Question 1

What is the most appropriate intervention for the nurse to recommend for a pregnant client who complains of swelling in her feet and ankles?

Accepted Answer

Answer reason: Dependent edema in pregnancy is commonly caused by venous stasis from uterine pressure on pelvic veins and the vena cava, so interventions should promote venous return. Elevating the lower extremities decreases hydrostatic pressure and helps fluid shift back into the vascular space, reducing ankle and foot swelling. Restricting fluids is not recommended for typical pregnancy edema because it can contribute to dehydration without addressing venous pooling. Diuretics are generally avoided for uncomplicated pregnancy edema because they can reduce plasma volume and potentially compromise uteroplacental perfusion.

Question 2

The cervix of a 26-year-old primigravida in labor is 5 cm dilated and 75% effaced, and the fetus is at 0 station. The physician prescribes an epidural regional block. Into which position should the nurse place the client when the epidural is administered?

Accepted Answer

Answer reason: A side-lying (lateral) position with the back arched (“C” shape) provides this flexion while also being practical during labor and reducing aortocaval compression compared with supine positioning. Supine positioning can worsen maternal hypotension after sympathetic blockade and compromise uteroplacental perfusion. Lithotomy and prone positions do not facilitate standard epidural placement and are not used for routine administration during labor.

Question 3

The nurse is preparing a client in labor for the administration of an epidural. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Epidural anesthesia can cause sympathetic blockade leading to maternal vasodilation and acute hypotension, which may reduce uteroplacental perfusion and trigger fetal heart rate decelerations. Administering an IV fluid bolus before placement helps expand intravascular volume and lowers the risk and severity of hypotension. The other assessments listed are not the key preventive safety intervention immediately prior to epidural placement. Preventing hypotension is the priority because it directly impacts both maternal hemodynamic stability and fetal oxygenation.

Question 4

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?

Accepted Answer

Answer reason: The urge to have a bowel movement in an experienced (multiparous) laboring client commonly indicates fetal descent and pressure on the rectum, suggesting transition and possible imminent birth. The priority nursing action is to assess cervical dilation and fetal station to determine whether the client is fully dilated and should not ambulate to the bathroom. Allowing the client to get up or use a bedpan can delay care and increases the risk of an uncontrolled delivery if birth is imminent. Fetal heart rate assessment is important, but it does not answer the immediate question of labor progress that drives the safety decision in response to this symptom.

Question 5

The nurse is prioritizing care of a client in the immediate postpartum period (first 2 hours). What is the most important assessment for the nurse to perform?

Accepted Answer

Answer reason: Assessing fundal height and tone verifies that the uterus is firm and involuting appropriately, which correlates with reduced bleeding risk. A boggy or rising fundus suggests poor uterine contraction and may indicate retained clots or bladder distention requiring prompt intervention. Blood glucose, ECG, and stool occult blood do not address the primary life-threatening complication in the first 2 hours after birth.

Question 6

A nurse should expect to observe which behavior in a client on the fourth postpartum day?

Accepted Answer

Answer reason: By postpartum day 3–5, many clients enter the “taking-hold” phase, marked by increased confidence building and active learning about infant care. This stage is characterized by asking questions, seeking feedback, and focusing on mastering practical newborn-care skills. Wanting the nurse to make decisions for her (meals) or needing help with basic self-care is more consistent with earlier dependency needs or complications limiting functioning. Relating the birth story can occur early, but the key expected day-4 pattern is active engagement and information-seeking about the baby.

Question 7

A postpartum mother asks the nurse what would cause a decreased supply of breast milk. What is the best response by the nurse?

Accepted Answer

Answer reason: When the infant receives formula supplements, time at the breast and overall milk removal typically decrease, reducing stimulation and signaling the body to make less milk. In contrast, frequent feedings generally increase supply by increasing breast emptying and hormonal stimulation. Vitamin C intake does not typically suppress lactation, and while alcohol can interfere with let-down and infant feeding patterns, the most direct and common cause of a true decreased supply in this context is reduced breastfeeding due to supplementation.

Question 8

A nurse is assessing a multiparous client on her first postpartum day. Which assessment finding indicates that the client is at risk for hemorrhage?

Accepted Answer

Answer reason: A boggy, poorly contracted uterus (atony) allows continued bleeding and is a key early warning finding for hemorrhage risk on postpartum day 1. A hemoglobin of 12 g/dl is within a normal range and does not indicate imminent hemorrhage. Moderate lochia rubra is expected in the first few days postpartum, while thrombophlebitis signals venous clot risk rather than bleeding.

Question 9

A client has delivered twins. What is the most important intervention for a nurse to implement?

Accepted Answer

Answer reason: Multiple gestation increases uterine overdistention, which raises the risk for uterine atony and postpartum hemorrhage. The most urgent nursing priority after birth is early detection of excessive bleeding and inadequate uterine contraction by checking fundal firmness/position and the amount and character of lochia. Perineal ice packs and analgesics improve comfort but do not address the highest-risk, life-threatening complication. Encouraging voiding can help prevent uterine displacement and promote tone, but assessment of uterine tone and bleeding is the immediate, most critical intervention to identify hemorrhage promptly.

Question 10

The nurse is about to auscultate an F HR on the client in triage. What information should the nurse determine first in order to find the correct placement for auscultation?

Accepted Answer

Answer reason: Determining fetal position/lie and presentation (e.g., cephalic vs breech; left vs right) guides where on the maternal abdomen to place the Doppler or fetoscope. Placental location may add some sound attenuation but does not determine the optimal landmark for strongest fetal heart tones. Contractions influence timing of assessment but not the initial anatomic placement for auscultation.

Question 11

The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 1005- How should the nurse document this FHR?

Accepted Answer

Answer reason: A drop from the 130s to about 100 sustained over the last 2 hours reflects a new, persistent low baseline rather than an episodic change. Late decelerations are transient decreases associated with contractions and are not used to label a sustained baseline shift. Tachycardia would require a baseline above 160 bpm, and “within normal limits” would be 110–160 bpm, so neither fits this finding.

Question 12

The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?

Accepted Answer

Answer reason: A long axis “lying across” the maternal abdomen indicates the fetus is perpendicular to the maternal axis, which is a transverse lie, commonly associated with malpresentation. The described abdominal contour being elongated also supports a non-longitudinal lie because the presenting part is not aligned toward the pelvis. Vertex and breech describe presentation (which part enters the pelvis first) in a longitudinal lie, while brow describes an attitude/cephalic presenting position, not the lie.

Question 13

The labor nurse observes a sinusoidal FHR pattern on the monitor tracing. How should the nurse interpret this pattern?

Accepted Answer

Answer reason: A true sinusoidal fetal heart rate pattern is a smooth, regular, wave-like baseline oscillation with absent normal variability and is classically associated with severe fetal anemia and/or fetal hypoxia (e.g., fetomaternal hemorrhage, Rh isoimmunization). This pattern is ominous because it reflects impaired fetal oxygen-carrying capacity rather than benign autonomic cycling. In contrast, fetal sleep typically produces decreased variability but not a persistent, regular sinusoidal waveform. Therefore this finding warrants urgent evaluation and intervention to address potential life-threatening fetal compromise.

Question 14

The first-trimester pregnant client asks the nurse if the activities in which she participates are safe in the first trimester. Which activity should the nurse verify as a safe activity during the client's first trimester?

Accepted Answer

Answer reason: Intercourse does not harm the fetus because it is protected by the amniotic sac and cervix, and mild uterine contractions after orgasm are typically benign in low-risk pregnancies. In contrast, hot tub use can raise core maternal temperature, and early gestation hyperthermia is associated with increased risk of fetal neural tube defects. Pesticide exposure and unnecessary chemical exposures are avoided in pregnancy due to potential teratogenic and toxicity risks, making them less safe to “verify” without precautions.

Question 15

A client who is pregnant and has developed preeclampsia asks the nurse why magnesium sulphate has been prescribed for her. What is the best response by the nurse?

Accepted Answer

Answer reason: Magnesium sulfate is the standard medication used for seizure prophylaxis and treatment in preeclampsia/eclampsia because it depresses neuromuscular transmission and reduces CNS irritability. The main life-threatening complication of worsening preeclampsia is progression to eclampsia (tonic-clonic seizures), so preventing seizures is the priority therapeutic goal. It is not a primary antihypertensive; blood pressure control is managed with agents like labetalol, hydralazine, or nifedipine. It also is not given to prevent hemorrhage or to correct low magnesium; in fact, toxicity is a key concern, requiring monitoring of respirations, reflexes, urine output, and serum levels.

Question 16

What would be the most appropriate medication to administer for a client who has been in early labor (contractions every 10 to 12 minutes) for 12 hours without progression to help stimulate uterine contractions?

Accepted Answer

Answer reason: In a client with prolonged early labor and minimal cervical change, a uterotonic is the standard pharmacologic method to promote effective contractions (with appropriate monitoring for tachysystole and fetal response). Estrogen and fetal cortisol are physiologic contributors to the onset of labor but are not used clinically as medications to augment labor. Progesterone maintains uterine quiescence in pregnancy, so it would counter the goal of increasing contractions.

Question 17

A client is at 33 weeks’ gestation and has had diabetes since she was 21. When checking her fasting blood sugar level, which value would indicate to the nurse that the client’s disease was controlled?

Accepted Answer

Answer reason: A fasting glucose goal is typically about 60–95 mg/dL (often

Question 18

A nurse is planning the care of a pregnant client. Which condition would require more frequent visits?

Accepted Answer

Answer reason: These clients need tighter surveillance with more frequent prenatal visits to adjust insulin regimens, review glucose logs, monitor blood pressure and renal status, and coordinate fetal testing (e.g., growth ultrasounds/nonstress testing as indicated). In contrast, being blood type O positive is not a risk factor requiring extra visits because Rh incompatibility concerns relate to Rh-negative status. Advanced maternal age risk generally becomes more prominent at ≥35 years, and an allergy history alone does not typically change routine prenatal visit frequency unless it affects medication or emergency planning.

Question 19

Which intervention should a nurse recommend to a client having severe heartburn during her pregnancy?

Accepted Answer

Answer reason: Pregnancy-related heartburn is commonly caused by progesterone-mediated relaxation of the lower esophageal sphincter and increased intra-abdominal pressure from the enlarging uterus, both of which promote reflux. Smaller, more frequent meals reduce gastric distention and decrease the likelihood of reflux episodes. In contrast, acidic beverages can worsen symptoms by increasing gastric acidity and irritating the esophageal mucosa. Advice like eating crackers on waking is more aligned with nausea management rather than reflux control.

Question 20

A pregnant client is visiting the clinic and complains about the tiny, blanched, slightly raised end arterioles on her face, neck, arms, and chest. The nurse should explain that these are normal during pregnancy and referred to as which finding?

Accepted Answer

Answer reason: They present as small, blanching, slightly raised “spider-like” end-arteriole dilations on the face, neck, upper chest, and arms and commonly regress postpartum. In contrast, linea nigra is hyperpigmentation along the abdominal midline, and striae gravidarum are stretch marks from dermal tearing. Epulis is a localized pregnancy-associated gingival growth rather than diffuse superficial vascular markings.

Question 21

A client who’s at 36 weeks’ gestation comes into the labor-and-delivery unit with mild contractions. The client states that she has placenta previa. The nurse is aware that this client is at risk for which of the following?

Accepted Answer

Answer reason: This makes painless, bright-red bleeding in late pregnancy the hallmark risk and a major cause of maternal hemorrhage. Mild contractions at 36 weeks increase the likelihood of bleeding as the cervix effaces/dilates. Sudden rupture of membranes is more classically associated with cord prolapse or infection-related issues rather than being the primary complication of previa.

Question 22

The nurse is assessing the fetal heart rate of a laboring woman who is full term. What does the nurse anticipate the fetal heart rate to be?

Accepted Answer

Answer reason: This range reflects normal fetal autonomic regulation and adequate oxygenation when variability and other tracing features are also reassuring. Values below this range suggest fetal bradycardia and may indicate cord compression, hypoxia, or maternal hypotension, requiring further assessment and interventions. Values persistently above this range suggest fetal tachycardia, which can be associated with maternal fever/infection, dehydration, or fetal hypoxia. Among the options, only the listed range aligns with the expected normal baseline for a term fetus.

Question 23

A client is admitted to the labor-and-delivery unit with a known anencephalic fetus. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Supportive intrapartum nursing care for a pregnancy with a lethal fetal anomaly prioritizes the client’s emotional needs, dignity, and ability to cope during labor. Maintaining privacy reduces unnecessary exposure to others and helps create a safe space for grief responses, family presence, and individualized decision-making. Routine fetal surveillance is not the priority when the condition is known to be incompatible with life and may add distress without changing management. False reassurance or avoiding discussion blocks therapeutic communication and can invalidate the client’s feelings.

Question 24

A laboring client in the latent stage of labor begins complaining of pain in the epigastric area, blurred vision, and a headache. The nurse knows that which medication should be prepared for administration?

Accepted Answer

Answer reason: The priority medication to prepare is an anticonvulsant for seizure prophylaxis and maternal stabilization. This drug also helps reduce neuromuscular irritability and is standard intrapartum management for severe preeclampsia/eclampsia risk. Calcium gluconate is the antidote for toxicity and should be available, but it is not the primary medication to initiate based on these symptoms. Uterotonic or tocolytic agents do not address the underlying hypertensive emergency and seizure risk suggested by the findings.

Question 25

A client is admitted to the labor-and-delivery unit in labor, with blood flowing down her legs. Which nursing intervention would be most appropriate?

Accepted Answer

Answer reason: Heavy, painless vaginal bleeding in a laboring patient is an obstetric emergency concerning for placenta previa and potential rapid maternal hemorrhage with fetal compromise. Vaginal/cervical examination can worsen bleeding if the placenta overlies the cervical os, so it is contraindicated until previa is excluded. The priority nursing action is to treat this as an emergency and initiate preparations for operative delivery while the team stabilizes the patient (e.g., IV access, labs, blood availability) and expedites definitive management. Continuous fetal monitoring is important but does not address the immediate need for rapid delivery and hemorrhage control, and an indwelling catheter is supportive but not the most urgent intervention.

Question 26

A 36-week neonate born weighing 1,800 g has microcephaly and microphthalmia. Based on these findings, which risk factor might be expected in the maternal history?

Accepted Answer

Answer reason: The combination of low birth weight for gestational age and microcephaly is classic for fetal alcohol spectrum disorders. Marijuana exposure is more commonly associated with subtle neurobehavioral effects rather than characteristic structural anomalies like microphthalmia. Gestational diabetes more often leads to macrosomia and metabolic complications, and maternal GBS status relates to neonatal infection risk rather than congenital malformations.

Question 27

Which client action should alert a nurse to a potential problem in a client with mastitis?

Accepted Answer

Answer reason: Feeding only every 6 hours is too infrequent and can lead to engorgement, plugged ducts, and escalation of symptoms (pain, redness, fever). Nursing teaching typically encourages continuing breastfeeding/pumping about every 2–3 hours and ensuring good drainage. Starting on the affected side and fully emptying the breast are generally supportive measures because they improve milk flow and relieve obstruction, whereas infrequent feeding signals a potential problem.

Question 28

A nurse is reviewing the plan of care for a client with an episiotomy on the third postpartum day. It is most important for the plan to include which instruction?

Accepted Answer

Answer reason: By postpartum day 3, perineal care shifts from cold therapy to moist heat to promote local circulation, reduce edema, improve comfort, and support wound healing after an episiotomy. Sitz baths provide this moist heat and are a standard comfort and healing measure in the subacute postpartum period. Ice is most beneficial in the first 24 hours to limit swelling and should not be the primary instruction on day 3. Massaging the area can disrupt the incision and increase pain/bleeding, and clients are typically encouraged—not discouraged—to begin gentle pelvic floor (Kegel) exercises once comfortable to support tone and healing.

Question 29

Which client behavior indicates an understanding of the nurse’s teaching plan for breastfeeding?

Accepted Answer

Answer reason: Breastfeeding teaching emphasizes preventing nipple trauma and maintaining skin integrity while supporting continued lactation. Air-drying after feeds helps reduce moisture-related maceration and irritation and is a common nonpharmacologic strategy to prevent soreness and cracking. Washing nipples with soap can strip natural oils and increase dryness and irritation. A proper latch requires the infant to take in the areola (not just the nipple), and detaching should be done by breaking suction first rather than pulling the infant off to avoid nipple injury.

Question 30

When performing a comprehensive fundal check during a postpartum assessment, a nurse evaluates which fundal state?

Accepted Answer

Answer reason: A complete fundal check includes palpating for firmness (consistency), determining midline versus displaced position (location), and measuring the level relative to the umbilicus (height) to trend involution. Evaluating only height or only location misses key findings such as uterine atony or bladder-related displacement. This triad provides the most comprehensive and clinically actionable assessment data for early detection of complications.

Question 31

A client arrives at the emergency department in her third trimester with painless vaginal bleeding. Based on the assessment data, the nurse suspects that the client is experiencing which of the following?

Accepted Answer

Answer reason: This condition causes bleeding as the lower uterine segment thins and the cervix begins to efface/dilate, without the uterine tenderness and hypertonicity typical of placental abruption. Preterm labor would be expected to include regular contractions and cervical change rather than isolated painless bleeding. An STI may cause spotting or discharge, but it does not typically present as significant third-trimester painless bleeding requiring emergent evaluation.

Question 32

The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?

Accepted Answer

Answer reason: Immediate left lateral positioning relieves vena cava compression, rapidly improving maternal blood pressure and perfusion (and fetal oxygen delivery) without delaying for additional orders. Oxygen can be added if symptoms persist, but it does not correct the primary mechanical cause. Provider notification is appropriate after stabilizing the client, not before the first, fastest corrective intervention.

Question 33

The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor?

Accepted Answer

Answer reason: A history of prior cesarean birth alone (especially with an otherwise uncomplicated, stable labor course) does not automatically place the client into a high-risk monitoring category. In contrast, post-term pregnancy (41 weeks), preeclampsia, and gestational diabetes increase the risk of uteroplacental insufficiency and fetal compromise, making continuous electronic fetal monitoring more appropriate. Therefore, among the options, the prior cesarean client is the best candidate for intermittent monitoring.

Question 34

The nurse assesses the fundal height for multiple pregnant clients. For which client should the nurse conclude that a fundal height measurement is most accurate?

Accepted Answer

Answer reason: Uterine fibroids can enlarge or irregularly shape the uterus, making the measurement unreliable. Polyhydramnios increases uterine size beyond what would be expected for gestational age, falsely elevating fundal height. Maternal obesity can make palpation of landmarks more difficult and reduce measurement precision, whereas fetal movement itself does not distort uterine size and is a normal finding that does not impair accuracy.

Question 35

The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?

Accepted Answer

Answer reason: First-trimester nausea is often worsened by an empty stomach and by sudden rising, so a small, dry carbohydrate before getting out of bed helps stabilize gastric irritation and blood glucose. Dry crackers are a classic first-line, low-risk nonpharmacologic strategy for morning nausea in pregnancy. Resting can help discomfort but does not address the common trigger of an empty stomach on waking. Ginger is commonly used to reduce nausea in pregnancy, so avoiding it is not an evidence-based recommendation for uncomplicated morning sickness.

Question 36

The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?

Accepted Answer

Answer reason: Tuna is a common food where portion size and type matter (e.g., limiting albacore/white tuna and avoiding large predatory fish), so this choice signals a need for further guidance about safe fish intake. The other options reflect generally appropriate pregnancy foods that can support key needs such as iron/folate (beans/greens; beef/lentils) and calcium/vitamin D (milk). A frequent distractor is assuming all fish is unsafe; the safer teaching point is choosing low-mercury fish and keeping intake within recommended limits.

Question 37

The nurse is teaching the client who is wishing to travel by airplane during the first 36 weeks of her pregnancy. Which is the primary risk of air travel for this client that the nurse should address?

Accepted Answer

Answer reason: This is why teaching focuses on frequent ambulation, calf exercises, adequate hydration, and avoiding restrictive clothing on flights. Air travel itself is not a primary cause of spontaneous abortion, and routine flying is generally safe in uncomplicated pregnancies up to airline-specific gestational limits. While preterm labor can be a concern in higher-risk pregnancies, the most universally applicable primary risk tied specifically to flying is venous thromboembolism.

Question 38

The pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client’s chart notation to most accurately describe the client’s condition?

Accepted Answer

Answer reason: Incomplete abortion is characterized by partial expulsion of products of conception, leading to continued bleeding and uterine cramping while the cervix remains dilated. By contrast, a complete abortion typically results in a closed cervix after all tissue is expelled and symptoms begin to subside. Ectopic pregnancy is not defined by an open cervical os and often presents with adnexal pain and signs of intra-abdominal bleeding rather than cervical dilation.

Question 39

The client who is actively bleeding due to a spontaneous abortion asks the nurse why this is happening. The nurse advises the client that the majority of first-trimester losses are related to which problem?

Accepted Answer

Answer reason: These chromosomal abnormalities (often sporadic aneuploidy) lead to nonviable pregnancies that typically present with early bleeding and pregnancy loss. Cervical incompetence more commonly causes painless dilation and second-trimester losses rather than early first-trimester miscarriage. Chronic maternal disease and implantation problems can contribute to miscarriage risk, but they account for a smaller proportion than fetal chromosomal causes in the first trimester.

Question 40

The nurse is counseling the pregnant client who has painful hemorrhoids. Which initial recommendation should be made by the nurse?

Accepted Answer

Answer reason: First-line management of hemorrhoids in pregnancy focuses on preventing constipation and minimizing straining, because increased venous pressure and slowed GI motility commonly worsen symptoms. Increasing dietary fiber (often paired with adequate fluid intake) softens stools and reduces rectal pressure, addressing the root contributor in a safe, nonpharmacologic way. Topical steroid preparations may be used for short-term symptom relief but are not typically the initial foundational recommendation and should be used cautiously. Surgical treatment is rarely indicated during pregnancy and is generally reserved for severe complications after conservative measures fail.

Question 41

A pregnant client is admitted to the hospital. On initial assessment the client is determined to be febrile. The nurse should?

Accepted Answer

Answer reason: Maternal fever in pregnancy can quickly affect fetal status, most notably by causing fetal tachycardia and signaling possible intraamniotic infection. The most immediate, priority nursing action on admission is to assess both maternal and fetal physiologic responses, which requires obtaining separate fetal and maternal heart rates to establish a baseline and detect distress. Giving aspirin is unsafe in pregnancy due to bleeding risks and potential fetal effects, so it is not an appropriate first action. IV fluids and isolation may be needed depending on findings and suspected cause, but they follow initial maternal-fetal assessment and provider notification based on the assessment results.

Question 42

The nurse is teaching a client with placenta previa who has developed placenta accreta. Which statement concerning this condition would be the most correct?

Accepted Answer

Answer reason: Placenta accreta is defined by abnormal adherence of chorionic villi due to defective decidua basalis, causing the placenta to be firmly attached to the uterine wall with invasion into the superficial myometrium. This creates difficulty with placental separation after delivery and greatly increases the risk of severe postpartum hemorrhage and need for hysterectomy. The option describing cervical os coverage refers to placenta previa, not accreta. Terms like “invades” or “penetrates” more closely describe deeper variants (increta/percreta) rather than accreta.

Question 43

While assessing a client in her 24th week of pregnancy, the nurse learns that the client has been experiencing signs and symptoms of pregnancy-induced hypertension, or preeclampsia. Which sign or symptom helps differentiate preeclampsia from eclampsia?

Accepted Answer

Answer reason: Preeclampsia can present with severe symptoms such as headache, visual changes, and edema/rapid weight gain, but these can occur without seizures. The development of seizures indicates neurologic involvement and a life-threatening progression requiring emergent stabilization and magnesium sulfate therapy. Headache and blurred vision are warning signs of worsening disease but do not, by themselves, establish eclampsia.

Question 44

A pregnant client with sickle cell anemia is at an increased risk for having a sickle cell crisis during pregnancy. The nurse anticipates that aggressive management of a sickle cell crisis would include which treatment?

Accepted Answer

Answer reason: I.V. fluids Vaso-occlusive sickle cell crisis is worsened by dehydration, which increases blood viscosity and promotes red cell sickling and microvascular obstruction. Rapid hydration helps improve perfusion, reduce further sickling, and supports maternal-fetal oxygen delivery as part of aggressive crisis management (often alongside oxygen and analgesia). Diuretics would further deplete intravascular volume and can precipitate or worsen a crisis. Acetaminophen may help mild pain but is not the key aggressive intervention for crisis stabilization compared with restoring hydration.

Question 45

A pregnant client asks the nurse why she should lie on her left side when resting or sleeping in the later stages of pregnancy. What is the best response by the nurse?

Accepted Answer

Answer reason: This decreases maternal cardiac output and can lower uteroplacental perfusion, causing maternal hypotension (supine hypotensive syndrome) and fetal compromise. Left lateral positioning shifts the uterus off the great vessels, improving venous return and placental blood flow. Digestive comfort or bladder emptying may change with positioning but are not the key safety rationale, and fetal anomalies are not caused by maternal sleep position late in pregnancy.

Question 46

Which dose of Rho (D) immune globulin (RhoGAM) is appropriate for a pregnant client at 28 weeks’ gestation?

Accepted Answer

Answer reason: Standard antenatal prophylaxis is given at about 28 weeks and the typical dose is 300 mcg (1500 IU), which covers exposure up to ~30 mL of fetal whole blood. Clients who are already sensitized (positive antibody screen) do not benefit from immune globulin because antibodies are already formed; they require fetal surveillance instead. The 50 mcg dose is used for early gestation events (e.g., first-trimester bleeding/procedures) and is insufficient for routine 28-week prophylaxis.

Question 47

A 32-year-old female client has her first prenatal visit at 15 weeks’ gestation. Which finding during this visit is abnormal?

Accepted Answer

Answer reason: At 15 weeks, a fundal height of 18 cm suggests the uterus is larger than expected for gestational age, raising concern for incorrect dating, multiple gestation, or other causes of uterine enlargement. The blood pressure shown is within normal range for pregnancy, and urine negative for protein is an expected normal screening finding. A single weight value without a pre-pregnancy baseline is not inherently abnormal at an initial prenatal visit.

Question 48

A client in labor has been receiving oxytocin (Pitocin) to aid her progress. The nurse caring for her notes that contractions are lasting 100 seconds. Which action should the nurse take first?

Accepted Answer

Answer reason: Uterine contractions lasting around 100 seconds suggest uterine tachysystole/hyperstimulation, which decreases uteroplacental perfusion and can rapidly compromise fetal oxygenation. Because oxytocin is the precipitating, titratable cause, the most time-critical nursing action is to stop the infusion to reduce contraction intensity/duration. Additional intrauterine resuscitation measures (such as lateral positioning and further evaluation) may follow, but they do not remove the trigger as directly or as quickly. Notifying the provider is appropriate after immediate corrective nursing action, while continuing usual monitoring is unsafe in the presence of suspected hyperstimulation.

Question 49

The effectiveness of drug therapy for a client at 34 weeks’ gestation with hypertension of pregnancy can be determined by which finding?

Accepted Answer

Answer reason: The absence of seizures is therefore the most direct indicator that therapy is achieving its primary life-threatening risk-reduction outcome. The other options describe ongoing pathology or potential deterioration: 4 lb/week suggests worsening edema/fluid retention, a BP of 154/90 remains hypertensive, and urine output of 25 mL/hr indicates oliguria and possible renal hypoperfusion (expected goal is typically at least 30 mL/hr). Thus, seizure prevention best reflects effective management.

Question 50

Which finding in a client who is at 36 weeks’ gestation indicates that premature rupture of the membranes has occurred?

Accepted Answer

Answer reason: Amniotic fluid contains sodium chloride that crystallizes as it dries, producing a characteristic ferning pattern on microscopy, which supports rupture of membranes. This finding helps distinguish amniotic fluid leakage from other vaginal secretions. Nitrazine testing typically turns alkaline (not acidic) with amniotic fluid, so an acidic pH argues against membrane rupture. Cervical dilation of 8 cm and contractions every 3 minutes indicate active labor but do not specifically confirm membrane rupture.

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