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The pregnant client asks the nurse, who is teaching a prepared childbirth class, when she should expect to feel fetal movement. The nurse responds that fetal movement usually can first be felt during which time frame?
- A. 8 to 12 weeks of pregnancy
- B. 12 to 16 weeks of pregnancy
- C. 18 to 20 weeks of pregnancy
- D. 22 to 26 weeks of pregnancy
Correct Answer: C
Rationale: Subtle fetal movement (quickening) can be felt as early as 18 to 20 weeks of gestation, and it gradually increases in intensity. Eight to 12 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twelve to 16 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twenty-two to 26 weeks of pregnancy is later than expected to feel the first fetal movement.
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The experienced nurse is observing the new nurse determine the fetal position of the pregnant client using Leopold maneuver. The experienced nurse determines that the new nurse correctly identifies the first Leopold maneuver when placing the hands in which position illustrated first?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: B
Rationale: This illustration shows the first step of Leopold’s maneuver. The nurse palpates the fundus to determine which fetal body part (e.g., head or buttocks) occupies the uterine fundus. Image A shows the fourth Leopold maneuver. The nurse’s fingertips are used to determine the location of the cephalic prominence. Image C shows the third Leopold maneuver (“Pawlik maneuver”). During this maneuver the fetal part in the fundal region is compared with the part in the lower uterine segment. It is completed primarily to confirm that the fetus is in a cephalic (head) presentation. Image D shows the second Leopold maneuver. The second maneuver determines the location of the fetal back or spine.
The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?
- A. Monitor maternal temperature.
- B. Inspect characteristics of the fluid.
- C. Perform a sterile vaginal examination.
- D. Assess the fetal heart rate pattern.
Correct Answer: D
Rationale: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
Which explanation by the nurse accurately identifies the recommended weight gain for a pregnant client who has a normal prepregnancy weight?
- A. Less than 15 pounds (<6.8 kg)
- B. 15 to 20 pounds (6.8 to 9 kg)
- C. 25 to 35 pounds (11.3 to 15.9 kg)
- D. No more than 40 pounds (≤18.1 kg)
Correct Answer: C
Rationale: For a woman with normal prepregnancy weight, the recommended weight gain is 25-35 pounds to support fetal development.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for which problems? Select all that apply.
- A. Susceptibility to infection
- B. Easily fatigued
- C. Increased risk for preeclampsia
- D. Increased risk of diabetes
- E. Congenital defects
Correct Answer: A,B,C
Rationale: Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. Iron-deficiency anemia is not associated with an increased risk of diabetes. Iron-deficiency anemia is not associated with an increased risk of congenital defects.