Nokea
The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
- A. Two finger-breadths above the symphysis pubis
- B. Halfway between the symphysis pubis and the umbilicus
- C. At the level of the umbilicus
- D. Two finger-breadths above the umbilicus
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.
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Which activity should the nurse recommend to prepare for labor?
- A. Practicing relaxation and breathing techniques
- B. Increasing caffeine intake
- C. Avoiding all physical activity
- D. Taking daily hot baths
Correct Answer: A
Rationale: Practicing relaxation and breathing techniques helps manage labor pain and prepares the client for childbirth.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
- A. 2 hours
- B. 24 hours
- C. 48 hours
- D. 72 hours
Correct Answer: B
Rationale: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.
Which pregnant client should the nurse encourage to undergo hepatitis B testing?
- A. A client with a history of cigarette smoking
- B. A client who is a health care worker
- C. A client who emigrated in the past year from Haiti
- D. A client who was recently exposed to Haemophilus influenzae
Correct Answer: C
Rationale: Clients from high-prevalence areas like Haiti are at higher risk for hepatitis B, warranting testing during pregnancy.
The 39-year-old client with type 1 DM presents at 36 weeks’ gestation with Drag and Drop contractions. An HCP decides to do an amniocentesis. Which statement best supports why the nurse and NA should prepare the client for an amniocentesis now?
- A. Diabetic women have a higher incidence of birth defects, and the HCP wants to determine if a birth defect is present.
- B. The client is over 35, at 36 weeks’ gestation with Drag and Drop contractions, and is at risk for chromosomal disorders.
- C. An amniocentesis performed at 36 weeks’ gestation is being completed to determine if the fetal lungs have matured.
- D. The amniocentesis is more accurate than the fetal fibronectin test in determining if delivery is imminent.
Correct Answer: C
Rationale: Infants of diabetic mothers are less likely to have mature lung capacity at 36 weeks; knowing lung maturity can influence whether delivery should proceed. In mid pregnancy, the cells in amniotic fluid can be studied for genetic abnormalities such as Down’s syndrome and birth defects, but amniocentesis would not be performed for this purpose when the client is in preterm labor. Many women over the age of 35 have amniocentesis completed to test for chromosomal disorders, but not this late in the pregnancy. Fetal fibronectin testing is used to determine if a preterm birth is likely, but it cannot be used to determine lung maturity.