occur during pregnancy and allows for the expression of feelings. Answer 1 is factual information, but
answer 3 allows the woman to express her feelings. The question says that “she blushes.” This may indicate that
the woman has concerns about sex. Answer 2 gives factual information but does not allow the woman to express
her concerns. Answer 4 again does not give the woman a chance to discuss this with the nurse. The nurse should
be able to answer this question.
Question 5336)
The doctor told a pregnant woman to eat a well balanced diet and increase her
iron intake. She says, “I hate liver. How can I increase my iron?” What is the best response for the
nurse to make?
A. “Although liver is a good source of iron, beets, poultry, and milk are also good sources.”
B. “Many people dislike liver. Red meats, dark green vegetables, and dried fruits are also good sources of iron.”
C. “You should eat liver as it is the best source of iron. There are lots of ways to disguise the taste.”
D. “You can eat almost anything you like because your prenatal vitamins have all the vitamins and minerals needed
for a healthy pregnancy.”
Answer: B
Explanation: This answer recognizes that a dislike of liver is common and suggests good sources of iron. Answer 1
includes information that is not correct; milk contains no iron. Answer 3 has some correct information; liver is high
in iron. It is also high in cholesterol. There are many other sources of iron. It is not necessary to eat liver to get
iron in the diet. At one time, eating liver regularly was thought to be the best way to get iron. Answers 3 vitamins
do contain iron. However, they should not be considered a substitute for a proper diet
Question 5337)
A woman who is at about six weeks gestation asks if she can listen to the baby’s
heartbeat today. What should be included in the nurse’s reply
A. The heart is not beating at six weeks.
B. The heart is formed and beating but is too weak to be heard with a stethoscope
C. The heartbeat can be heard with an electronic fetoscope.
D. The heart does not start beating until 20 weeks gestation.
Answer: B
Explanation: The heart chambers are formed and the heart is beating by four weeks gestation. However, it cannot
be heard even with a fetoscope. Answer 1 is incorrect. The heart is beating by four weeks. Answer 3 is not correct.
It cannot be heard at this time. Answer 4 is incorrect. The heart rate will be audible with a standard fetoscope by
20 weeks, but it has been beating since about four weeks.
Question 5338)
A woman who is in early pregnancy asks the nurse what to do about her “morning
sickness.” What should the nurse include in the reply?
A. Eating a heavy bedtime snack containing fat helps to keep nausea from developing in the morning.
B. Eating dry crackers before getting out of bed may help.
C. Drinking liquids before getting up in the morning helps relieve nausea
D. The doctor can prescribe an antiemetic if she has had three or more vomiting episodes.
Answer: B
Explanation: Eating dry carbohydrates in the morning before rising often helps. The woman should avoid fatty foods
and those with strong odors. Drinking liquids in the morning usually makes morning sickness worse, not better.
Antiemetics are not prescribed because of the possible teratogenic effect on the developing embryo.
Question 5339)
A woman who is 38 weeks gestation tells the nurse that she sometimes gets dizzy
when she lies down. Which information is it important for the nurse to give the client?
A. This is a sign of a serious complication and should be reported to the physician whenever it occurs.
B. Try to sleep in an upright position on your back to prevent the dizziness.
C. Try lying on your left side rather than on your back.
D. Sleeping on your back with several pillows should help.
Answer: C
Explanation: Dizziness when lying on the back suggests that she may have vena caval syndrome—pressure on the
vena cava from the enlarged uterus and fetus that decreases venous return and causes the blood pressure to drop.
Lying on the left side usually reduces pressure on the vena cava and prevents the drop in blood pressure and
dizziness. Sleeping in an upright position on her back will cause vena caval syndrome. Sleeping on the back with
several pillows is similar to answer 2, which was incorrect
Question 5340)
The nurse asks the newly pregnant woman if she has a cat for which of the
following reasons?
A. Cats may suffocate new babies and should not be in the home when a baby arrives
B. Cat feces may cause toxoplasmosis, which can lead to blindness, brain defects, and stillbirth.
C. If the mother gets scratched by a cat, the baby may develop heart defects.
D. Cats are jealous of babies and may try to kill them during infancy.
Answer: B
Explanation: Cats may become infected with toxoplasmosis, which, if ingested by the mother, can cause
toxoplasmosis and lead to neurologic lesions causing blindness, brain defects, and death. Parents should be alert
for safety with any pet, but cats do not suffocate new babies or try to kill them. It is not being scratched by a cat
that is the biggest danger during pregnancy; it is the possibility of developing toxoplasmosis from the feces. Raw
meat can also carry toxoplasmosis.
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