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Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
- A. A client who is pregnant for the fifth time
- B. A client who is 16 years old
- C. A client who has a history of twins in the family
- D. A client who has primary hypertensive disease
- E. A client who works 40 hours a week in a factory
- F. A client who reports spotting in the first trimester
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
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Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?
- A. Immediately begin to massage the uterus
- B. Document the findings of the fundus
- C. Assess the client for bladder distention
- D. Monitor for increased vaginal bleeding
Correct Answer: B
Rationale: Uterine massage is indicated only if the uterus does not feel firm and contracted. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.
Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
- A. Avoid exercising during hot, humid weather.
- B. Avoid exercises involving bouncing or jumping movements.
- C. Drink plenty of fluids before and after exercising.
- D. Limit strenuous activity to no more than 60 minutes a session.
- E. Perform exercises only in the supine position.
- F. Limit exercising to once per week.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.
The nurse teaches the client to monitor which newborn condition?
- A. Umbilical cord stump for infection
- B. Daily weight gain over 1 pound
- C. Frequent crying as abnormal
- D. No bowel movements for a week
Correct Answer: A
Rationale: Monitoring the umbilical cord stump for infection (redness, discharge) is critical for newborn health.
The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?
- A. Eat crackers while still in bed in the morning.
- B. Lie down and rest whenever nausea occurs.
- C. Eat more frequently throughout the day.
- D. Avoid food items containing ginger.
Correct Answer: A
Rationale: The nurse should instruct the client to eat dry crackers before rising from bed. This typically relieves some of the nausea. Lying down when the nausea occurs may increase heartburn and reflux, thereby increasing nausea. Eating frequently may increase heartburn and reflux, thereby increasing nausea. Food items with ginger may help to alleviate nausea and are recommended (rather than avoided), including ginger tea.
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.