Complete Solutions
A 40-year-old woman with a high body mass index (BMI) is 10
weeks pregnant. Which diagnostic tool should the nurse identify
as being appropriate to assess the pregnancy?
a. Biophysical profile
b. Transvaginal ultrasound
c. Amniocentesis
d. Maternal serum alpha-fetoprotein (MSAFP) Correct Answers
b. Transvaginal ultrasound
Rationale: An ultrasound is the method of biophysical
assessment of the infant that is performed at this gestational age.
Transvaginal ultrasound is especially useful for obese women,
whose thick abdominal layers cannot be penetrated adequately
with the abdominal approach.
A client calls a provider's office and reports having contractions
for 2 hrs that increased w/ activity & did not decrease w/ rest.
The client denies leaking of vaginal fluid but did notice blood
when wiping after voiding. Which of the following is the client
experiencing?
a. Braxton Hicks contractions
b. Rupture of membranes
c. Fetal descent
d. True contractions Correct Answers d. True contractions
,A client has just delivered a healthy newborn. Which action
should the nurse peform based on evidence-based care practice
in the immediate newborn period?
a. After drying, the infant should be given to the mother
wrapped in a receiving blanket.
b. The healthy newborn should be taken to the nursery for a
complete assessment.
c. Skin-to-skin contact of mother and baby should be
encouraged.
d. The father or support person should be encouraged to hold the
infant while awaiting delivery of the placenta. Correct Answers
c. Skin-to-skin contact of mother and baby should be
encouraged.
Rationale: The unwrapped infant should be placed on the
woman's bare chest or abdomen, then covered with a warm
blanket. Skin-to-skin contact keeps the newborn warm, prevents
neonatal infection, enhances physiologic adjustment to
extrauterine life, and fosters early breastfeeding.
A client has undergone an amniocentesis for evaluation of fetal
well-being. Which intervention would be included in the nurse s
plan of care after the procedure? (Select all that apply.)
a. Observe the client for possible uterine contractions.
b. Perform a minicatheterization to obtain a urine specimen to
assess for bleeding.
c. Perform ultrasound to determine fetal positioning.
d. Administer RhoGAM to the client if she is Rh negative.
Correct Answers a and d
,A group of nurses are discussing the concept of pain experience
during labor. Which statement should the nurses identify as
correct?
a. Sensory pain for nulliparous women often is greater than for
multiparous women during early labor.
b. Affective pain for nulliparous women usually is less than for
multiparous women throughout the first stage of labor.
c. Women with a history of substance abuse experience more
pain during labor.
d. Multiparous women have more fatigue from labor and
therefore experience more pain. Correct Answers a. Sensory
pain for nulliparous women often is greater than for multiparous
women during early labor.
A group of nurses are discussing the strengths and limitations of
various biochemical assessments during pregnancy. Which
statement should the nurses indicate as correct?
a. Chorionic villus sampling (CVS) is becoming more popular
because it provides early diagnosis.
b. Percutaneous umbilical blood sampling (PUBS) is one of the
quad-screen tests for Down syndrome.
c. MSAFP is a screening tool only; it identifies candidates for
more definitive procedures.
d. Screening for maternal serum alpha-fetoprotein (MSAFP)
levels is recommended only for women at risk for neural tube
defects. Correct Answers c. MSAFP is a screening tool only; it
identifies candidates for more definitive procedures.
, A group of nurses are reviewing Category Characteristics of
Fetal Monitoring. Which finding should the nurses identify as
being representative of Category I ?
a. Early decelerations, either present or absent.
b. Bradycardia not accompanied by baseline variability.
c. Tachycardia.
d. Sinusoidal pattern. Correct Answers a. Early decelerations,
either present or absent.
A multiparous client, Gravida 3 Para 2002 was examined 5
minutes ago. Her cervix was 8cm, 90% effaced. She now states
that she has to move her bowels. Which of the following should
the nurse do first?
a. Offer the client the bedpan.
b. Evaluate the progress of labor.
c. Notify the provider.
d. Encourage the client to push. Correct Answers b. Evaluate
the progress of labor.
A nurse caring for a pregnant patient suspected of being in
preterm labor recognizes which sign as diagnostic of preterm
labor?
a. Cervical dilation of at least 2 cm
b. Uterine contractions occurring every 15 minutes.
c. Spontaneous rupture of membranes
d. Presence of fetal fibronectin in cervical secretions. Correct
Answers a. Cervical dilation of at least 2 cm