Pittman Review Exam 1 FA24

The nurse is providing counseling to a group of sexually active single women who have expressed a desire to have children in the future but not within the next few years. Which actions will the nurse suggest the women take to protect their fertility for the future? Select all that apply.

• Use condoms during intercourse.

• Refrain from smoking cigarettes.

• Maintain an appropriate weight for height.

• Exercise in moderation.

• Refrain from drinking carbonated beverages.

The nurse is caring for a client right after an amniocentesis. Which intervention is the highest priority at this time?

• Assess the fetal heart rate.

• Check the client’s temperature.

• Acknowledge the client’s anxiety about the possible findings.

• Answer questions regarding the genetic abnormality.

Answer explanation

1. Assessing the fetal heart rate is the highest priority since, although rare, the fetus may have been injured during the procedure. Taking the client’s temperature is not the most important action to take at this time. Psychosocial issues are always significant, but they must take a back seat to physiological assessments. It is important to answer all questions posed by clients but, again, these should be answered only after physiological

interventions are completed.

Which statement by an asymptomatic woman being treated for HIV infection indicates an understanding of her care?

• “If I get pregnant, my baby will be HIV positive.”

• “Although my partner is also HIV positive, we will use a condom for sexual intercourse.”

• “I should have my viral load and antibody levels checked every day.”

• “To be safe, my partner and I engage only in oral sex.”

Answer explanation

The HIV virus is prone to mutation. It is important that clients use condoms whenever they have intercourse because if the virus mutates and the client becomes infected with two strains of the virus, the progression to AIDS is hastened. Transmission through oral sex is low but still possible. ART therapy during pregnancy and therapy for the infant after delivery has an almost zero transmission rate. Viral load and CD4 counts should be monitored, but not daily.

The nurse is caring for an adolescent in the emergency department who states, “I took a pregnancy test today. I’m pregnant. My parents will be furious with me!! I have to do something!” Which response by the nurse is most appropriate?

• “You can take medicine to abort the pregnancy so your parents won’t know.”

• “Let’s talk about your options.”

• “I can help you tell your parents.”

• “The best thing for you to do is to have the baby and to give it up for adoption.”

Answer explanation

The nurse should discuss with the client all of her possible options. Once the options are provided, she may decide to maintain the pregnancy and be in need of assistance to tell her parents. Adoption is not appropriate as an initial response.

The nurse working in an outpatient obstetric office assesses four primigravid clients. Which client finding will the nurse recommend the healthcare provider see first?

• 17 weeks’ gestation; denies feeling fetal movement.

• 27 weeks’ gestation; salivates excessively.

• 34 weeks’ gestation; experiences uterine cramping.

• 37 weeks’ gestation; complains of hemorrhoidal pain.

Answer explanation

The client experiencing uterine cramping may be going into preterm labor. Excessive salivation, called ptyalism, is an expected finding in pregnancy as well as hemorrhoids. It is common for primigravid women not to feel fetal movement until 19 to 20 weeks’ gestation.

A 36-week gestation gravid client is complaining of dyspnea when lying flat.

Which is the most likely reason for this complaint?

• Maternal hypertension

• Fundal height

• Hydramnios

• Congestive heart failure

Answer explanation

As the uterus enlarges, the woman’s organs are affected. At 36 weeks, the fundus is at the level of the xiphoid process. The diaphragm is elevated and the lungs are displaced. When a client lies flat she has difficulty breathing. Most women use multiple pillows at night for sleep. Whenever caring for a pregnant woman, the nurse should elevate the head of the bed.

The nurse is caring for a gravid client who thinks labor has begun. Which assessments will the nurse perform before contacting the primary healthcare provider? Select all that apply.

• Fetal heart rate

• Contraction pattern

• Urinalysis

• Vital signs

• Biophysical profile

Answer explanation

The fetal heart, contraction pattern, and maternal vitals all should be assessed to provide the healthcare practitioner with a picture of the health status of the mother and fetus. In some institutions, the nurse may also do a vaginal exam for dilation. The HCP may order a urinalysis and BPP based on other factors.

A nurse is caring for client in labor whose membranes just ruptured. The nurse assesses the characteristics of the fluid and documents which finding as normal?

• Clear

• Cloudy

• Malodorous

• Green

Answer explanation

Amniotic should be clear and non-odorous. Any variation indicates infection or fetal meconium.

The nurse giving report on a laboring client reports the fetal heart rate as tachycardic. Which value does this indicate?

• 134 beats per minute

• 108 beats per minute

• 156 beats per minute

• 170 beats per minute

Answer explanation

Normal fetal heart rate is 110-160

A nurse is preparing a client for a non-stress test and places the client into a semi-Fowler position. What is the rationale for this measure?

• To prevent supine hypotension syndrome

• To decrease the heart rate of the fetus

• To aid the woman as she pushes during labor

• To prevent the woman from falling out of bed

Answer explanation

The NST is an assessment of the fetal heart rate for whether a good baseline rate and long- and short-term variability are present. For this, a woman is placed in a semi-Fowler position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test.