Nursing 317- Maternal Adaptation During
Pregnancy (NCLEX Questions And Review)
Exam With Complete Solutions
The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment
should the nurse anticipate documenting?
-Slack, soft breast tissue
-Deeply fissured nipples
-Enlarged lymph nodes
-Darkened breast areolae - answer -Darkened breast areolae
A pregnant woman tells the nurse she often has allergic responses to drugs. She is
concerned that she will be allergic to her fetus or her body will reject the pregnancy.
The nurse's reply would be based on which statement?
-Immunologic activity is decreased during pregnancy.
-The level of aldosterone during pregnancy reduces production of IgG antibodies.
-The decreased corticosteroid activity during pregnancy ensures this will not happen.
-The kidneys release a hormone during pregnancy to prevent this from happening. -
answer -Immunologic activity is decreased during pregnancy.
It is unproven why women do not reject fetal (foreign) tissue, but a substance secreted
by the placenta is thought to decrease the usual immunologic response and prevent this
from happening.
A new mother asks the postpartum nurse if her baby is getting enough nourishment
from breast-feeding within the first 24 hours following birth. The nurse would provide
her what information?
-The mother needs to supplement breast-feedings with formula until her milk comes in.
-Breast milk comes in within 12 hours after delivery and nourishment should not be a
problem.
-Most infants need minimal nourishment for the first 24 hours, so the mother should not
be concerned.
-Colostrum, which is the first milk produced, is rich in calories and protein that
nourishes the infant well. - answer -Colostrum, which is the first milk produced, is rich in
,calories and protein that nourishes the infant well.
Colostrum is present prior to delivery and provides the infant with adequate nutrition for
the first 3 days of life, at which time the mother's actual milk should come in. Formula is
not recommended. Infants need nutrition shortly after birth to keep their blood glucose
normal.
Amanda's menstrual period is two weeks late. She has been feeling tired and has had
bouts of nausea in the morning. What classification of pregnancy symptoms is Amanda
experiencing?
-Positive
-Presumptive
-Probable
-No classification - answer -Presumptive
The most common presumptive sign of pregnancy is a missed menstrual period, or
amenorrhea. Other presumptive signs include nausea, fatigue, swollen, tender breasts,
and frequent urination.
A woman in a prenatal clinic tells the nurse that her pregnancy was unplanned and
unwanted. At what point in pregnancy does the average woman change her mind about
an unwanted pregnancy?
-Around the third month
-When quickening occurs
-After lightening happens
-After the seventh month - answer -When quickening occurs
Quickening, or feeling the baby move inside the body, is such a dramatic event that it
can cause a woman's perceptions about the pregnancy to change.
What is Quickening? - answer -Fetal movements felt by the mother
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The
woman is now 15 weeks pregnant. The nurse would expect this woman's heart rate to be
approximately:
-85 beats per minute.
-90 beats per minute.
, -95 beats per minute.
-100 beats per minute. - answer -85 beats per minute
During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20
weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart
rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per
minute.
Which assessment finding in the pregnant woman at 12 weeks' gestation should the
nurse find most concerning? The inability to:
-Detect fetal heart sounds with a Doppler.
-Feel fetal movements.
-Hear the fetal heartbeat with a stethoscope. -Palpate the fetal outline. - answer -Detect
fetal heart sounds with a Doppler.
Fetal heart sounds are audible with a Doppler at 10 to 12 weeks of gestation but cannot
be heard through a stethoscope until 18 to 20 weeks of gestation. Fetal movements can
be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around
20 weeks' gestation. The fetal outline is also palpable around 20 weeks of gestation.
A nurse who has been caring for a pregnant client understands that the client has pica
and has been regularly consuming soil. For which condition should the nurse monitor
the client?
-Iron-deficiency anemia
-Constipation
-Tooth fracture
-Inefficient protein metabolism - answer -Iron-deficiency anemia
Pica is characterized by a craving for substances that have no nutritional value.
Consumption of these substances can be dangerous to the client and her developing
fetus. The nurse should monitor the client for iron-deficiency anemia as a manifestation
of the client's compulsion to consume soil. Consumption of ice due to pica is likely to
lead to tooth fractures. The nurse should monitor for inefficient protein metabolism if the
client has been consuming laundry starch as a result of pica. The nurse should monitor
for constipation in the client if she has been consuming clay.
A mother comes in with her 17-year-old daughter to find out why she has not had a
menstrual cycle for a few months. Examination confirms the daughter is pregnant with a
Pregnancy (NCLEX Questions And Review)
Exam With Complete Solutions
The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment
should the nurse anticipate documenting?
-Slack, soft breast tissue
-Deeply fissured nipples
-Enlarged lymph nodes
-Darkened breast areolae - answer -Darkened breast areolae
A pregnant woman tells the nurse she often has allergic responses to drugs. She is
concerned that she will be allergic to her fetus or her body will reject the pregnancy.
The nurse's reply would be based on which statement?
-Immunologic activity is decreased during pregnancy.
-The level of aldosterone during pregnancy reduces production of IgG antibodies.
-The decreased corticosteroid activity during pregnancy ensures this will not happen.
-The kidneys release a hormone during pregnancy to prevent this from happening. -
answer -Immunologic activity is decreased during pregnancy.
It is unproven why women do not reject fetal (foreign) tissue, but a substance secreted
by the placenta is thought to decrease the usual immunologic response and prevent this
from happening.
A new mother asks the postpartum nurse if her baby is getting enough nourishment
from breast-feeding within the first 24 hours following birth. The nurse would provide
her what information?
-The mother needs to supplement breast-feedings with formula until her milk comes in.
-Breast milk comes in within 12 hours after delivery and nourishment should not be a
problem.
-Most infants need minimal nourishment for the first 24 hours, so the mother should not
be concerned.
-Colostrum, which is the first milk produced, is rich in calories and protein that
nourishes the infant well. - answer -Colostrum, which is the first milk produced, is rich in
,calories and protein that nourishes the infant well.
Colostrum is present prior to delivery and provides the infant with adequate nutrition for
the first 3 days of life, at which time the mother's actual milk should come in. Formula is
not recommended. Infants need nutrition shortly after birth to keep their blood glucose
normal.
Amanda's menstrual period is two weeks late. She has been feeling tired and has had
bouts of nausea in the morning. What classification of pregnancy symptoms is Amanda
experiencing?
-Positive
-Presumptive
-Probable
-No classification - answer -Presumptive
The most common presumptive sign of pregnancy is a missed menstrual period, or
amenorrhea. Other presumptive signs include nausea, fatigue, swollen, tender breasts,
and frequent urination.
A woman in a prenatal clinic tells the nurse that her pregnancy was unplanned and
unwanted. At what point in pregnancy does the average woman change her mind about
an unwanted pregnancy?
-Around the third month
-When quickening occurs
-After lightening happens
-After the seventh month - answer -When quickening occurs
Quickening, or feeling the baby move inside the body, is such a dramatic event that it
can cause a woman's perceptions about the pregnancy to change.
What is Quickening? - answer -Fetal movements felt by the mother
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The
woman is now 15 weeks pregnant. The nurse would expect this woman's heart rate to be
approximately:
-85 beats per minute.
-90 beats per minute.
, -95 beats per minute.
-100 beats per minute. - answer -85 beats per minute
During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20
weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart
rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per
minute.
Which assessment finding in the pregnant woman at 12 weeks' gestation should the
nurse find most concerning? The inability to:
-Detect fetal heart sounds with a Doppler.
-Feel fetal movements.
-Hear the fetal heartbeat with a stethoscope. -Palpate the fetal outline. - answer -Detect
fetal heart sounds with a Doppler.
Fetal heart sounds are audible with a Doppler at 10 to 12 weeks of gestation but cannot
be heard through a stethoscope until 18 to 20 weeks of gestation. Fetal movements can
be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around
20 weeks' gestation. The fetal outline is also palpable around 20 weeks of gestation.
A nurse who has been caring for a pregnant client understands that the client has pica
and has been regularly consuming soil. For which condition should the nurse monitor
the client?
-Iron-deficiency anemia
-Constipation
-Tooth fracture
-Inefficient protein metabolism - answer -Iron-deficiency anemia
Pica is characterized by a craving for substances that have no nutritional value.
Consumption of these substances can be dangerous to the client and her developing
fetus. The nurse should monitor the client for iron-deficiency anemia as a manifestation
of the client's compulsion to consume soil. Consumption of ice due to pica is likely to
lead to tooth fractures. The nurse should monitor for inefficient protein metabolism if the
client has been consuming laundry starch as a result of pica. The nurse should monitor
for constipation in the client if she has been consuming clay.
A mother comes in with her 17-year-old daughter to find out why she has not had a
menstrual cycle for a few months. Examination confirms the daughter is pregnant with a
