A nursing student is preparing a prenatal class on the process of fetal circulation. The nursing instructor asks the student specifically to describe the
... [Show More] process through the umbilical cord. Which of the following statements from the student is correct?
1. "The one artery carries freshly oxygenated blood and nutrient-rick blood back from the placenta to the fetus."
2. "The two arteries carry freshly oxygenated blood back from the placenta to the fetus."
3. "The two arteries in the umbilical cord carry deoxygenated blood and waste products away from the fetus to the placenta."
4. "The two veins in the umbilical cord carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."
3. "The two arteries in the umbilical cord carry deoxygenated blood and waste products away from the fetus to the placenta."
Rational: Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. When oxygenated, the blood is returned by one umbilical vein.
A pregnant client tells the clinic nurse that she wants to k now the sex of her baby as soon as it can be determined. The nurse understands that the client should be able to find out at 12 weeks' gestation because by the end of the twelfth week:
1. The sex of the fetus can be determined by the appearance of the external genitalia.
2. The sex of the fetus can be determined because the external genitalia begin to differentiate.
3. The sex of the fetus can be determined because the testes are descended into the scrotal sac.
4. The sex of the fetus can be determined because the internal differences in males and females becomes apparent.
1. The sex of the fetus can be determined by the appearance of the external genitalia.
Rational: By the end of the 12th week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually.
A nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the FHR is 174/bpm. On the basis of this finding, the appropriate nursing action is to:
1. Notify the physician
2. Document the findings.
3. Check the mother's heart rate
4. Tell the client that the FHR is normal.
1. Notify the physican
Rational: The FHR depends on gestational age and ranges from 160-170/bpm in the 1st trimester, but slows with fetal growth to 120-160/bpm near or at term. Because the FHR is increased from the reference range, the nurse should notify the physican.
A nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the Fallopian tube for 3 days, the nurse responds that the reason for this is that it:
1. Promotoes the fertilized ovum's changes of survival.
2. Promotes the fertilized ovum's exposure to estrogen & progesterone.
3. Promotes the fertilized ovum's normal implantation in the top portion of the uterus.
4. Promotes the fertilized ovum's exposure to LH and FSH
3. Promotes the fertilized ovum's normal implantation in the top portion of the uterus.
A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducing a prenatal teaching session. The instructor asks the student to describe the FSH and LF. The student accurately responds by stating that:
1. FSH & LH are secreted by the adrenal glands.
2. FSH & LH are released from the anterior pituitary gland
3. FSH & LH are secreted by the corpus luteum of the ovary
4. FSH & LH stimulate the formation of the milk during pregnancy.
2. FSH & LH are released from the anterior pituitary gland
A nurse explains some of the purposes of the placenta to a client during a prenatal visit. The nurse determins that the client understands some of these purposes when the client states that the placenta:
1. Cushions and protects the baby
2. Maintains the temperature of the baby
3. Is the way the baby gets food and oxygen
4. Prevents all antibodies and viruses from passing to the baby.
3. Is the way the baby gets food and oxygen.
A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of the amniotic fluid? SELECT ALL THAT APPLY.
1. Allows for fetal movement
2. Is a measure of kidney function
3. Surrounds, cushions, and protects the fetus
4. Maintains the body temperature of the fetus
5. Prevents large particles such as bacteria from passing to the fetus
6. Provides an exchange of nutrients and waste products between the mother and fetus
1. Allows for fetal movement
2. Is a measure of kidney function
3. Surrounds, cushions, and protects the fetus
4. Maintains the body temperature of the fetus
A nurse is performing an assessment of a pregnant client who is at 28 wks gestation. The nurse measures the fundal height in centimeters and expects he finding to be which of the following?
1. 22 cm
2. 30 cm
3. 36 cm
4. 40 cm
2. 30 cm
Rational: During the 2nd/3rd trimesters (18 wks-30wks), fundal height in cm approximately equals the fetus' age in weeks +/- 2cm. At 16 wks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20-22 wks, the fundus is at the umbilicus. At 36 wks, the fundus is at the xiphoid process.
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 wks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as:
1. G3, T2, P0, A0, L1
2. G2, T1, P0, A0, L1
3. G1, T1, P1, A0, L1
4. G2, T0, P0, A0, L1
2. G2, T1, P0, A0, L1
A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that she is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
1. Contact the physician
2. Instruct the client to maintain bedrest for the remainder of the pregnancy.
3. Inform the client that these contractions are common and may occur throughout the pregnancy.
4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.
3. Inform the client that these contractions are common and may occur throughout the pregnancy.
A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. The nurse tells the client that:
1. Total abstinence from sexual intercourse is necessary during the entire pregnancy.
2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present.
3. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy.
4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.
4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.
A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse determines that this sign indicates:
1. A softening of the cervix.
2. The presence of fetal movement
3. The presence of HCG in the urine
4. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.
1. A softening of the cervix.
A client arrives at the clinic for the first prenatal assessment. The client tells a nurse that the first day of her LMP was October 19, 2012. Using Nagele's rule, the nurse determines the EDD is:
1. July 12, 2012
2. July 26, 2013
3. August 12, 2013
4. August 26, 2013
2. July 26, 2013
A nurse-midwife is assessing a pregnant client for the presence of ballottement. To make this determination, the nurse mid-wife does which of the follwoing?
1. Auscultates for fetal heart sounds
2. Assesses the cervix for compressibility
3. Palpates the abdomen for fetal movement
4. Initiates a gentle upward tap on the cervix.
4. Initiates a gentle upward tap on the cervix.
A nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her 2nd trimester of pregnancy. Which of the following indicates an ABNORMAL physical finding that necessitates further testing?
1. Quickening
2. Braxton Hicks Contractions
3. FHR of 180/bpm
4. Consistent increase in fundal height
3. FHR of 180/bpm
A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for PROBABLE signs of pregnancy. Which of the following are probably signs of pregnancy? SELECT ALL THAT APPLY.
1. Ballottement
2. Chadwick's Sign
3. Uterine enlargement
4. Braxton Hicks contractions
5. FHR detected by a non-electronic devise
6. Outline of fetus via radiography or ultrasonography
1. Ballottement
2. Chadwick's Sign
3. Uterine enlargement
4. Braxton Hicks contractions
A nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. The nurse tells the client that:
1. Strict bed rest is required after the procedure.
2. An informed consent needs to be signed before the procedure
3. Hospitalization is necessary for 24 hours after the procedure
4. A fever is expected after the procedure because of the trauma to the abdomen.
2. An informed consent needs to be signed before the procedure
A pregnant client in the 1st trimester calls a nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
1. "Come to the clinic immediately."
2. "Report the ED at the maternity center immediately."
3. "The vaginal drainage may be bothersome, but is a normal occurrence."
4. "Use tampons if the discharge is bothersome, but to be sure to change the tampons ever 2 hours."
3. "The vaginal drainage may be bothersome, but is a normal occurrence."
Rational: Leukorrhea begins during the 1st trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the clinic or ED.
A nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive and understand that this indicates:
1. Normal findings
2. Abnormal findings
3. The need for further evaluation
4. That the findings on the monitor were difficult to interpreet
1. Normal findings
Rational: A reactive NST is a normal result. To be considered reactive, the baseline FHR must be within normal range, 120-160/bpm, with good long-term variability. In addition, 2+ FHR accelerations of t least 15/bpm must occur, each with a duration of at least 15 sec, in a 20-minute interval. [Show Less]