Nokea
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?
- A. Vertex
- B. Breech
- C. Transverse
- D. Brow
Correct Answer: C
Rationale: A transverse lie occurs in 1 in 300 births and is marked by the fetus’s lying in a side-lying position across the abdomen. Vertex presentations result in the lie’s being vertical. Breech presentations result in the lie’s being vertical. A brow presentation is also a vertical lie.
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The pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client’s chart notation to most accurately describe the client’s condition?
- A. Ectopic pregnancy
- B. Complete abortion
- C. Imminent abortion
- D. Incomplete abortion
Correct Answer: C
Rationale: In imminent abortion, the client’s bleeding and cramping increase and the cervix is open, which indicates that abortion is imminent or inevitable. In ectopic pregnancy, the pregnancy is outside of the uterus, and intervention is indicated to resolve the pregnancy. A complete abortion indicates that the contents of the pregnancy have been passed. In an incomplete abortion, a portion of the pregnancy has been expelled, and a portion remains in the uterus.
Which client statement indicates a need for immediate intervention?
- A. I feel the baby move daily.
- B. I have mild swelling in my ankles.
- C. I haven't felt the baby move today.
- D. I'm eating a balanced diet.
Correct Answer: C
Rationale: A lack of fetal movement may indicate fetal distress, requiring immediate assessment and intervention.
Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
- A. A client who is pregnant for the fifth time
- B. A client who is 16 years old
- C. A client who has a history of twins in the family
- D. A client who has primary hypertensive disease
- E. A client who works 40 hours a week in a factory
- F. A client who reports spotting in the first trimester
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
In the primigravid client, when is fetal movement typically felt for the first time?
- A. Between 10 and 14 weeks' gestation
- B. Between 16 and 20 weeks' gestation
- C. Between 22 and 26 weeks' gestation
- D. Between 28 and 32 weeks' gestation
Correct Answer: B
Rationale: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
The RN and the student nurse are caring for the postpartum client who is 16 hours postdelivery. The RN evaluates that the student needs more education about uterine assessment when the student is observed doing which activity?
- A. Elevating the client’s head 30 degrees before doing the assessment
- B. Supporting the lower uterine segment during the assessment
- C. Gently palpating the uterine fundus for firmness and location
- D. Observing the abdomen before beginning palpation
Correct Answer: A
Rationale: For uterine assessment, the client should be positioned in a supine position so the height of the uterus is not influenced by an elevated position. When beginning the assessment, one hand should be placed at the base of the uterus just above the symphysis pubis to support the lower uterine segment. This prevents the inadvertent inversion of the uterus during palpation. Once the lower hand is in place, the fundus of the uterus can be gently palpated. The abdomen should be observed prior to palpation for contour to detect distention and for the appearance of striae or a diastasis.