NURSING 317: MATERNAL ADAPTATION DURING PREGNANCY (NCLEX QUESTIONS AND REVIEW)

NURSING 317: MATERNAL
ADAPTATION DURING PREGNANCY
(NCLEX QUESTIONS AND REVIEW)
The nurse is assessing a pregnant client at her 20-
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week visit. Which breast assessment should the nurse anticipate documenting?
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-Slack, soft breast tissue qf qf qf qf


-Deeply fissured nipples qf qf qf


-Enlarged lymph nodes qf qf qf


-Darkened breast areolae - ANSWERS--Darkened breast areolae qf qf qf qf qf qf




A pregnant woman tells the nurse she often has allergic responses to drugs. She is c
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oncerned that she will be allergic to her fetus or her body will reject the pregnancy. T
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he nurse's reply would be based on which statement?
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-Immunologic activity is decreased during pregnancy. qf qf qf qf qf qf


-The level of aldosterone during pregnancy reduces production of IgG antibodies.
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The decreased corticosteroid activity during pregnancy ensures this will not happen.
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-The kidneys release a hormone during pregnancy to prevent this from happening. -
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ANSWERS--Immunologic activity is decreased during pregnancy.
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It is unproven why women do not reject fetal (foreign) tissue, but a substance secrete
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d by the placenta is thought to decrease the usual immunologic response and preve
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nt this from happening.
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A new mother asks the postpartum nurse if her baby is getting enough nourishment f
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rom breast- qf


feeding within the first 24 hours following birth. The nurse would provide her what inf
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ormation?

-The mother needs to supplement breast-
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feedings with formula until her milk comes in. - qf qf qf qf qf qf qf qf


Breast milk comes in within 12 hours after delivery and nourishment should not be a
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problem. qf


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Most infants need minimal nourishment for the first 24 hours, so the mother should n
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ot be concerned.
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Colostrum, which is the first milk produced, is rich in calories and protein that nourish
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es the infant well. - ANSWERS--
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Colostrum, which is the first milk produced, is rich in calories and protein that nourish
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es the infant well.
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Colostrum is present prior to delivery and provides the infant with adequate nutrition f
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or the first 3 days of life, at which time the mother's actual milk should come in. Form
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, ula is not recommended. Infants need nutrition shortly after birth to keep their blood
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glucose normal. qf




Amanda's menstrual period is two weeks late. She has been feeling tired and has ha
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d bouts of nausea in the morning. What classification of pregnancy symptoms is Am
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anda experiencing? qf




-Positive qf


-Presumptive qf


-Probable qf


-No classification - ANSWERS--Presumptive
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The most common presumptive sign of pregnancy is a missed menstrual period, or a
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menorrhea. Other presumptive signs include nausea, fatigue, swollen, tender breast
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s, and frequent urination.
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A woman in a prenatal clinic tells the nurse that her pregnancy was unplanned and u
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nwanted. At what point in pregnancy does the average woman change her mind abo
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ut an unwanted pregnancy?
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-Around the third month qf qf qf qf


-When quickening occurs qf qf qf


-After lightening happens qf qf qf


-After the seventh month - ANSWERS--When quickening occurs
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Quickening, or feeling the baby move inside the body, is such a dramatic event that it
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can cause a woman's perceptions about the pregnancy to change.
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What is Quickening? - ANSWERS--Fetal movements felt by the mother
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Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The
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woman is now 15 weeks pregnant. The nurse would expect this woman's heart rate
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to be approximately:
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-85 beats per minute.
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-90 beats per minute.
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-95 beats per minute.
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-100 beats per minute. - ANSWERS--85 beats per minute
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During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 an
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d 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnan
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cy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87
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beats per minute. qf qf




Which assessment finding in the pregnant woman at 12 weeks' gestation should the
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nurse find most concerning? The inability to:
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-Detect fetal heart sounds with a Doppler. qf qf qf qf qf qf qf


-Feel fetal movements. qf qf qf


-Hear the fetal heartbeat with a stethoscope. -Palpate the fetal outline. - ANSWERS-
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-Detect fetal heart sounds with a Doppler. qf qf qf qf qf qf


Fetal heart sounds are audible with a Doppler at 10 to 12 weeks of gestation but can
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not be heard through a stethoscope until 18 to 20 weeks of gestation. Fetal moveme
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nts can be felt by a woman as early as 16 weeks of pregnancy and felt by the exami
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ner around 20 weeks' gestation. The fetal outline is also palpable around 20 weeks o
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f gestation.
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