Nokea
Which assessment finding best represents a positive sign of pregnancy?
- A. Palpable fetal outline
- B. Blotchy tan facial skin
- C. Positive pregnancy test
- D. Fetal heartbeat
Correct Answer: D
Rationale: A fetal heartbeat, detected by Doppler or ultrasound, is a positive sign of pregnancy, as it directly confirms the presence of a living fetus.
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The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
- A. Auscultate maternal heart tones.
- B. Measure the height of the fundus.
- C. Measure the client’s abdominal girth.
- D. Complete a third-trimester ultrasound.
- E. Auscultate the fetal heart tones (FHT).
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.
The nurse is caring for the client who is Rh negative at 13 weeks’ gestation. The client is having cramping and has moderate vaginal bleeding. Which HCP order should the nurse question?
- A. Administer Rho(D) immune globulin (RhoGAM).
- B. Obtain a beta human chorionic gonadotropin level (BHCG).
- C. Schedule for an immediate ultrasound.
- D. Place on continuous external fetal monitoring.
Correct Answer: B
Rationale: Obtaining the BHCG level is not indicated at 13 weeks’ gestation. BHCG levels are followed in early pregnancy before a fetal heartbeat can be confirmed. RhoGAM is indicated for any pregnant client with bleeding who is Rh negative. An ultrasound can identify the cause of bleeding and confirm fetal viability. Continuous external fetal monitoring can be used to confirm a fetal heartbeat, fetal viability, and fetal risk.
The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client’s parity?
Correct Answer: 1
Rationale: The client has given birth to her first child; her parity is 1.
The nurse uses which tool to measure fundal height?
- A. Tape measure
- B. Doppler device
- C. Ultrasound machine
- D. Blood pressure cuff
Correct Answer: A
Rationale: A tape measure is used to measure fundal height, assessing uterine growth and fetal development.
The client is diagnosed with pregnancy-related diabetes at 28 weeks’ gestation. In teaching the client, the nurse includes which information for managing her blood glucose levels? Select all that apply.
- A. Drawing glycosylated hemoglobin A1c levels
- B. Performing home blood glucose monitoring
- C. Developing a weight management plan
- D. Engaging in appropriate daily exercise
- E. Taking oral diabetic agents in the am.
Correct Answer: A,B,C,D
Rationale: Hgb A1c will be drawn and monitored throughout the pregnancy, with a goal of reaching a level of less than 7%. Home blood glucose monitoring will help the client identify when her blood glucose is outside normal parameters. Excessive weight gain worsens control of glucose levels. Exercise adapted for the pregnant body is important to glucose control. Oral diabetic agents are contraindicated in pregnant clients.