Question

A nurse is educating a client who is 23 weeks pregnant about immunizations. Which statement should the nurse include in the teaching?

Answer 1

Correct Answers:

You can receive an influenza vaccination during pregnancy.

Rationale :

🔹 Influenza vaccination is safe and recommended during pregnancy, regardless of the trimester, because pregnant individuals are at increased risk for severe flu-related complications.

🔹 Receiving the inactivated influenza vaccine helps protect both the mother and the newborn during early infancy.

🔹 Live-virus vaccines (e.g., varicella, MMR) are contraindicated during pregnancy but may be given postpartum.

🔹 Tdap is recommended between 27–36 weeks, not after delivery.

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Answer 2

Correct Answers:

I will use only nonprescription medications while pregnant.

Rationale :

✳️ This statement reflects a misconception that over-the-counter (OTC) medications are always safe during pregnancy, which is incorrect.

✳️ Many OTC medications, including pain relievers, decongestants, and herbal supplements, can be harmful to fetal development, especially during the first trimester.

✳️ Pregnant clients must consult their healthcare provider before using any medications, prescription or nonprescription, to avoid teratogenic risks.

✳️ The nurse should reinforce education that "natural" or OTC does not equate to safe, particularly in pregnancy.

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Answer 3

Correct Answers:

What part of the exam makes you most nervous?

Rationale :

✳️ This open-ended question uses therapeutic communication, which encourages the client to express her feelings and concerns.

✳️ It allows the nurse to assess the source of the anxiety and tailor emotional support or education accordingly.

✳️ This approach builds trust and promotes patient-centered care, especially important for adolescents or first-time clients.

✳️ Using judgmental or minimizing phrases like “Don’t worry” can shut down communication and increase distress.

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Answer 4

Correct Answers:

Shortly after giving birth.

Rationale :

✳️ Rubella is a live attenuated vaccine, and live vaccines are contraindicated during pregnancy because they pose a theoretical risk to the fetus.

✳️ If a pregnant person is found non-immune to rubella, the immunization should be administered postpartum, ideally before hospital discharge.

✳️ Postpartum administration protects future pregnancies by preventing congenital rubella syndrome, a serious condition causing fetal anomalies.

✳️ The client should also be instructed to avoid pregnancy for at least 28 days after rubella vaccination.

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Answer 5

Correct Answers:

A 38-year-old client who reports smoking one pack of cigarettes every day.

Rationale :

✳️ Age over 35 combined with smoking is a major contraindication for combined oral contraceptives due to the significantly increased risk of thromboembolism, stroke, and myocardial infarction.

✳️ Estrogen-containing contraceptives further raise the clotting risk in smokers, making them an unsafe choice.

✳️ Alternative methods such as progestin-only pills, IUDs, or implants are typically recommended for these clients.

✳️ The other clients (e.g., those with benign breast disease or PID) do not have absolute contraindications to oral contraceptives based on current clinical guidelines.

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Answer 6

Correct Answers:

Moderate exercise improves circulation.

Rationale :

💠 Moderate-intensity exercise during pregnancy is recommended to improve cardiovascular circulation and overall health.

💠 It helps reduce the risk of gestational diabetes, hypertension, and excessive weight gain.

💠 Exercise also promotes better mood, reduced stress, and improved sleep in pregnant clients.

💠 Clients should avoid high-impact activities or those that involve a risk of falling, but moderate aerobic or stretching exercises are encouraged.

💠 Education should include warming up, staying hydrated, and listening to the body's limits.

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Answer 7

Correct Answers:

Offer the option to view products of conception.

Rationale :

🔷 Supporting the patient emotionally during an inevitable abortion is crucial, and offering to view the products of conception can promote healthy grief processing.

🔷 Giving this option respects the client's autonomy and emotional needs, especially in early pregnancy loss.

🔷 This action helps validate the loss and can reduce long-term psychological distress.

🔷 While not all clients choose to view, they should be informed of the option as part of trauma-informed care.

🔷 The nurse should also ensure privacy and a calm, supportive environment for this discussion.

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Answer 8

Correct Answers:

Unilateral, cramp-like abdominal pain.

Rationale :

✴️ An ectopic pregnancy often presents with sharp, localized pain, typically on one side (unilateral), due to implantation in the fallopian tube.

✴️ Pain may worsen with movement, and is frequently accompanied by vaginal spotting or light bleeding.

✴️ If undiagnosed, ectopic pregnancy can rupture, leading to life-threatening internal hemorrhage.

✴️ Symptoms typically appear around 6–8 weeks of gestation, making prompt recognition and intervention critical.

✴️ Other signs include shoulder pain (if bleeding irritates the diaphragm) and hypotension with advanced rupture.

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Answer 9

Correct Answers:

Chloasma.
Linea nigra.
Striae gravidarum.

Rationale :

Chloasma

🔶 Chloasma, also called the “mask of pregnancy,” is a common pigmentation change during the second trimester.

🔶 It appears as symmetric, blotchy, brownish hyperpigmentation over the cheeks, forehead, and nose due to elevated estrogen and melanocyte-stimulating hormone levels.

🔶 This condition is more noticeable in women with darker skin tones and worsens with sun exposure.

Linea nigra

🔶 Linea nigra is a vertical line of dark pigmentation extending from the pubic symphysis to the umbilicus (or higher) and is commonly observed in the second trimester.

🔶 It results from hormonal stimulation of melanocytes and typically fades postpartum.

🔶 Although harmless, it is a reassuring and expected finding in pregnancy skin assessments.

Striae gravidarum

🔶 These are reddish or purple stretch marks that appear on the abdomen, breasts, hips, or thighs due to skin stretching and hormonal changes.

🔶 Striae gravidarum typically appear in the second and third trimesters as the uterus expands rapidly.

🔶 They are not harmful but are cosmetic changes and often fade to silvery lines after delivery.

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Answer 10

Correct Answers:

Abdominal pain.
Sudden gush of fluid from the vagina.
Vaginal bleeding.

Rationale :

Abdominal pain

🌸 Abdominal pain, especially if persistent or severe, can be a sign of complications such as preterm labor, placental abruption, or ectopic pregnancy.

🌸 It should never be assumed to be normal unless evaluated, especially in the second or third trimester.

🌸 Clients should be instructed to report new or worsening pain to their provider promptly.

🌸 Prompt evaluation is essential to protect maternal and fetal well-being.

Sudden gush of fluid from the vagina

🌸 A sudden gush of fluid often indicates rupture of membranes, which could lead to preterm labor or infection if it occurs prematurely.

🌸 It warrants immediate evaluation to determine amniotic fluid status and fetal safety.

🌸 The nurse should educate the client that this is not a normal finding and requires urgent attention.

🌸 This is a key warning sign that labor or complications may be beginning.

Vaginal bleeding

🌸 Any amount of vaginal bleeding during pregnancy should be taken seriously as it may signal placenta previa, placental abruption, or miscarriage.

🌸 Bleeding is not considered normal in pregnancy, especially after the first trimester.

🌸 Nurses must emphasize that clients should immediately report any spotting or bleeding.

🌸 Early detection of the cause can prevent serious maternal or fetal outcomes.

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RN ATI Nur223 Maternal Newborn Exam 1

No.

1 :
A nurse is educating a client who is 23 weeks pregnant about immunizations. Which statement should the nurse include in the teaching?

2 :
A nurse is educating a client who is 12 weeks pregnant about expected gestational changes. Which statement by the client indicates a need for further teaching?

3 :
A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which response should the nurse make?

4 :
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. When is the recommended time for rubella immunization?

5 :
A nurse is reviewing contraception options for four clients. Which client has a contraindication for receiving oral contraceptives?

6 :
A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which statement should the nurse include in the teaching?

7 :
A nurse is formulating a care plan for a patient who is 10 weeks pregnant and reports abdominal pain and moderate vaginal bleeding. The preliminary diagnosis is an inevitable abortion. Which nursing interventions should be included in the care plan?

8 :
A nurse is caring for a patient suspected of having an ectopic pregnancy at 8 weeks of gestation. Which symptoms should the nurse expect to identify as consistent with the diagnosis?

9 :
A nurse in a prenatal clinic is conducting a skin assessment of a patient in her second trimester. Which findings should the nurse anticipate (Select all that apply.)

10 :
When assessing a patient's understanding of symptoms to report during her pregnancy, which statement would indicate to the nurse that the patient comprehends the information provided?

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RN ATI Nur223 Maternal Newborn Exam 1

No.

1 : A nurse is educating a client who is 23 weeks pregnant about immunizations. Which statement should the nurse include in the teaching?

2 : A nurse is educating a client who is 12 weeks pregnant about expected gestational changes. Which statement by the client indicates a need for further teaching?

3 : A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which response should the nurse make?

4 : A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. When is the recommended time for rubella immunization?

5 : A nurse is reviewing contraception options for four clients. Which client has a contraindication for receiving oral contraceptives?

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

7 : A nurse is formulating a care plan for a patient who is 10 weeks pregnant and reports abdominal pain and moderate vaginal bleeding. The preliminary diagnosis is an inevitable abortion. Which nursing interventions should be included in the care plan?

8 : A nurse is caring for a patient suspected of having an ectopic pregnancy at 8 weeks of gestation. Which symptoms should the nurse expect to identify as consistent with the diagnosis?

9 : A nurse in a prenatal clinic is conducting a skin assessment of a patient in her second trimester. Which findings should the nurse anticipate (Select all that apply.)

10 : When assessing a patient's understanding of symptoms to report during her pregnancy, which statement would indicate to the nurse that the patient comprehends the information provided?

1 :
A nurse is educating a client who is 23 weeks pregnant about immunizations. Which statement should the nurse include in the teaching?

2 :
A nurse is educating a client who is 12 weeks pregnant about expected gestational changes. Which statement by the client indicates a need for further teaching?

3 :
A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which response should the nurse make?

4 :
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. When is the recommended time for rubella immunization?

5 :
A nurse is reviewing contraception options for four clients. Which client has a contraindication for receiving oral contraceptives?

6 :
A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which statement should the nurse include in the teaching?

7 :
A nurse is formulating a care plan for a patient who is 10 weeks pregnant and reports abdominal pain and moderate vaginal bleeding. The preliminary diagnosis is an inevitable abortion. Which nursing interventions should be included in the care plan?

8 :
A nurse is caring for a patient suspected of having an ectopic pregnancy at 8 weeks of gestation. Which symptoms should the nurse expect to identify as consistent with the diagnosis?

9 :
A nurse in a prenatal clinic is conducting a skin assessment of a patient in her second trimester. Which findings should the nurse anticipate (Select all that apply.)

10 :
When assessing a patient's understanding of symptoms to report during her pregnancy, which statement would indicate to the nurse that the patient comprehends the information provided?