Maternal Monitoring

Maternal Monitoring Related

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The nurse is educating a pregnant patient who is at 36 weeks gestation about the signs of labor. Which statement by the patient indicates effective teaching?

  • A. I should report regular contractions that occur every 5 minutes for 1 hour.
  • B. I should avoid drinking fluids until my contractions stop.
  • C. If I lose my mucous plug, I should go to the hospital immediately.
  • D. I should stay home and rest as long as my contractions are not painful.
Correct Answer: A

Rationale: The correct answer is A because reporting regular contractions occurring every 5 minutes for 1 hour is a key sign of active labor. This pattern indicates the onset of true labor and the need to seek medical attention.

Explanation:
1. Regular contractions every 5 minutes indicate active labor is likely.
2. Sustained contractions for an hour suggest progression of labor.
3. Seeking medical advice is crucial for appropriate management.

Incorrect Choices:
B. Incorrect. Staying hydrated is important during labor to prevent dehydration.
C. Incorrect. Losing the mucous plug is a sign of early labor, not an emergency.
D. Incorrect. Painful contractions are not the sole indicator of active labor; regularity is key.

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The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?

  • A. Inadequate space in the uterus
  • B. Inadequate blood supply
  • C. Inadequate maternal health
  • D. Inadequate placental nutrition
Correct Answer: D

Rationale: The single placenta may not be able to provide adequate nutrition to two fetuses.

A pregnant patient at 28 weeks gestation reports lightheadedness and fainting when standing up. What is the most likely cause of these symptoms?

  • A. Dehydration and electrolyte imbalance
  • B. Increased blood volume and decreased blood pressure
  • C. Iron-deficiency anemia
  • D. Hyperglycemia from gestational diabetes
Correct Answer: B

Rationale: The correct answer is B: Increased blood volume and decreased blood pressure. At 28 weeks gestation, the pregnant patient's blood volume significantly increases to support the developing fetus, causing a relative decrease in blood pressure when standing up (orthostatic hypotension). This can lead to lightheadedness and fainting. Dehydration and electrolyte imbalance (choice A) can contribute to these symptoms but are less likely in a pregnant patient. Iron-deficiency anemia (choice C) can cause similar symptoms but is less common at 28 weeks gestation. Hyperglycemia from gestational diabetes (choice D) typically presents with other symptoms like excessive thirst and urination, rather than lightheadedness and fainting.

An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.

  • A. Amenorrhea.
  • B. Breast tenderness.
  • C. Quickening.
  • D. Frequent urination.
Correct Answer: A

Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.

The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?

  • A. Fetal heart rate via Doppler.
  • B. Positive pregnancy test.
  • C. Positive Chadwick’s sign.
  • D. Montgomery gland enlargements.
Correct Answer: A

Rationale: A fetal heart rate detected via Doppler is a positive sign of pregnancy. A positive pregnancy test, Chadwick’s sign, and Montgomery gland enlargements are probable signs but not definitive.

What fetal change occurs when the fundal height reaches the xiphoid process?

  • A. Surfactant forms in lungs
  • B. Eyes begin to open and close
  • C. Respiratory movements begin
  • D. Spinal column is complete
Correct Answer: A

Rationale: Surfactant production begins in the lungs around this stage of pregnancy, preparing them for postnatal breathing.

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