Question 1

The nurse is caring for a client in labor. Which components of labor contractions would be the most accurate for the nurse to assess with this client?

Accepted Answer

Answer reason: Frequency (how often), duration (how long), and intensity (strength by palpation or monitor) are the standard components used to evaluate adequacy of contractions and response to interventions. These measures guide decisions about maternal positioning, hydration, pain management, and when to notify the provider for abnormal patterns (e.g., tachysystole or inadequate labor). Pelvic type is part of labor risk assessment, but it is not a component of the contraction pattern itself, making options that include pelvic type less accurate. “Contraction type” is not a primary standardized parameter compared with the core triad used in routine nursing documentation and fetal-maternal surveillance.

Question 2

A nurse is caring for four clients on an antepartum unit. Which client would be carrying a viable conceptus at the earliest stage?

Accepted Answer

Answer reason: This threshold is generally taught around 24 weeks’ gestation, when lung development and other organ system maturation may allow survival in a NICU. Gestations of 9 and 14 weeks are previable because fetal organ systems are not sufficiently developed to sustain life ex utero. While 30 weeks is also viable, the question asks for the earliest stage at which viability is expected.

Question 3

On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which action is appropriate?

Accepted Answer

Answer reason: A deviated (often displaced) postpartum fundus is most commonly caused by a distended bladder, which can push the uterus laterally and interfere with uterine contraction. The safest, least invasive first nursing action is to assist the client to void and then reassess fundal position and tone. Immediate straight catheterization is reserved for inability to void or significant urinary retention after noninvasive measures, due to infection and trauma risks. Calling the provider is not necessary before implementing this standard postpartum nursing intervention when bladder distention is suspected.

Question 4

Which assessment finding in a postpartum client requires further nursing assessment?

Accepted Answer

Answer reason: By postpartum day 2, the fundus should typically be at or slightly below the umbilicus; being 2 cm above suggests subinvolution or uterine atony and warrants assessment for excessive bleeding and uterine tone. Deviation to the right commonly indicates a distended bladder, which can prevent effective uterine contraction and increase postpartum hemorrhage risk. This finding should prompt bladder assessment/voiding and reassessment of fundal height and lochia after intervention.

Question 5

A nurse is assessing a client with type 1 diabetes mellitus whose delivery was complicated by polyhydramnios and macrosomia. The nurse is aware that this client is at risk for which of the following?

Accepted Answer

Answer reason: Polyhydramnios and fetal macrosomia both stretch the uterus, making effective postpartum contraction and involution less likely after delivery. With poor uterine tone, the placental implantation site vessels are not adequately compressed, increasing the likelihood of heavy bleeding. Increased insulin needs is less likely immediately postpartum because placental hormone levels fall and insulin requirements typically decrease. Gestational hypertension is an antepartum condition and is not the key postpartum risk linked to uterine overdistension in this scenario.

Question 6

The nurse is preparing a plan of care for a client who has had a cesarean delivery. What is the most important intervention for the nurse to include?

Accepted Answer

Answer reason: Promoting lung expansion with coughing and deep breathing is a high-priority preventive intervention that reduces respiratory complications early in recovery. Douching increases infection risk and is not recommended postpartum, while early abdominal strengthening such as sit-ups is inappropriate as the incision and abdominal wall require more healing time. Side-rolling can support mobility and comfort, but it does not address the more immediate physiologic risk of postoperative hypoventilation and secretion retention.

Question 7

The nurse is assessing a postpartum client who has lochia serosa. When the client asks the nurse how long to expect this type of bleeding, how should the nurse respond?

Accepted Answer

Answer reason: Lochia serosa is the pinkish-brown, more watery discharge that typically follows lochia rubra and lasts from about day 4 through roughly day 10 postpartum. This timeframe best matches expected physiologic bleeding and helps distinguish normal involution from concerning late postpartum hemorrhage. Options describing only days 3–4 are too short for the serosa phase, while 10–14 and 14–42 correspond more to the later lochia alba stage.

Question 8

A nurse is assessing the fundus of a client who is 12 hours postpartum and finds that the fundus is boggy. Which action should the nurse take first?

Accepted Answer

Answer reason: A boggy uterus postpartum indicates uterine atony, the most common cause of postpartum hemorrhage, and the immediate nursing priority is to promote uterine contraction. Fundal massage is a rapid, bedside intervention that can restore uterine tone and reduce bleeding while further assessment continues (e.g., check lochia and bladder distention). Uterotonic medications may be indicated next if massage does not firm the uterus, but they are not the first action when the nurse identifies uterine atony. Blood products and surgery are reserved for ongoing significant hemorrhage or refractory causes and do not address the immediate, correctable loss of uterine tone.

Question 9

During the third postpartum day, which observation about a client should the nurse be most likely to make?

Accepted Answer

Answer reason: On postpartum day 2–3, many clients enter the “taking-hold” phase, characterized by increased alertness, active engagement with the newborn role, and a strong need to review and process the labor/birth events. Verbally recounting the birth experience is a typical adaptive behavior that helps the client integrate the experience and gain confidence. By contrast, intense focus on sleeping when the infant is away is more consistent with the immediate “taking-in” phase in the first 24–48 hours. Interest in neonatal care education does occur in taking-hold, but the classic, most expected observation around day 3 is repeated discussion of the birth experience.

Question 10

A prenatal client, age 13, asks about getting fat while she’s pregnant. A nurse tells her she needs to gain enough weight to be in the upper portions of her recommended weight due to her age to prevent which of the following?

Accepted Answer

Answer reason: Inadequate gestational weight gain is strongly associated with fetal growth restriction and low birth weight due to insufficient caloric and protein intake. Advising the client to aim for the upper end of recommended weight gain helps reduce the risk of delivering a small-for-gestational-age infant. While prematurity can be influenced by many factors, weight gain counseling is most directly tied to preventing low birth weight rather than preventing labor timing. Preeclampsia risk is more closely related to factors such as hypertension and placental dysfunction, not primarily low maternal weight gain.

Question 11

The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/— and that the fetal HR is 148. What priority information should the nurse collect before proceeding?

Accepted Answer

Answer reason: g., NICU, corticosteroids/tocolysis considerations) may be needed. A cervical exam finding of 4 cm/50% effacement suggests active labor may be approaching, and interpreting its significance depends on whether the client is preterm, term, or post-term. Fetal heart rate 148 is within the normal baseline range, so the next priority is determining pregnancy dating to guide urgency and management. Details like last meal, provider identity, or general past illnesses are important but do not direct immediate obstetric triage decisions as strongly as gestational age does.

Question 12

The full-term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/96 mm Hg, and her pulse is 109 bpm. The nurse should immediately implement interventions for which possible complication?

Accepted Answer

Answer reason: Intense abdominal pain plus maternal tachycardia and elevated blood pressure (often associated with abruption risk) signals potential rapid maternal hemorrhage and fetal hypoxia from impaired placental perfusion. Immediate nursing actions focus on stabilization (large-bore IV access, fluids/blood products as ordered, continuous fetal monitoring, oxygen as indicated) and rapid escalation for possible urgent delivery. A common distractor is placenta previa, which classically causes painless bright red bleeding without significant abdominal pain or uterine rigidity.

Question 13

The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?

Accepted Answer

Answer reason: This tracing describes variable decelerations (abrupt V-shaped drops) which are most consistent with umbilical cord compression, along with mild fetal tachycardia but preserved moderate variability. The first nursing action is an intrauterine resuscitation measure that relieves cord compression by changing maternal position (side-to-side or knee-chest). Provider notification is appropriate if decelerations persist or worsen after initial corrective measures, but the immediate priority is a rapid, independent intervention. Supplemental oxygen is not the best first step for isolated variable decelerations when a positional maneuver may correct the cause more directly.

Question 14

The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn’s father?

Accepted Answer

Answer reason: Pointing out physical similarities demonstrates recognition, bonding, and acceptance of the infant as “his.” Speaking from across the room can indicate interest but is less specific for deep attachment behaviors. Frustration with crying or hesitancy to touch suggests anxiety or difficulty adapting rather than engrossment.

Question 15

The pregnant client has an abnormal 1-hour glucose screen and completes a 3-hour, 100-g oral glucose tolerance test (OGTT). Which test results should the nurse interpret as being abnormal?

Accepted Answer

Answer reason: Using commonly taught Carpenter-Coustan criteria, the fasting cutoff is ≥95 mg/dL, so a fasting value of 104 mg/dL exceeds the normal range. The other values listed are below their respective cutoffs (1-hour ≥180, 2-hour ≥155, 3-hour ≥140 mg/dL), so they would not be interpreted as abnormal. Because at least two abnormal values are typically required for diagnosis, this set shows an abnormal fasting level but not enough elevated values to meet diagnostic criteria by itself.

Question 16

The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the clinic nurse expect to palpate the client’s uterine height?

Accepted Answer

Answer reason: By about 20 weeks’ gestation, the uterine fundus typically reaches the level of the umbilicus on abdominal palpation. Before this point (around 16 weeks), it is generally midway between the symphysis pubis and the umbilicus, making that choice more consistent with an earlier gestational age. Above the umbilicus is expected later (roughly after 20 weeks), so that option would overestimate the uterine height for this gestation.

Question 17

The nurse is screening prenatal clients who may be caniers for potential genetic abnormalities. Which ethnic group should the nurse identify as having the lowest risk for hemoglobinopathies, such as sickle cell disease and thalassemia?

Accepted Answer

Answer reason: Sickle cell trait/disease is most associated with African ancestry, while thalassemias are more prevalent in Mediterranean and many Southeast Asian populations. Northern European/Scandinavian ancestry has comparatively lower baseline prevalence of these hemoglobin variants, making it the lowest-risk group among the choices. Screening still depends on personal and family history, but ethnicity helps identify higher-prevalence groups for targeted testing.

Question 18

A client is determined to be newly pregnant and is prescribed prenatal vitamins by the physician. The nurse knows further teaching is necessary when the client states?

Accepted Answer

Answer reason: I eat a balanced diet. I don’t need vitamins. Prenatal vitamins are used to help meet increased pregnancy micronutrient requirements, especially folic acid and iron, to reduce preventable maternal and fetal complications. Even with a balanced diet, many pregnant clients do not consistently achieve adequate intake of these key nutrients due to higher physiologic demands and variable absorption/intake. This statement shows a misconception that diet alone makes supplementation unnecessary and therefore indicates a need for further teaching. The other statements reflect personal/social context or a request for clarification and do not inherently demonstrate incorrect understanding of the prescribed prenatal vitamins.

Question 19

A 23-year-old client who is at 27 weeks’ gestation arrives at her physician’s office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which diagnosis is most likely?

Accepted Answer

Answer reason: Pregnancy increases risk of ascending infection due to ureteral dilation and urinary stasis, making this presentation particularly concerning for renal involvement. Lower UTI/cystitis typically causes dysuria, frequency, and urgency without high fever or CVA tenderness. Asymptomatic bacteriuria lacks symptoms by definition, and bacterial vaginosis presents with vaginal discharge/odor rather than flank pain and CVA tenderness.

Question 20

During an examination, a client who’s 32 weeks pregnant becomes dizzy, light-headed, and pale. While the client is lying supine, which nursing intervention should take priority?

Accepted Answer

Answer reason: In late pregnancy, the supine position can compress the inferior vena cava, reducing venous return and cardiac output, leading to maternal hypotension and decreased uteroplacental perfusion (supine hypotensive syndrome). The priority is to correct the physiologic cause immediately with a position change that relieves vena cava compression. Left lateral positioning rapidly improves maternal circulation and fetal oxygenation without waiting for further assessment. Checking blood pressure or fetal heart tones can follow once the acute hemodynamic compromise is addressed, while deep breathing does not treat the underlying mechanical obstruction.

Question 21

A pregnant client asks the nurse about the pregnancy stage in which maternal and fetal blood are exchanged. Which response by the nurse would be most accurate?

Accepted Answer

Answer reason: Maternal and fetal circulations are normally separated by the placental membrane, which allows diffusion/transport of gases, nutrients, and waste without direct mixing of whole blood. What occurs throughout pregnancy is exchange of substances across placental villi, not routine exchange of maternal and fetal blood. Direct mixing is generally limited to small fetomaternal hemorrhages (e.g., trauma, delivery, procedures) and is not a normal “stage” of pregnancy. Therefore, selecting a specific gestational age for blood exchange is inaccurate, making the statement that they are never exchanged the best answer in the typical physiologic sense tested.

Question 22

A nurse is assessing a client who is experiencing a normal pregnancy. The nurse would anticipate the assessment to include which finding?

Accepted Answer

Answer reason: A small rise in respiratory rate can be an expected physiologic change, even though tidal volume often increases more than rate. In contrast, maternal heart rate typically increases (not decreases) and blood pressure tends to decrease slightly in mid-pregnancy due to reduced systemic vascular resistance. Leukocyte count usually increases in pregnancy (physiologic leukocytosis), so a drop would be unexpected.

Question 23

A pregnant client is concerned about lack of fetal movement. What is the best response by the nurse?

Accepted Answer

Answer reason: Decreased fetal movement can indicate possible fetal compromise, and the appropriate initial nursing teaching is a structured daily fetal movement count to assess ongoing fetal well-being. Having the client rest in a side-lying position and focus on counting movements provides a practical, standardized way to detect a meaningful change from baseline and decide when to seek prompt evaluation. Suggestions like warm baths or high-sugar foods are not evidence-based as primary guidance and can be misleading or inappropriate (especially if diabetes is a concern). Doubling prenatal vitamins does not address fetal status and could increase adverse effects without improving fetal movement.

Question 24

A client at 18 weeks’ gestation reports fluttering sensations in her abdomen. Which statement made by the client indicates that the nurse’s teaching was successful?

Accepted Answer

Answer reason:  Quickening is the normal perception of fetal movement, often described as fluttering, and commonly begins around 16–20 weeks’ gestation (often earlier in multiparous clients). Recognizing this sensation as expected fetal movement demonstrates accurate understanding of normal pregnancy changes and appropriate reassurance. Seeking urgent medical attention for typical quickening reflects misunderstanding and could lead to unnecessary anxiety and visits. Labor at 18 weeks would be abnormal and would present with other symptoms (eg, contractions, bleeding, rupture of membranes), not simple fluttering.

Question 25

A nurse has admitted a client to the labor-and-delivery unit and is teaching her about the stages of labor. The client demonstrates an understanding of these stages when she states that birth occurs during which stage?

Accepted Answer

Answer reason: The second stage spans from complete cervical dilation (10 cm) to delivery of the newborn, which is when birth of the baby occurs. The first stage ends at full dilation and is primarily cervical effacement and dilation rather than delivery. The third stage is after the newborn is delivered and involves placental separation and expulsion, and the fourth stage is immediate postpartum recovery and stabilization.

Question 26

A nurse is monitoring a client in labor and notes on the external fetal monitor that the fetal heart rate (FHR) drops with the start of each contraction. What is the priority action by the nurse?

Accepted Answer

Answer reason: An FHR drop that begins with the start of the contraction is most consistent with early decelerations from fetal head compression, a common, benign pattern during labor. Because this finding is typically physiologic and associated with cervical dilation and descent, the immediate priority is to continue monitoring to confirm the pattern and assess variability and overall fetal status. Interventions like lateral positioning or oxygen are more appropriate when there is evidence of uteroplacental insufficiency (e.g., late decelerations) or nonreassuring features. Trendelenburg is not a routine first-line response to this pattern and may be reserved for specific complications such as suspected cord prolapse with provider notification.

Question 27

The nurse is teaching an intrapartum client about fetal presentation. Which statement about fetal presentation would be the most accurate?

Accepted Answer

Answer reason: This makes the description of the part entering the maternal pelvis first the most precise definition. In contrast, the relationship of the long axes describes fetal lie, not presentation. The relationship of the presenting part to the maternal pelvis refers more to position/denominator orientation rather than the definition of presentation itself.

Question 28

Which is the most common and popular method for assessing fetal status throughout labor?

Accepted Answer

Answer reason: Electronic fetal monitoring provides ongoing FHR data with documentation and trend recognition (baseline, variability, accelerations, and decelerations), which makes it widely used in many labor units. Intermittent auscultation with a stethoscope can assess FHR but does not provide continuous recording and is less commonly used where EFM is available. Maternal perception of fetal movement and pelvic exams do not directly and reliably assess fetal oxygenation status during labor.

Question 29

A nurse is caring for a client with short, mild contractions and cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?

Accepted Answer

Answer reason: Variable decelerations are most commonly caused by umbilical cord compression, leading to intermittent decreased fetal oxygenation. The first nursing action is an intrauterine resuscitation measure—maternal repositioning—to relieve cord compression and improve uteroplacental perfusion; left lateral positioning is a safe, immediate intervention. Oxygen by face mask may be added if the pattern persists or the tracing becomes nonreassuring, but it is not the first step compared with repositioning. Preparing for delivery or for a stillbirth is premature at 4 cm dilation and before attempting corrective measures for variable decelerations.

Question 30

While performing a cervical examination, a nurse’s fingertips feel pulsating tissue. What would be the most appropriate nursing intervention?

Accepted Answer

Answer reason: Pulsating tissue felt during a cervical exam suggests an umbilical cord prolapse, which is an obstetric emergency due to cord compression and acute fetal hypoxia. The immediate nursing priority is to relieve pressure on the cord by keeping the examining hand in the vagina and elevating the presenting part while summoning help. Calling for assistance without leaving the bedside prevents worsening compression and speeds mobilization of the emergency response for urgent birth. Leaving the client to call the physician delays critical decompression, and asking the client to push can increase compression and fetal compromise.

Question 31

A breastfeeding mother is experiencing engorged breasts and asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement?

Accepted Answer

Answer reason: Warmth and gentle expression before feeds help trigger let-down and remove enough milk to reduce pressure and pain without suppressing lactation. Ice can be useful after feeding to reduce edema and discomfort but does not address the immediate problem of milk stasis as effectively as facilitating expression. A binder and bromocriptine are aimed at suppressing lactation, which is inappropriate for a mother who intends to breastfeed and can worsen blocked ducts and mastitis risk.

Question 32

During the assessment of a postpartum client, the nurse notes continuous seepage of blood from the vagina and a firm uterus 1 cm below the umbilicus. The nurse suspects that the client may have experienced which of the following?

Accepted Answer

Answer reason: A cervical tear commonly causes continuous oozing/bleeding despite an appropriately involuting, firm uterus. Uterine atony would typically present with a boggy, enlarged uterus and heavy bleeding that improves with fundal massage/uterotonics. Retained placental tissue more often prevents adequate uterine contraction (subinvolution/bogginess) and is less consistent with a firm fundus.

Question 33

Which statement by a client shows an understanding of how to prevent breast engorgement while breastfeeding?

Accepted Answer

Answer reason:  Frequent, effective milk removal is the primary way to prevent milk stasis and the breast fullness that leads to engorgement. Feeding on demand (about every 1–3 hours early postpartum) supports adequate drainage, matches supply to infant needs, and reduces painful distention. Moist heat may help with let-down and comfort but is not the key prevention strategy and can worsen swelling if overused. Wearing a tight bra can impede milk flow and increase the risk of blocked ducts and mastitis, making it an unsafe approach.

Question 34

The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?

Accepted Answer

Answer reason: A visible or palpable depression under the umbilicus can reflect the fetal back being posterior with the fetal limbs more anterior, contributing to an irregular contour. In contrast, occiput-anterior positions more commonly produce abdominal/back discomfort that is less concentrated in the sacral area and typically allow more efficient fetal descent and rotation. Therefore the best documentation is the posterior occiput position rather than a specific left/right anterior variant.

Question 35

The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?

Accepted Answer

Answer reason: The turtle sign is a classic intrapartum finding indicating that after the fetal head delivers it retracts against the perineum because the anterior shoulder is impacted behind the maternal symphysis pubis. This pattern reflects a mechanical obstruction at the shoulders rather than a head–pelvis size mismatch as the head has already delivered. Occiput posterior more commonly causes prolonged labor and malposition issues but does not produce head retraction after delivery. Umbilical cord prolapse presents with sudden fetal heart rate decelerations and/or a palpable cord, not the turtle sign.

Question 36

The pregnant client presents with regular contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?

Accepted Answer

Answer reason: The key principle is that true labor is characterized by regular, progressively strong contractions accompanied by cervical change (dilation and/or effacement). Cervical dilation to 3 cm with strong, regular contractions is consistent with the latent/early phase of the first stage of labor (commonly 0–3 cm). False labor contractions may be uncomfortable but typically do not produce progressive cervical dilation. Cervical ripening and lightening can occur before labor and do not, by themselves, account for this combination of regular strong contractions plus 3 cm dilation.

Question 37

The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?

Accepted Answer

Answer reason: This results in increased maternal heart rate and blood pressure as compensatory cardiovascular responses to maintain perfusion. Cardiac output typically rises rather than falls because contractions autotransfuse blood from the uterus into the maternal circulation. Leukocytosis can occur in labor, but it is a hematologic change rather than the key cardiovascular change being monitored here.

Question 38

The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?

Accepted Answer

Answer reason: When external assessment is limited by maternal body habitus, the most accurate way to determine fetal presentation and position is imaging. Ultrasound directly visualizes fetal landmarks (head, spine, back) and reliably confirms lie, presentation, and position when Leopold maneuvers or inspection are inconclusive. Abdominal inspection and palpation are less reliable in morbid obesity because thick adipose tissue obscures contour and fetal parts. Vaginal examination can help with presenting part and station, but it may be unable to accurately define position if the presenting part is high or molding/caput limits landmark identification.

Question 39

The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?

Accepted Answer

Answer reason: Persistently expressing disappointment about having a male infant suggests unresolved negative feelings toward the newborn that may reduce affectionate behaviors and responsiveness to infant cues. In contrast, asking how to provide care and making family-resemblance comments are common, positive attachment behaviors during the taking-in/taking-hold period. Misnaming can occur but, by itself, is less specifically tied to ongoing rejection than repeated verbalization of wanting a different-sex infant.

Question 40

The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?

Accepted Answer

Answer reason: A macrosomic infant causes uterine overdistention, and a prolonged labor further contributes to uterine muscle exhaustion, making this client the highest risk to monitor closely. In contrast, a firm fundus indicates the uterus is already contracting adequately, lowering immediate atony concern. Ongoing oxytocin infusion supports uterine tone rather than predisposing to atony, so it is less concerning than clear overdistention plus fatigue risk factors.

Question 41

After delivering the full-term infant, the breastfeeding mother asks the nurse if there is any contraceptive method that she should avoid while she is breastfeeding. Which contraceptive should the nurse advise the client to avoid?

Accepted Answer

Answer reason: This makes combined oral contraceptives a method to avoid for a breastfeeding client because decreased supply can compromise infant intake and breastfeeding success. In contrast, progestin-only methods are considered compatible with breastfeeding and do not meaningfully suppress milk production. Nonhormonal options like a diaphragm and many IUDs are also generally acceptable during breastfeeding, with timing/placement considerations handled at follow-up care.

Question 42

The pregnant client (GIPO) in the first trimester tells the nurse that she is anxious about losing her baby, prenatal care, and her labor and birth. Which teaching need should the nurse identify as priority?

Accepted Answer

Answer reason: Explaining expected fetal growth milestones and common first-trimester developments helps the client understand what is typical versus warning signs that require reporting, which directly targets her fear of pregnancy loss. Education on labor and delivery options and preparing items for the baby are later-pregnancy needs and do not match the client’s current stage or primary anxiety. Teaching about sexual relations may be appropriate if the client asks or has restrictions, but it is not the most broadly relevant priority compared with foundational first-trimester fetal development education.

Question 43

The nurse is caring for the antepartum client with a velamentous cord insertion. The client asks what symptom she would most likely experience first if one of the vessels should tear. The nurse should respond that she would most likely experience which symptom first?

Accepted Answer

Answer reason: When a vessel tears, the earliest and most noticeable maternal symptom is painless vaginal bleeding, which may represent fetal blood loss and can rapidly compromise fetal oxygenation. Cramping or uterine contractions are not required for the bleeding to occur and may be absent initially. Placental abruption is a different pathology characterized by painful bleeding and uterine tenderness/rigidity, not the primary expected first sign of ruptured exposed cord vessels.

Question 44

The 22-year-old client tells the clinic nurse that her last menstrual period was 3 months ago, which began on November 21. She has a positive urine pregnancy test. Using Naegele's rule, which date should the nurse calculate to be the client's estimated date of confinement (EDC)?

Accepted Answer

Answer reason: Starting from November 21, adding 7 days gives November 28. Subtracting 3 months from November 28 yields August 28. The January options reflect moving forward only a couple of months rather than accounting for the full 40-week gestational length used in this calculation.

Question 45

Female clients are encouraged to receive regularly scheduled health care screenings and examinations throughout each pregnancy. The primary value of prenatal care is to?

Accepted Answer

Answer reason: Prenatal care’s overarching goal is ongoing surveillance to promote maternal-fetal wellbeing and to identify deviations from normal early. Regular visits allow assessment of maternal status (e.g., blood pressure, weight gain, symptoms), fetal growth and wellbeing, and timely screening for conditions like anemia, gestational diabetes, and preeclampsia. While detecting preterm birth risk and offering genetic screening can be important components, they are narrower objectives within the broader monitoring function. Planning for route of delivery is not the primary purpose of routine prenatal screening and is determined by evolving maternal-fetal factors later in pregnancy.

Question 46

The nurse is caring for a client suspected of having a hydatidiform mole. Which signs and symptoms would confirm this diagnosis?

Accepted Answer

Answer reason: The hallmark confirming finding is ultrasound showing diffuse echogenic intrauterine material classically described as a “snowstorm” appearance, typically without an identifiable fetus or normal gestational sac in a complete mole. Findings like fetal cardiac activity argue against a complete molar pregnancy because embryonic tissue is absent. The other options describe menstrual-pattern bleeding or uterine leiomyomas, which do not confirm trophoblastic disease.

Question 47

A pregnant client who reports painless vaginal bleeding at 28 weeks’ gestation is diagnosed with placenta previa. The placental edge reaches the internal os. The nurse would suspect the client has which type of placenta previa?

Accepted Answer

Answer reason: When the placental edge reaches the internal os but does not cover it, this corresponds to a marginal previa. If any portion of the placenta covers the os, it would be classified as partial or total depending on the degree of coverage. Low-lying indicates the placenta is implanted in the lower uterine segment but remains near, not reaching, the os; the description here is more advanced than that.

Question 48

A nurse is assessing a client at 33 weeks’ gestation. Leopold’s maneuvers indicate that the fetus is in a breech position. What is the best location for the nurse to auscultate fetal heart tones?

Accepted Answer

Answer reason: In a breech presentation, the fetal head is up near the maternal fundus, so the fetal chest/back and strongest heart sounds are typically above the umbilicus. With a right-sided fetal back (a common assumed orientation when a specific side is offered), the optimal listening point is in the right upper quadrant. A common distractor is the area below the umbilicus, which is more consistent with a cephalic/vertex presentation where the back is lower.

Question 49

Expectant management of the client with a placenta implanted in the lower uterine segment includes which procedure or treatment?

Accepted Answer

Answer reason: Serial ultrasound is used to reassess placental location/migration and to guide timing and mode of delivery. Steroids are indicated when preterm delivery is anticipated (typically before 34 weeks), so giving them after 34 weeks is not routine. Immediate preterm delivery in a hemodynamically stable patient is generally avoided unless there is uncontrolled hemorrhage or fetal compromise.

Question 50

In twin-to-twin transfusion syndrome, the arterial circulation of one twin is in communication with the venous circulation of the other twin. One fetus is considered the “donor” twin, and one becomes the “recipient” twin. Assessment of the recipient twin would most likely show which condition?

Accepted Answer

Answer reason: The recipient therefore becomes hypervolemic with increased red cell mass, making elevated hematocrit a likely finding. This excess volume also drives increased renal perfusion and urine output (often associated with polyhydramnios), whereas the donor tends toward hypovolemia with anemia and growth restriction. Thus the option most consistent with the recipient twin is increased RBC mass.

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