Question

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should recognize that this diagnosis means which of the following?

Answer 1

Correct Answers:

An excessive amount of amniotic fluid is present.

Rationale :

🔸 Polyhydramnios is defined as an excessive accumulation of amniotic fluid, typically diagnosed when the amniotic fluid index (AFI) exceeds 24 cm or the deepest vertical pocket is greater than 8 cm on ultrasound.

🔸 It can be associated with maternal diabetes, fetal anomalies (e.g., anencephaly, GI obstructions), or idiopathic causes, but the defining feature remains the fluid volume excess.

🔸 The condition may lead to complications such as preterm labor, premature rupture of membranes, or cord prolapse, making close monitoring essential.

🔸 While congenital anomalies can be a cause or consequence of polyhydramnios, that is not its definition, making choices C and D incorrect as definitions.

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Answer 2

Correct Answers:

Slightly above the umbilicus

Rationale :

🔸 Fundal height correlates with gestational age in centimeters between 18 to 30 weeks. At 20 weeks, the fundus is at the level of the umbilicus.

🔸 By 22 weeks, the fundus typically rises about 2 cm above the umbilicus, making “slightly above” the most accurate general descriptor.

🔸 This measurement is used to assess fetal growth, uterine size, and amniotic fluid volume.

🔸 The nurse uses a non-stretch measuring tape, starting from the symphysis pubis to the top of the fundus during palpation.

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Answer 3

Correct Answers:

"Daily jogging for up to 30 minutes is fine throughout the pregnancy."

Rationale :

🏃‍♀️ Exercise during pregnancy is encouraged for most women, including those in the first trimester, as long as there are no contraindications.

🏃‍♀️ Moderate-intensity aerobic activity, such as jogging or brisk walking, for at least 150 minutes per week is recommended by the CDC and ACOG.

🏃‍♀️ Regular physical activity promotes circulation, mood stability, and muscular strength, and can reduce the risk of gestational diabetes and hypertension.

🏃‍♀️ Clients should be advised to avoid high-risk activities, overexertion, and those that increase core temperature excessively, such as hot yoga or saunas.

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Answer 4

Correct Answers:

"Ambivalent feelings are quite common for women early in pregnancy."

Rationale :

🌸 Ambivalence is a normal emotional response during the first trimester, even in planned pregnancies. Hormonal changes, physical symptoms, and life transitions can lead to mixed emotions.

🌸 By reassuring the client that these feelings are common and expected, the nurse provides emotional support and validation without dismissing or pathologizing her experience.

🌸 This response fosters therapeutic communication, which is essential in prenatal care, encouraging the client to feel safe expressing her emotions.

🌸 It also helps normalize her concerns and reduces anxiety, allowing for ongoing open dialogue in future visits.

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Answer 5

Correct Answers:

"This will occur between the fourth and fifth months of pregnancy."

Rationale :

🟠 Quickening refers to the first noticeable fetal movements felt by the pregnant individual.

🟠 It typically occurs between 16 to 20 weeks gestation, which corresponds to the 4th and 5th months of pregnancy.

🟠 First-time mothers (primigravidas) often feel it closer to 20 weeks, while those with previous pregnancies may notice it earlier.

🟠 Quickening is considered a subjective but reassuring milestone, reflecting fetal development and movement awareness.

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Answer 6

Correct Answers:

Shortly after giving birth

Rationale :

🧬 Rubella is a live attenuated virus vaccine, which is contraindicated during pregnancy due to the risk of fetal harm, including congenital rubella syndrome.

🧬 If a pregnant client is found to be non-immune to rubella, the recommended plan is to administer the MMR vaccine postpartum, ideally before discharge from the birthing facility.

🧬 Postpartum immunization ensures future pregnancies are protected, and the client is advised to avoid pregnancy for at least 1 month after receiving the vaccine.

🧬 Educating the client about the timing and importance of postpartum vaccination helps promote long-term maternal and fetal health.

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Answer 7

Correct Answers:

It prevents the formation of Rh antibodies in mothers who are Rh negative.

Rationale :

🩸 Rh(D) immunoglobulin is given to Rh-negative mothers to prevent isoimmunization when there is a risk of fetal-maternal blood mixing, such as postpartum delivery of an Rh-positive newborn.

🩸 The injection works by suppressing the immune response of the Rh-negative mother so she does not develop antibodies against Rh-positive blood cells.

🩸 This is crucial because if sensitization occurs, future pregnancies with Rh-positive fetuses are at risk for hemolytic disease of the newborn (HDN).

🩸 It is typically administered within 72 hours postpartum and also at 28 weeks gestation during pregnancy if indicated.

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Answer 8

Correct Answers:

Consume foods fortified with folic acid.

Rationale :

🧠 Folic acid is essential in the prevention of neural tube defects (NTDs) such as spina bifida and anencephaly, which develop early in fetal life—often before a woman knows she's pregnant.

🧠 The CDC and WHO recommend women of childbearing age consume at least 400 mcg of folic acid daily from fortified foods or supplements starting before conception and continuing through early pregnancy.

🧠 Sources include fortified cereals, leafy green vegetables, legumes, and prenatal vitamins.

🧠 Educating women on folic acid intake prior to conception is a critical public health measure to reduce the incidence of NTDs.

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Answer 9

Correct Answers:

4-0-1-2-2

Rationale :

📘 GTPAL stands for:

G (Gravida): Total number of pregnancies (including current)

T (Term births): Births ≥ 37 weeks gestation

P (Preterm births): Births 20–36 weeks gestation

A (Abortions): Pregnancy losses < 20 weeks (elective or spontaneous)

L (Living children): Total living children

🔹 Gravida (G) = 4 → One elective abortion (9 wks), one twin birth (36 wks), one spontaneous abortion (15 wks), and currently pregnant

🔹 Term births (T) = 0 → No delivery ≥ 37 weeks

🔹 Preterm births (P) = 1 → Twins born at 36 weeks

🔹 Abortions (A) = 2 → One elective at 9 wks and one spontaneous at 15 wks

🔹 Living children (L) = 2 → The twins are living children

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Answer 10

Correct Answers:

Intrauterine growth restriction

Rationale :

🚭 Smoking during pregnancy causes vasoconstriction and reduces oxygen delivery to the fetus due to carbon monoxide and nicotine exposure.

🚭 This leads to intrauterine growth restriction (IUGR), where the fetus fails to grow at the expected rate, resulting in low birth weight and increased perinatal complications.

🚭 Nicotine impairs placental blood flow, and chronic hypoxia limits fetal development and nutrient delivery.

🚭 Smoking is also associated with placental abruption, preterm labor, and stillbirth, making early cessation critical.

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RN ATI Concept of Nursing Exam II

No.

1 :
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should recognize that this diagnosis means which of the following?

2 :
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?

3 :
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

5 :
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?

6 :
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. Which of the following times should the nurse understand is recommended for rubella immunization?

7 :
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?

8 :
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?

10 :
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

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RN ATI Concept of Nursing Exam II

No.

1 : A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should recognize that this diagnosis means which of the following?

2 : 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?

3 : A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

5 : 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?

6 : 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. Which of the following times should the nurse understand is recommended for rubella immunization?

7 : A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?

8 : 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?

10 : A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

1 :
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should recognize that this diagnosis means which of the following?

2 :
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?

3 :
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

5 :
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?

6 :
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. Which of the following times should the nurse understand is recommended for rubella immunization?

7 :
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?

8 :
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?

10 :
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?