Question 5341)
The nurse is caring for a woman who is 30 weeks gestation, has gained 17 pounds
during the pregnancy, and has a blood pressure of 110/70. The woman states that she feels
warmer than everyone around her. Which interpretation of these findings is most correct?
A. All of these findings are normal.
B. Her weight gain is excessive for this point in pregnancy.
C. The blood pressure is abnormal
D. She should be evaluated for a serious infection because pregnant women are usually cooler than other people.
Answer: A
Explanation: All of these findings are within normal limits. Weight gain during the first trimester is usually 3 to 5 lb.
After that, the normal weight gain is around 12 oz (three-quarters of a pound) a week. Using these guidelines, her
weight gain should be 16 to 18 lb. Her blood pressure is well within normal limits, even though we are not given a
baseline. Pregnant women have a high metabolic rate and usually feel warmer than everyone else.
Question 5342)
What should the nurse do to assess for a positive sign of pregnancy?
A. Perform a pregnancy test on the woman’s urine.
B. Auscultate for fetal heart sounds
C. Ask the woman when she had her last menstrual period
D. Ask the woman if her breasts are tender.
Answer: B
Explanation: Fetal heart sounds, sonograms, and x-rays are positive signs of pregnancy. A positive pregnancy test is
a probable sign of pregnancy. Amenorrhea and breast tenderness are presumptive signs of pregnancy.
Question 5343)
An oxytocin challenge test is ordered for a woman who is 42 weeks pregnant.
What should the nurse plan for in the care of this client?
A. Place her in the supine position during the test.
B. Keep her NPO before the test
C. Have her empty her bladder before the test.
D. Prepare the client for the insertion of internal monitors.
Answer: C
Explanation: The mother should empty her bladder before oxytocin is given and contractions begin. It is not
necessary to be supine; the head will be elevated. NPO is not essential. The monitor with an oxytocin challenge
test is external, not internal
Question 5344)
Woman comes to Doctor office for her routine checkup. She is 34 weeks gestation.
The nurse notes all of the following. Which would be of greatest concern to the nurse?
A. Weight gain of 2 lb in two weeks
B. Small amount of dependent edema
C. Fetal heart rate of 155 bpm
D. Blood pressure of 150/94
Answer: D
Explanation: A blood pressure of 150/94 is indicative of pregnancy-induced hypertension. Weight gain of a pound a
week, slight dependent edema, and a fetal heartbeat of 155 are all normal.
Question 5345)
A pregnant woman is admitted to the hospital. Her initial admitting vital signs are
blood pressure 160/94; pulse 88; respirations 24; and temperature 98°F. She complains of
epigastric pain and headache. What should the nurse do initially?
A. Insert an indwelling catheter.
B. Give Maalox 30 cc now.
C. Contact the doctor stat with findings
D. Provide supportive care for impending convulsion.
Answer: D
Explanation: Epigastric pain and headache suggest that a seizure is imminent. Supportive care to protect the client
from injury is essential. An indwelling catheter may be inserted but only after the nurse ensures that the client is
safe should a seizure occur. The epigastric pain is most likely related to preeclampsia, not gastritis. The doctor
should be notified, but the client should be made safe first.
Question 5346)
Magnesium sulfate is ordered for a client who is hospitalized for pregnancyinduced hypertension (PIH). What effects would the nurse expect to see as a result of this
medication?
A. CNS depression
B. Decreased gastric acidity
C. Onset of contractions
D. Decrease in number of bowel movements
Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant. It is given to prevent seizures. Magnesium
hydroxide gel is an antacid. Oxytocin is given to initiate contractions. Magnesium sulfate may decrease
contractions. Magnesium sulfate does not cause constipation. Some laxatives contain magnesium
Question 5347)
A client with PIH asks the nurse, “When will I get over this?” What is the best
response for the nurse to make?
A. “Your disease can be controlled with medication
B. “After your baby is born.”
C. “After delivery, you will need further testing.”
D. “You could have this condition for years.”
Answer: B
Explanation: Preeclampsia is pregnancy-induced hypertension and disappears shortly after the birth of the baby
Question 5348)
A 40-year-old woman who is 28 weeks gestation comes to the emergency room
with painless, bright red bleeding of 1.5 hours duration. What condition does the nurse suspect
this client has?
A. Abruptio placenta
B. Placenta previa
C. Hydatidiform mole
D. Prolapsed cord
Answer: B
Explanation: Placenta previa is characterized by painless bleeding in the third trimester. Abruptio is characterized
by abdominal pain and a rigid abdomen with or without obvious bleeding. Shock develops rapidly in placenta
abruptio. Hydatidiform mole is characterized by severe nausea and vomiting and the passage of grapelike vesicles.
Prolapsed cord often occurs when the membranes rupture and is not characterized by bleeding.
Question 5349)
A woman who is 28 weeks gestation comes to the emergency room with painless,
bright red bleeding of 1.5 hours in duration. Which of the following would the nurse expect during
assessment of this woman?
A. Alterations in fetal heart rate
B. Board-like uterus
C. Severe abdominal pain
D. Elevated temperature
Answer: A
Explanation: The history suggests placenta previa. The baby may well develop fetal distress. A boardlike abdomen
and severe pain are characteristic of abruptio placenta. Elevated temperature is not characteristic of placenta
previa.
Question 5350)
A woman is admitted with suspected placenta previa. What test does the nurse
expect will be done to confirm the diagnosis?
A. Internal exam
B. Nonstress test
C. Oxytocin challenge test
D. Ultrasound
Answer: D
Explanation: A sonogram will show the position of the placenta in the uterus. An internal exam will probably not be
done because it can cause severe bleeding when there is a placenta previa. The nonstress test and the oxytocin
challenge test are done to see how the fetus responds to contractions
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