NCLEX Flashcards on Obstetric Nursing
51. A nurse is performing an assessment of primipara who is being evaluated in clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding that necessities further testing?
a) quickening
b) braxton hicks contractions
c) consistent increase in fundal height
d) fetal heart rate of 180 bpm
52. 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 and expects the finding to be which of the following?
a) 22 cm
b) 30 cm
c) 36 cm
d) 40 cm
53. 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 his sign indicates:
a) a softening of the cervix
b) the presence of fetal movement
c) the presence of human chorionic gonadotrophin in the urine
d) a soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.
54. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.
a) ballotment
b) chadwick's sign
c) uterine enlargement
d) braxton hicks contractions
e) outline of fetus via radiography or ultrasonography
f) fetal heart rate detected by a nonelectronic device
55. A nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further teaching?
a) I should avoid straining during bowel movements
b) I can gently replace the hemorrhoids into the rectum
c) I can apply ice packs to the hemorrhoids to reduce the swelling
d) I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink
NCLEX Flashcards on Obstetric Nursing:
ANSWERS AND RATIONALE
51) D
- the normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 bpm in the first trimester and slows with fetal growth. Near at term, the fetal heart rate ranges from 120 to 160 bpm. Option A, B and C are normal expected findings.
52) B
- during the second and third trimester (weeks 18 to 30), fundal height in centimeters approximately equal s the fetus age in weeks +- 2cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus, and at 36 weeks the fundus is at the xiphoid process.
53) A
- in the early weeks of pregnancy, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening is noted by the examiner dung pelvic examination. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta. Human chorionic gonadotrophin is noted in maternal urine in a positive urine pregnancy test. Goodell's sign does not indicate the presence of fetal movement.
54) A, B, C, D
- the probable signs of pregnancy include uterine enlargement, hegar's sign (softening and thinning of the lower uterine segment that occurs about week 6), goodell's sign (softening of the cervix that occurs at the beginning of the second month), chadwick's sign (bluish coloration of the mucous membranes of the cervix, vagina and vulva that occurs about week 6), ballotment (rebounding of the fetus against the examiner's fingers on palpation), braxton hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotrophin (HCG). Positive signs of pregnancy include fetal heart rate detected by electronic device (doppler tranducer) at 10 to 12 weeks and by a nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.
55) D
- measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners; ointments or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs will increase the blood flow to the area and worsen the discomfort from hemorrhoids.
Or go back to NCLEX Flashcards on Obstetric Nursing (1-5) to start the practice test from the beginning.
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