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Client at 18 weeks of gestation, felt light fluttering in stomach the previous day
The nurse should use which of the following terms to document this finding?
- A. Lightening
- B. Chloasma
- C. Ballotement
- D. Quickening
Correct Answer: D
Rationale: The correct answer is D: Quickening. Quickening refers to the first perception of fetal movements by the mother, typically around 16-20 weeks of gestation. It is an important milestone in pregnancy. Lightening (A) is the descent of the fetus into the pelvis. Chloasma (B) is a skin condition characterized by hyperpigmentation. Ballotement (C) is the rebounding of the fetus when the examiner pushes against the mother's abdomen. These terms are not relevant to the finding described in the question.
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Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.
Client at first prenatal visit
Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.
- A. Breast tenderness
- B. Nausea and vomiting
- C. Quickening
- D. Goodell's sign
- E. Striae gravidarum
- F. Lightening
Correct Answer: A,B,C,D,E,F
Rationale: The correct order is A, B, C, D, E, F. Firstly, breast tenderness (A) typically occurs early in pregnancy due to hormonal changes. Next, nausea and vomiting (B) often start around the 6th week. Quickening (C), the first fetal movements felt by the mother, occurs around 16-20 weeks. Goodell's sign (D), softening of the cervix, happens around the 6th-8th week. Striae gravidarum (E), stretch marks, appear later in pregnancy due to skin stretching. Finally, lightening (F), when the baby drops lower in the pelvis, occurs in the last few weeks before labor. Other options are incorrect as they do not follow the chronological order of gestation milestones.
Client at 28 weeks of gestation, history of one elective abortion at 9 weeks, birth of twins at 36 weeks, spontaneous abortion at 15 weeks
According to the GTPAL system, which of the following describes her present parity?
- A. 4-0-0-2-2
- B. 4-2-0-2-2
- C. 4-0-2-2-2
- D. 4-0-1-2-2
Correct Answer: D
Rationale: According to the GTPAL system, "G" represents the total number of pregnancies. In this case, the correct answer is D (4-0-1-2-2) because it indicates the woman has had 4 pregnancies, 0 term births, 1 preterm birth, 2 living children, and 2 abortions/miscarriages. This is the correct interpretation of her present parity. Choices A, B, and C have incorrect numbers for preterm births, living children, or abortions/miscarriages, making them incorrect.
Client experiencing preterm labor, scheduled for amniocentesis
The client needs an amniocentesis to determine which of the following findings?
- A. Gender of the fetus
- B. Weeks of gestation
- C. Maturity of lungs
- D. Anatomic abnormalities
Correct Answer: C
Rationale: The correct answer is C: Maturity of lungs. Amniocentesis is a prenatal test that involves taking a sample of amniotic fluid to analyze fetal cells. The test can determine the maturity of the fetal lungs by measuring the level of surfactant, a substance produced by mature lungs. This information is crucial for assessing the fetus's lung function and determining the need for medical intervention if the lungs are not mature enough for birth.
Incorrect answers:
A: Gender of the fetus - Amniocentesis can determine the gender of the fetus, but this is not the primary purpose of the test.
B: Weeks of gestation - The gestational age can be estimated through ultrasound or other methods, not specifically through amniocentesis.
D: Anatomic abnormalities - While amniocentesis can detect some genetic abnormalities, it is not primarily used to detect anatomic abnormalities.
Client might have a hydatidiform mole
The nurse should monitor the client for which of the following findings?
- A. Whitish vaginal discharge
- B. Fetal heart rate irregularities
- C. Excessive uterine enlargement
- D. Rapidly dropping human chorionic gonadotropin (hCG) levels
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. This finding is important to monitor in a pregnant client as it may indicate conditions such as multiple gestation, hydramnios, or molar pregnancy, which could pose risks to both the mother and baby. Monitoring uterine size helps in assessing fetal growth and development. Whitish vaginal discharge (A) could be a normal finding or indicate a yeast infection, while fetal heart rate irregularities (B) would be monitored using fetal monitoring, not uterine size. Rapidly dropping hCG levels (D) could suggest a miscarriage or ectopic pregnancy, but it is not directly related to uterine enlargement.