Question

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

Answer 1

Correct Answers:

"Moderate exercise improves circulation."

Rationale :

🟢 Moderate exercise during pregnancy has multiple proven benefits, including enhancing circulation, reducing constipation, improving mood, and decreasing the risk of gestational diabetes.

🟢 It helps maintain cardiovascular fitness and promotes healthy weight gain during pregnancy, which is vital for both maternal and fetal well-being.

🟢 Safe moderate exercises in the first trimester include walking, swimming, stationary cycling, and prenatal yoga—activities that are not overly strenuous but still promote blood flow and muscle tone.

🟢 The nurse should educate clients to avoid high-risk or high-impact activities, but not discourage safe stretching or moderate aerobic movement.

🟢 Individual fitness level, pregnancy risk status, and provider recommendations should also guide any exercise plan.

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Answer 2

Correct Answers:

Discontinue the infusion of the IV oxytocin.

Rationale :

🔴 The uterine contractions occurring every 2 minutes and lasting 90 seconds indicate uterine tachysystole, which is defined as more than 5 contractions in 10 minutes, potentially compromising fetal oxygenation.

🔴 The presence of uniform decelerations beginning at the peak of contractions and returning after suggests late decelerations, which are associated with uteroplacental insufficiency.

🔴 Oxytocin, a uterotonic agent, can lead to overstimulation of the uterus, increasing the risk of fetal distress and hypoxia.

🔴 The immediate action is to discontinue the oxytocin infusion, allowing the uterus to rest and improving fetal perfusion.

🔴 Additional actions may include repositioning the patient, administering oxygen, and notifying the provider, but the first priority is stopping the agent causing the excessive contractions.

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Answer 3

Correct Answers:

"l will use only nonprescription medications while pregnant."

Rationale :

🔴 This statement requires further teaching because it reflects a misunderstanding about medication safety during pregnancy.

🔴 Even nonprescription (over-the-counter) medications can pose risks to fetal development, especially during the first trimester, when organogenesis occurs.

🔴 Pregnant clients should be advised to consult their healthcare provider before using any medication, including herbals, supplements, and OTC drugs, to prevent potential teratogenic effects.

🔴 The nurse must emphasize that all substances, even those perceived as "safe," can cross the placenta and impact fetal health.

🔴 The other statements reflect appropriate understanding of prenatal health behaviors like weight monitoring, stress reduction, and caution with home remedies.

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Answer 4

Correct Answers:

Take a folic acid supplement for at least 3 months before you get pregnant.

Rationale :

🟢 Folic acid (vitamin B9) is essential for proper neural tube development, and taking it prior to conception significantly reduces the risk of neural tube defects (NTDs) such as spina bifida and anencephaly.

🟢 The neural tube closes by day 28 of gestation—often before many women even know they are pregnant—so preconception supplementation is critical.

🟢 The CDC and other health authorities recommend taking 400 to 800 mcg of folic acid daily, beginning at least 1 month before conception, but ideally 3 months or longer for maximum protection.

🟢 While iron, alcohol avoidance, and general nutrition are important during pregnancy, folic acid intake before pregnancy is the most specific and effective action to prevent NTDs.

🟢 Folic acid can be taken alone or as part of a prenatal multivitamin.

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Answer 5

Correct Answers:

"This test requires the presence of an adequate volume of amniotic fluid."

Rationale :

🔵 Amniocentesis involves the aspiration of amniotic fluid using a needle under ultrasound guidance, typically performed between 15–20 weeks for genetic testing and later (after 32 weeks) to assess fetal lung maturity.

🔵 At 15 weeks, the test is done only if there is sufficient amniotic fluid, which surrounds and protects the fetus and allows for adequate sample collection.

🔵 It is not performed based solely on fetal heart tones, and at this gestational age, lung maturity is not the target, as lungs are not fully developed.

🔵 If the mother is Rh-negative (not Rh-positive), she should receive Rh immune globulin (Rho(D) immune globulin) post-procedure to prevent isoimmunization due to potential fetal blood exposure.

🔵 The presence and volume of amniotic fluid are essential prerequisites to safely carry out the procedure and obtain accurate results.

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Answer 6

Correct Answers:

2 cm above the umbilicus

Rationale :

🟢 By 22 weeks of gestation, the fundus (top of the uterus) is typically located approximately 2 cm above the umbilicus, following the general rule that the fundal height in centimeters correlates with weeks of gestation between 18 and 30 weeks.

🟢 At 20 weeks, the fundus is usually at the level of the umbilicus. After this point, it rises about 1 cm per week.

🟢 Measuring fundal height helps assess fetal growth and amniotic fluid volume, and deviations from expected measurements may indicate IUGR or polyhydramnios.

🟢 The nurse uses a non-elastic tape measure, measuring from the symphysis pubis to the top of the fundus, ensuring the client is in a supine position with an empty bladder for accuracy.

🟢 Consistent and accurate fundal measurements are important for tracking gestational progress and fetal well-being.

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Answer 7

Correct Answers:

"This usually happens between the fourth and fifth months of pregnancy."

Rationale :

🟣 Quickening refers to the first perception of fetal movement felt by the mother, often described as fluttering, bubbling, or light tapping sensations.

🟣 It typically occurs between 16 and 20 weeks of gestation, which corresponds to the fourth and fifth months of pregnancy, especially for primigravidas (first-time mothers) who may recognize it a bit later.

🟣 Multiparous women (those who have been pregnant before) may feel quickening slightly earlier due to increased awareness of fetal movement.

🟣 Quickening is considered a subjective (presumptive) sign of pregnancy, and its timing helps providers confirm gestational milestones.

🟣 At 6 weeks, fetal movement is present on ultrasound but not yet perceptible to the mother.

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Answer 8

Correct Answers:

A surge of energy

Rationale :

🟢 A sudden burst of energy, often called “nesting,” is a common sign that labor may begin soon and typically occurs in the days or hours prior to labor onset.

🟢 This energy increase may lead clients to clean, organize, or prepare their home, and it is linked to hormonal shifts in preparation for labor.

🟢 Other signs that precede labor include lightening (fetus descending into the pelvis), increased vaginal discharge or bloody show, backache, and mild irregular contractions.

🟢 In contrast, urinary frequency (not retention) and slight weight loss (not gain) are more typical signs prior to labor onset.

🟢 Nurses should educate clients on these signs so they can distinguish between true labor and prodromal symptoms.

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Answer 9

Correct Answers:

Encourage the client to empty her bladder every 2 hr.

Rationale :

🟢 During the active phase of the first stage of labor, a distended bladder can hinder fetal descent and intensify discomfort by occupying pelvic space.

🟢 After an amniotomy (artificial rupture of membranes), it's especially important to maintain an empty bladder to promote efficient labor progression and reduce infection risk.

🟢 Encouraging voiding every 2 hours helps keep the pelvis unobstructed, ensures maternal comfort, and supports effective uterine contractions.

🟢 Lithotomy position is generally reserved for second stage (pushing) or delivery, and bearing down too early (before full dilation) can lead to cervical edema and fatigue.

🟢 Vaginal exams should be minimized post-amniotomy to reduce the risk of ascending infection, unless clinically indicated.

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Answer 10

Correct Answers:

Observe for crowning.

Rationale :

🟣 A +3 station indicates that the fetal head is 3 cm below the ischial spines, which means the fetus is very low in the birth canal and likely to crown soon.

🟣 Crowning is when the fetal head becomes visible at the vaginal opening and does not retract between contractions—indicating imminent delivery.

🟣 At this stage of labor, the nurse should closely monitor perineal bulging and visible scalp, and prepare for delivery.

🟣 This is not the time for oxytocin administration, which is used to stimulate labor earlier in the process, nor is fundal pressure appropriate as it increases the risk of trauma.

🟣 Nuchal cord assessment is done after crowning and during delivery, not in response to +3 station alone.

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QLexNursing

1 :
A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

3 :
A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

4 :
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

5 :
A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

6 :
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

7 :
A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

8 :
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

9 :
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

10 :
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

3 : A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

4 : A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

5 : A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

6 : A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

7 : A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

8 : A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

9 : A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

10 : A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

1 :
A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

3 :
A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

4 :
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

5 :
A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

6 :
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

7 :
A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

8 :
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

9 :
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

10 :
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?