Question 6001)
A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, what does the nurse document about the client's obstetric history?
A. G4 T3 P2 A1 L4
B. G5 T2 P2 A1 L4
C. G5 T2 P1 A1 L4
D. G4 T3 P1 A1 L4
Answer: C
Explanation: The acronym GTPAL reflects G-gravidity, T-term birth, P-preterm births, A-abortions,and L-living children, G5 T2 P1 A1 L4 indicates that there were 5 pregnancies, twins count as 1 pregnancy and the present pregnancy counts as 1.
Question 6002) A client at 8 weeks gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:
A. atony of the detrusor muscle.
B. compression by the enlarging uterus.
C. compromise of the autonomic reflexes.
D. narrowing of the ureteral entrance at the trigone
Answer: B
Explanation: The uterus and bladder occupy the pelvic cavity and lie closely together, as the uterus enlarges with the growing fetus, it impinges on the space occupied by the bladder and thereby diminishes bladder capacity.
Question 6003)
A nurse who is caring for a mother and her newborn infant reviews their record. Using the data below, which nursing intervention is required?
A. Neonatal blood transfusion
B. Maternal rubella vaccination
C. Maternal RhoGam injection
D. Neonatal 50% glucose infusion
Answer: B
Explanation: A
rubella titer of 1:2 is inadequate immunization. A titer of 1:8 is considered immune. Rubella immunization protects the fetus of future pregnancies from significant birth defects caused by a rubella infection. These laboratory results are borderline for pregnancy but were taken during the prenatal period and do not represent the woman's current status.
Question 6004)
What recommendation should a nurse give to clients who have fluid retention during pregnancy?
A. Decrease fluid intake.
B. Maintain a low-sodium diet.
C. Elevate the lower extremities.
D. Ask the health care provider for a diuretic
Answer: C
Explanation: Elevation of the extremities several times daily is recommended to decrease the dependent edema.
Question 6005)
During the postpartum period, a client tells a nurse she is having leg-cramps. Which foods should the nurse encourage the client to eat?
A. Liver and raisins
B. Cheese and broccoli
C. Eggs and lean meats
D. Whole wheat breads and cereals
Answer: B
Explanation: The leg cramps may be related to low calcium intake, cheese and broccoli both have a high calcium content.
Question 6006)
A nurse is caring for a primigravida during labor. At 7 cm dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?
A. Butorphanol (Stadol)
B. Hydroxyzine (Vistaril)
C. Promethazine (Phenergam)
D. Diphenhydramine (Benadryl)
Answer: A
Explanation: Respiratory depression may occur in the newborn because the duration of action of Butorphanol (Stadol) is 3 to 4 hours and circulating blood levels will be high if birth occurs within that time.
Question 6007)
At a prenatal visit a client who is at 36 weeks gestation states that she is having
uncomfortable irregular contractions. What should the nurse recommend?
A. "Lie down until they stop."
B. "Walk around until they subside."
C. "Time the contractions for 30 minutes."
D. "Take 2 extra-strength aspirins if the discomfort persists."
Answer: B
Explanation: Ambulation relieves the discomfort of preparatory (Braxton Hicks) contractions.
Question 6008)
Why should a nurse teach pregnant women the importance of conserving the "spurt of energy" before labor?
A. Energy helps to increase the progesterone level.
B. Fatigue may influence the need for pain medication.
C. Energy is needed to push during the first stage of labor.
D. Fatigue will increased the intensity of the uterine contractions
Answer: B
Explanation: Fatigue will influence other coping strategies, such as distraction.
Question 6009)
A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and 3 cm dilated. The fetal head is at +1 station. In what area of the client's pelvis is the fetal occiput?
A. Not yet engaged
B. Below the ischial spines
C. Entering the pelvic inlet
D. Visible at the vaginal opening
Answer: B
Explanation: A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
Question 6010)
A nurse assesses the frequency of a client's contractions by timing them from the
beginning of a contraction:
A. until the uterus starts to relax.
B. to the end of a second contraction.
C. until the uterus completely relaxes.
D. to the beginning of the next contraction.
Answer: D
Explanation: This is the accepted way to determine the frequency of the contractions.
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