NCLEX RN SAUNDERS MATERNITY

NCLEX RN SAUNDERS MATERNITY

NURSING EXAM (5

TH

EDITION)

A nursing student is preparing a prenatal class on the process of fetal circulation. The nursing instructor asks the student specifically to describe the process through the umbilical cord. Which of the following statements from the student is correct? Correct -"The two arteries in the umbilical cord carry deoxygenated blood & waste products away from the fetus to the placenta."

A nursing student is assigned to care for a client in labor. A nursing instructor asks the student to describe fetal circulation, specifically the ductus venous. The nursing instructor determines that the student understands fetal circulation if the student states that the ductus venous: Correct -Connects the umbilical vein to the inferior vena cava.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse understands that he client should be able to find out at 12 weeks' gestation because by the end of the twelfth week: Correct -The sex of the fetus can be determined by the appearance of the external genitalia.

A nurse is performing as assessment on a client who is at 38 weeks' gestation & notes that the fetal heart rate is 174 beats/min. On the basis of this finding, the appropriate

nursing action is to: Correct -Notify the physician.

A nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, the nurse responds that the reason for this is that it: Correct -Promotes the fertilized ovum's normal implantation in the top portion of the uterus.

A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducting a prenatal teaching session. The instructor asks the student to describe the follicle-stimulating hormone (FSH) & the luteinizing hormone (LH). The student accurately responds by stating that: Correct -FSH & LH are released from the anterior pituitary gland.

A couple comes to the family planning clinic & asks about sterilization procedures.Which question by the nurse would determine if this method of family planning would be appropriate? Correct -"Do you plan to have any other children?"

A nurse should explain which of the following to a pregnant client found to have a gynecoid pelvis? Correct -That her type of pelvis is the most favorable for labor & birth.

A nurse explains some of the purposes of the placenta to a client during a prenatal visit.The nurse determines that the client understands some of these purposes when the client states that the placenta: Correct -Is the way the baby gets food & oxygen.

A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of

amniotic fluid: Correct -* Allows for fetal movement

• Is a measure of kidney function
• Surrounds, cushions, & protects the fetus.
• Maintains the body temperature of the fetus.

A nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters & expects the finding to be which of the following? Correct -30 cm

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks & tells the nurse that she does not have a Hx of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as Correct -G=2, T=1, P=0, A=0, L=1

A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, & the nurse determines that she is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? Correct -Inform the client that these contractions are common & may occur throughout the pregnancy.

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. The nurse tells the client that: Correct -A cesarean section will be necessary if vaginal lesions are present at the time of labor.

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse

determines that this sign indicates: Correct -A softening of the cervix.

A client arrives at the clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was Oct. 19, 2012. Using Nagele's rule, the nurse determines the estimated date of confinement is: Correct -July 26, 2013

A nurse-midwife is assessing a pregnant client for the presence of ballottement. To make this determination, the nurse-midwife does which of the following? Correct - Initiates a gentle upward tap on the cervix.

A pregnant client asks a nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which of the following weeks of gestation? Correct -16 & 20

A nurse is performing as assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding that necessitates further testing? Correct -Fetal heart rate of 180 beats / min

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant & is checking the client for probable signs of pregnancy. Which of the following are probable signs of pregnancy. Correct -* Ballotement

• Chadwicks sign
• Uterine enlargement
• Braxton Hick's contractions/

A nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. The nurse tells the client that: Correct -An informed consent needs to be signed before the procedure.

A pregnant client in the first trimester calls nurse at a health care clinic & reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which assessment to the client? Correct -"The vaginal discharge may be bothersome, but is a normal occurrence."

A nurse has performed a non-stress test on a pregnant client & is reviewing the fetal monitor strip. The nurse interprets the test as reactive & understands that this indicates: Correct -Normal findings

A non-stress test is performed on a client who is pregnant, & the results of the test indicate non-reactive findings. The physician prescribes a contraction stress test, & the results are documented as negative. A nurse interprets the finding of the contraction

stress test as indicating: Correct -A normal test result.

A pregnant client tells a nurse that she has been craving "unusual foods." The nurse gathers additional assessment data from the client & discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed on the client. The nurse reviews the results * determines that which of the following indicates a physiological consequence of the client's practice? Correct - Hemoglobin 9.1 g/dL

A pregnant client asks a nurse about the types of exercises that are allowable during pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following? Correct -Swimming

A physician has prescribed transvaginal ultra-sonography for a client in the 1st trimester of pregnancy & the client asks a nurse about the procedure. The nurse tells the client that: Correct -The probe that will be inserted into the vagina will be covered with a disposable cover & coated with a gel.

A clinic nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? Correct -"I should wear knee-high hose, but I should not leave them on longer than 8 hours."

A pregnant client calls a clinic & tells a nurse that she is experiencing leg cramps that awaken her at night. To provide relief from the leg cramps, the nurse tells the client the following: Correct -"Bend your foot toward your body while extending the knee when the cramps occur."

A clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? Correct -"I should avoid eating foods that produce gas, such as beans & some vegetables, & fatty foods such as deep-dried chicken."

A nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?Correct -"I need to lie flat on my back to perform the procedure."

A nurse is providing instructions regarding treatment if hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? Correct -"I should apply hear packs to the hemorrhoids to help the hemorrhoids shrink."

A nurse providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. The nurse tells the client to: Correct -Wash the breasts with warm water & keep them dry.

A nurse is describing cardiovascular system changes that occur during pregnancy to a client & understands that which finding would be normal for a client in the 2nd trimester?Correct -Increase in pulse rate.

A rubella titer result of a 1-day postpartum client is less than 1:8, & a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information t the client about the vaccine? Correct -* Pregnancy needs to be avoided for 1 to 3 months.

• The vaccine is administered by the subcutaneous route.
• A hypersensitivity reaction can occur if the client has an allergy to eggs.
• Exposure to immuno-suppressed individuals needs to be avoided.

A nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn infant after delivery. The client asks the nurse about the feeding options that are available. The best response by the nurse is: Correct -"You will need to bottle-feed the newborn infant."