NCLEX-RN Maternity: Antepartum
Review with Practice Questions &
Verified Answers
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent
exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's
best response to the client? Refer to chart.
1."You should avoid all school-age children during pregnancy." 2."There is no need to be
concerned if you don't have a fever or rash within the next 2 days." 3."You were wise to
call. Your rubella titer indicates that you are immune and your baby is not at risk."
4."Be sure to tell the primary health care provider in 2 weeks, as additional screening
will be prescribed during your second trimester. - answers -:3."You were wise to call.
Your rubella titer indicates that you are immune and your baby is not at risk."
Rubella virus is spread by aerosol droplet transmission through the upper respiratory
tract and has an incubation period of 14 to 21 days. The risks of maternal and
subsequent fetal infection during the second trimester include hearing loss and
congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella
titer determination is a standard prenatal test for pregnant women during their initial
screening and entry into the health care delivery system. As noted in this client's chart,
she is immune to rubella. The correct option is the only option that helps clarify
maternal concerns with accurate information.
The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying
the food items highest in folic acid. The nurse determines that the client understands
the foods that supply the highest amounts of folic acid if the client states that she will
include which item in the daily diet?
1.Milk
2.Yogurt
3.Bananas
4.Leafy green vegetables - answers -:4. Leafy green vegetables
Leafy green vegetables are rich in folate (folic acid). Milk and yogurt supply calcium;
bananas provide potassium.
, The nurse is reviewing the record of a pregnant client seen in the health care clinic for
the first prenatal visit. Which data, if noted on the client's record, should alert the nurse
that the client is at risk for a spontaneous abortion?
1.Age 35 years
2.History of syphilis
3.History of genital herpes
4.History of diabetes mellitus - answers -:2.History of syphilis
Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of
spontaneous abortion. There is no evidence that genital herpes is a causative agent in
abortion, although the presence of active lesions at the time of birth presents concerns.
Maternal age greater than 40 years and diabetes mellitus are considered high-risk
factors in a pregnancy but are related to an increased risk of congenital malformations,
not abortions.
The nurse provides home care instructions to a pregnant client with a history of cardiac
disease. Which statement made by the client indicates a need for further teaching?
1."It is best that I rest on my left side to promote blood return to the heart."
2."I need to avoid excessive weight gain to prevent increased demands on my heart."
3."I need to try to avoid stressful situations because stress increases the workload on the
heart." 4."During the pregnancy, I need to avoid contact with other individuals as much
as possible to prevent infection. - answers -:"During the pregnancy, I need to avoid
contact with other individuals as much as possible to prevent infection."
To avoid infections, visitors with active infections should not be allowed to visit the
client; otherwise, restrictions are not required. Resting should be done while lying on
the left side to promote blood return. Too much weight gain can place further demands
on the heart. Stress causes increased workload on the heart, and the client should be
instructed to avoid stress.
During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be
180 beats/minute. What might the nurse suspect as the most likely cause of this
tachycardia?
1.Maternal infection
2.Gestational hypertension 3.Gestational diabetes mellitus 4.Consumption of recent
high-sugar snack - answers -:1. Maternal infection
The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute
in the first trimester but slows with fetal growth to approximately 110 to 160
beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110
beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in
distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate
intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes,
Review with Practice Questions &
Verified Answers
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent
exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's
best response to the client? Refer to chart.
1."You should avoid all school-age children during pregnancy." 2."There is no need to be
concerned if you don't have a fever or rash within the next 2 days." 3."You were wise to
call. Your rubella titer indicates that you are immune and your baby is not at risk."
4."Be sure to tell the primary health care provider in 2 weeks, as additional screening
will be prescribed during your second trimester. - answers -:3."You were wise to call.
Your rubella titer indicates that you are immune and your baby is not at risk."
Rubella virus is spread by aerosol droplet transmission through the upper respiratory
tract and has an incubation period of 14 to 21 days. The risks of maternal and
subsequent fetal infection during the second trimester include hearing loss and
congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella
titer determination is a standard prenatal test for pregnant women during their initial
screening and entry into the health care delivery system. As noted in this client's chart,
she is immune to rubella. The correct option is the only option that helps clarify
maternal concerns with accurate information.
The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying
the food items highest in folic acid. The nurse determines that the client understands
the foods that supply the highest amounts of folic acid if the client states that she will
include which item in the daily diet?
1.Milk
2.Yogurt
3.Bananas
4.Leafy green vegetables - answers -:4. Leafy green vegetables
Leafy green vegetables are rich in folate (folic acid). Milk and yogurt supply calcium;
bananas provide potassium.
, The nurse is reviewing the record of a pregnant client seen in the health care clinic for
the first prenatal visit. Which data, if noted on the client's record, should alert the nurse
that the client is at risk for a spontaneous abortion?
1.Age 35 years
2.History of syphilis
3.History of genital herpes
4.History of diabetes mellitus - answers -:2.History of syphilis
Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of
spontaneous abortion. There is no evidence that genital herpes is a causative agent in
abortion, although the presence of active lesions at the time of birth presents concerns.
Maternal age greater than 40 years and diabetes mellitus are considered high-risk
factors in a pregnancy but are related to an increased risk of congenital malformations,
not abortions.
The nurse provides home care instructions to a pregnant client with a history of cardiac
disease. Which statement made by the client indicates a need for further teaching?
1."It is best that I rest on my left side to promote blood return to the heart."
2."I need to avoid excessive weight gain to prevent increased demands on my heart."
3."I need to try to avoid stressful situations because stress increases the workload on the
heart." 4."During the pregnancy, I need to avoid contact with other individuals as much
as possible to prevent infection. - answers -:"During the pregnancy, I need to avoid
contact with other individuals as much as possible to prevent infection."
To avoid infections, visitors with active infections should not be allowed to visit the
client; otherwise, restrictions are not required. Resting should be done while lying on
the left side to promote blood return. Too much weight gain can place further demands
on the heart. Stress causes increased workload on the heart, and the client should be
instructed to avoid stress.
During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be
180 beats/minute. What might the nurse suspect as the most likely cause of this
tachycardia?
1.Maternal infection
2.Gestational hypertension 3.Gestational diabetes mellitus 4.Consumption of recent
high-sugar snack - answers -:1. Maternal infection
The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute
in the first trimester but slows with fetal growth to approximately 110 to 160
beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110
beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in
distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate
intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes,
