Full Test Bank Ch25 The Pregnant Woman - Health Assessment in Nursing 4e Test Bank by Cynthia Fenske. DOCX document preview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)
Chapter 25 The Pregnant Woman
- A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. Which information should the nurse include when addressing the client's concern? Select all that apply.
1. The stretch marks will fade but not disappear.
2. Cream will help the skin stay supple.
3. Cocoa butter lotions and creams will clear the marks completely.
4. The marks will lighten to a silvery tone after pregnancy.
5. Wearing supportive undergarments will help support the skin and reduce the appearance of the marks.
Page Ref: 634
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- A client who is 38 weeks pregnant reports increased urinary frequency. Based on this data, which response by the nurse is indicated?
1. "Your reports are consistent with a urinary tract infection."
2. "I will need to check your blood sugar as excessive urination is associated with gestational diabetes."
3. "Reducing your fluid intake will be helpful to manage this problem."
4. "This is normal occurrence in the later stages of pregnancy."
Page Ref: 636
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- While reviewing a pregnant client's medical record, the nurse notes that the cervix was soft in texture and nontender during the pelvic examination. Which is the appropriate terminology for the clinical finding?
1. Piskacek's sign.
2. Goodell sign.
3. Chadwick sign.
4. Hegar's sign.
Page Ref: 631
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 25.1: Describe the anatomy and physiology of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- A client's fundal height is slightly above the symphysis pubis. Based on this data, how many weeks gestation is the client?
1. 10-12 weeks.
2. 16 weeks.
3. 20-22 weeks.
4. 38 weeks.
Page Ref: 630, 632
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is preparing to measure the abdomen of a client who is 24 weeks gestation. Which is the anticipated height of the fundus?
1. 22 cm.
2. 24 cm.
3. 26 cm.
4. 28 cm.
Page Ref: 658
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is interviewing a female client who reports no menstrual periods for 2 months and breast soreness. The nurse would document this data as which classification of signs of pregnancy?
1. Objective.
2. Probable.
3. Presumptive.
4. Positive.
Page Ref: 640
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.5: Generate the appropriate documentation to describe the assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse examining a client notes a softening of the cervix. Which terminology should be documented to reflect the finding?
1. Goodell sign.
2. Hegar's sign.
3. Chadwick sign.
4. Ladin's sign.
Page Ref: 631
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.5: Generate the appropriate documentation to describe the assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odorless discharge from the vagina. Based on this data, which action by the nurse is the most appropriate?
1. Ask the client about vaginal discomfort.
2. Inquire about recent sexual intercourse.
3. Obtain a culture of the discharge.
4. Document the findings as normal.
Page Ref: 631
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is assessing a postpartum client and notes that the peri-pad has whitish-yellow discharge. Which term will the nurse use when documenting this finding in the medical record?
1. Postpartum bleeding.
2. Lochia rubra.
3. Lochia serosa.
4. Lochia alba.
Page Ref: 639
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.5: Generate the appropriate documentation to describe the assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts. Which action by the nurse is the most appropriate?
1. Ask the client if she is preparing for breastfeeding.
2. Notify the healthcare provider.
3. Document the findings as normal.
4. Obtain a culture of the discharge immediately.
Page Ref: 632
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is assisting the healthcare provider during a vaginal examination. The healthcare provider notes that the cervix has a bluish-purple change in coloration. Based on this data, which will the nurse document in the medical record?
1. Goodell sign.
2. Leukorrhea.
3. Chadwick sign.
4. Mucous plug.
Page Ref: 631
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.1: Describe the anatomy and physiology of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is discussing dietary recommendations with a client who has been experiencing a larger than recommended weight gain during her pregnancy. The client reports reducing the empty calories and red meat while significantly increasing intake of fish, poultry, fresh fruits, and vegetables. Based on this data, which response by the nurse is the most appropriate?
1. "It looks like you have things under control. Do you have any other questions?"
2. "Have you considered seeing a dietitian for nutritional counseling?"
3. "Tell me more about the meat and fish you are eating each day."
4. "I think we should discuss the risky dietary choices you are making with the healthcare provider."
Page Ref: 649-650
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.3: Determine questions about the pregnant woman to use for the focused interview.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- A client at 33 weeks' gestation calls the healthcare provider's office and reports she was attempting to nap when she became dizzy and felt faint. Which assessment data is the priority in this situation?
1. The position the client was in during the nap period.
2. Dietary intake prior to the episode.
3. History of hyperemesis.
4. No additional data is needed as this is an isolated incident.
Page Ref: 633
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The healthcare provider is using Leopold maneuvers to assess fetal positioning. Which maneuver is used to assess the fetal back?
1. First.
2. Second.
3. Third.
4. Fourth.
Page Ref: 660
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The nurse is preparing to assess the fetal heart tones for a client whose fetus is in the LOA position. Which maternal abdominal location should the nurse use to assess the fetal heart tones?
1. RUQ.
2. LUQ.
3. RLQ.
4. LLQ.
Page Ref: 662
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The nurse palpating a laboring client's contraction notes that it is mild. Which component of the contraction should the nurse associate the finding with?
1. Intensity.
2. Duration.
3. Frequency.
4. Length.
Page Ref: 658
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The nurse is caring for a pregnant client who desires to know the estimated date of birth (EDB) for the baby. The client reports that the last menstrual period (LMP) was May 10. Using Naegele's rule, which date will the nurse share with client?
1. February 17.
2. May 17.
3. May 24.
4. January 3.
Page Ref: 641
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection, the client reports she has not felt the baby move yet. Which response by the nurse is the most appropriate?
1. "We will listen for the heartbeat today."
2. "You need an ultrasound."
3. "Fetal movement may not be felt until the 18th week."
4. "Do you have reason to believe your baby is not ok?"
Page Ref: 629
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The nurse is examining a client who is 37 weeks pregnant. Which assessment finding would require immediate intervention by the nurse?
1. Patellar reflex 4+/0 - 4+ bilaterally.
2. Heart rate 104.
3. Trace protein in the urine.
4. Weight gain of two pounds in 2 months.
Page Ref: 656
Cognitive Level: Analyzing
Client Need & Sub: Physiological Adaptation; Medical Emergency
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require immediate intervention by the nurse?
1. "I have to get up during the night to void."
2. "I have not felt the baby move today."
3. "I am leaking a yellowish fluid from my breasts."
4. "I have been taking Tylenol (acetaminophen) for my backaches."
Page Ref: 649
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is preparing discuss self-care during pregnancy with a client. Which should the nurse include in this teaching session? Select all that apply.
1. Do not use soap on nipples.
2. Sleep 8-10 hours each night.
3. Eat four servings of dairy products daily.
4. Do not take iron supplements due to constipation.
5. Avoid resting in a back lying position.
Page Ref: 633-649
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Learn cooperatively and facilitate the learning of others. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
- A client expresses concern for her unborn baby after she learns her hemoglobin level was higher before her pregnancy. Which information should the nurse be prepared to initially discuss?
1. Dietary intake.
2. Changes in physiology.
3. Supplemental iron intake.
4. Prenatal vitamin supplementation.
Page Ref: 633
Cognitive Level: Applying
Client Need & Sub: Reduction of Risk Potential; Laboratory Values
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Learn cooperatively and facilitate the learning of others. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.1: Describe the anatomy and physiology of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is reviewing the risk factors of pregnancy for women over 35 yrs. Which should the nurse include? Select all that apply.
1. Hypertension.
2. Stillbirths.
3. Gestational diabetes.
4. Premature births.
5. Chromosomal abnormalities.
Page Ref: 638
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Learn cooperatively and facilitate the learning of others. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
- During a prenatal counseling session, a client tells the nurse she is concerned she may have a positive HIV test. Which statement by the nurse is indicated?
1. "I understand you are stressed about the outcome of the test."
2. "If you are HIV positive, your baby will also have HIV."
3. "Even if you do test HIV positive, preventive treatments have a good chance of providing protection for your baby."
4. "As long as you do not breastfeed and have a cesarean section, your baby will be protected."
Page Ref: 644
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
- The nurse is discussing the recommended weight gain for a client with a singleton pregnancy. Which recommendation should the nurse reinforce?
1. 28 to 40 lbs.
2. 25 to 30 lbs.
3. 15 to 25 lbs.
4. 11 to 20 lbs.
Page Ref: 652
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
- The nurse is examining a client in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
1. Pulse of 98 beats per minute.
2. Weight gain of 1.5 pounds in a month.
3. Blood pressure of 148/94 mmHg.
4. Respiratory rate of 26 per minute.
Page Ref: 633
Cognitive Level: Analyzing
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse reviewing a client's 1 hour GTT notes that the results are 155 mg/dl. Which should the nurse interpret the findings to indicate?
1. The client needs to repeat the test.
2. The client has gestational diabetes.
3. The client does not have gestational diabetes.
4. The client should follow up with a 3 hour GTT.
Page Ref: 656
Cognitive Level: Analyzing
Client Need & Sub: Reduction of Risk Potential; Diagnostic Tests
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- A client is diagnosed with Group B Streptococcus at 37 weeks' gestation. Which prescribed treatment should the nurse be prepared to discuss?
1. A 7-day course of prescribed oral antibiotics.
2. Treatment with IV antibiotics during active labor.
3. Initiation of treatment during the postpartum period.
4. IM antibiotic treatment to facilitate a rapid treatment.
Page Ref: 656
Cognitive Level: Applying
Client Need & Sub: Pharmacological and Parenteral Therapies; Parenteral/Intravenous Therapies
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- A newly pregnant client tells the nurse she takes daily herbal supplements. Which initial action should the nurse take?
1. Instruct the client to discuss the herbal supplementation with the healthcare provider.
2. Advise the client that the supplements may interfere with the prenatal
3. Instruct the client to stop taking the supplements.
4. Ask the client why she is taking supplements.
Page Ref: 822
Cognitive Level: Applying
Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- A pregnant client with hepatitis B asks the nurse if their baby will be born with the virus. Which information should the nurse include in the discussion?
1. "Your baby is not at risk for the virus."
2. "Your baby will be tested immediately after birth."
3. "Your baby will receive an immunoglobulin after birth."
4. "The virus has been transmitted through the placenta."
Page Ref: 644
Cognitive Level: Applying
Client Need & Sub: Pharmacological and Parenteral Therapies; Medication Administration
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman.
MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
- The nurse is preparing to obtain an obstetrical history from a client. Which question should the nurse include?
1. "Do you have a history of infertility?"
2. "What age did you become sexually active?"
3. "Have you ever had a sexually transmitted disease?"
4. "Have you had any spontaneous or induced abortions?"
Page Ref: 642
Cognitive Level: Applying
Client Need & Sub: Pharmacological and Parenteral Therapies; Medication Administration
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.3: Determine questions about the pregnant woman to use for the focused interview.
MNL Learning Outcome: 25.2 Plan questions related to the pregnancy for the focused interview of the pregnant woman.