Chapter 13

Question 1

The nurse is responding to phone calls. Which call should the nurse return first?

Answer 1

37 weeks’ gestation, reports no fetal movement for 24 hours

Question 2

A woman at 28 weeks’ gestation reports not feeling the baby move for over 30 minutes. How should the nurse respond first?

Answer 2

“Your baby might be asleep.”

Question 3

The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching had been effective?

Answer 3

“I might be able to see who the baby looks like with the ultrasound.”

Question 4

A pregnant client’s fundal height is 26 cm at 32 weeks’ gestation. Why would the healthcare provider schedule this client for sonograms every 2 weeks?

Answer 4

Evaluate fetal growth

Question 5

What should the nurse do when assisting a pregnant client who is having an abdominal ultrasound to determine fetal age?

Answer 5

Assists the woman into a supine position on the examining table

Question 6

A pregnant client is receiving the results of perinatal testing. Which statement indicates that the client understands the test result?

Answer 6

“The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby.”

Question 7

At 32 weeks’ gestation, a woman is scheduled for a second non-stress test. Which client response indicates an adequate understanding of this procedure?

Answer 7

“I cannot get up and walk around during the test.”

Question 8

During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test and last 20 seconds each. What should the nurse expect the outcome of this test will be?

Answer 8

A nonreactive test

Question 9

A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation?

Answer 9

There are more than three uterine contractions in a 6-minute period.

Question 10

The nurse is reviewing clients who would benefit from a biophysical profile (BPP). Which clients should the nurse identify as a priority? Select all that apply.

1. A gravida who is postterm
2. A gravida with intrauterine growth restriction
3. A gravida with mild hypertension of pregnancy
4. A gravida who is experiencing nausea and vomiting
5. A gravida who complains of decreased fetal movement for 2 days

Answer 10

1,2,3,5

Question 11

The nurse is reviewing nursing documentation related to the care of a client who had an amniocentesis. Which nursing note reflects appropriate client care?

Answer 11

The client was monitored for 30 minutes after completion of the test.

Question 12

A woman who is at 12 weeks’ gestation asks the nurse if she can undergo chorionic villus sampling (CVS) testing in order to determine whether her baby has a neural tube defect. Which response is best?

Answer 12

“No, because CVS testing alone at any stage cannot detect neural tube defects.”

Question 13

A woman who is at 15 weeks’ gestation received normal chorionic villus sampling (CVS) results and abnormal quadruple screen test results. For detection of congenital anomalies, which test should the nurse expect the woman to be offered next?

Answer 13

Amniocentesis

Question 14

How should the nurse interpret a pregnant client’s lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid?

Answer 14

Fetal lungs are mature.

Question 15

During a home visit the nurse observes a pregnant client assess fetal activity. Which observations indicate that the client understands the correct process for this count? Select all that apply.

1. Sits in a chair
2. Assumes a side-lying position
3. Counts the same time every day
4. Watches television while counting
5. Begins counting 1 hour after a meal

Answer 15

2,3,5

Question 16

A pregnant client is hesitant to have nuchal translucency testing. What should the nurse explain as being the advantages of having this test? Select all that apply.

1. It has a high false-positive rate.
2. It is performed early in the pregnancy.
3. There is no risk of spontaneous abortion.
4. It provides reassurance of the fetus’s development.
5. It accurately detects 90% of Down syndrome fetuses.

Answer 16

2,3,4,5

Question 17

The nurse is reviewing amniocentesis with a pregnant client. In which order should the nurse explain the steps that will occur during this procedure?

1. Conduct an ultrasound
2. Fetal heart rate assessed
3. Local anesthetic provided
4. Skin cleansed with antiseptic solution
5. Insertion site observed for fluid streaming
6. 22-gauge needle inserted to withdraw amniotic fluid

Answer 17

1,4,3,5,6,2

Question 18

A client’s amniocentesis results indicate that the fetus is at risk for respiratory distress. What testing values support this clinical decision? Select all that apply.

1. Amniotic glucose level 50 mg/dL
2. Phosphatidylglycerol (PG) negative
3. Lecithin/sphingomyelin (L/S) ratio 1:6
4. Amniotic fluid red blood cell count 5 mg/dL
5. Lamellar body counts (LBCs) 5000/counts/mcL

Answer 18

2,3,5

Question 19

The nurse is preparing teaching material on chorionic villus sampling (CVS) for a client who is entering the 10th week of gestation. What risks should the nurse include with this material? Select all that apply.

1. Bleeding
2. Embryonic puncture
3. Intrauterine infection
4. Inability to obtain a tissue sample
5. Inadvertent rupture of the membranes

Answer 19

1,3,4,5

Question 20

A client at 20 weeks’ gestation is scheduled for a transabdominal ultrasound. What should the nurse instruct this client about the examination? Select all that apply.

1. “The entire procedure takes between 20 and 30 minutes.”
2. “Arrive 30 minutes before the examination so pain medication will be effective.”
3. “Transmission gel will be spread over the abdomen during the examination.”
4. “Use an over-the-counter enema to empty the colon before the examination.”
5. “Drink 1.5 quarts of water 2 hours before the exam and refrain from voiding.”

Answer 20

1,3,5