At 20-weeks gestation, a client who has gained 20 pounds (9.1 kg) during this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the client’s only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?

Leakage from breasts.

Gestational weight gain.

Presence of fetal movement.

Fundal height measurement.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.

Choice B rationale

An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.

Choice C rationale

Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.

Choice D rationale

Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.

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Correct Answer is B

Explanation

Choice A rationale

While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.

Choice B rationale

Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.

Choice C rationale

Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.

Choice D rationale

Assessing temperature every hour is not specifically related to the care of a client with eclampsia.

A. Abruptio placenta. B. Chorioamnionitis. C. Round ligament strain. D. Viral infection.

Correct Answer is B

Explanation

Choice A rationale

Abruptio placenta is a condition where the placenta prematurely separates from the uterus. It typically presents with symptoms such as vaginal bleeding, back pain, and frequent contractions. However, the symptoms described by the client do not align with this condition.

Choice B rationale

Chorioamnionitis is an infection of the membranes surrounding the fetus and is associated with prolonged labor. Symptoms include fever, abdominal pain, and fetal tachycardia. The client’s symptoms of pain when the baby moves, a high temperature, and severe abdominal or uterine tenderness on palpation align with this condition.

Choice C rationale

Round ligament strain is a common cause of pain during pregnancy, particularly in the second trimester. It is caused by the stretching of the round ligaments that support the uterus.

However, it does not cause fever or severe abdominal tenderness.

Choice D rationale

While a viral infection could potentially cause a fever, it would not typically cause severe abdominal or uterine tenderness specifically when the baby moves.

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Naxlex Comprehensive Predictor Exams

A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.She is not currently convulsing.What intervention should the nurse plan to include in this client’s nursing care plan?

Correct Answer is B

Explanation

A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

Correct Answer is B

Explanation

A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.What advice should the nurse give the client?

A client who is anovulatory and has hyperprolactinemia is undergoing infertility treatment with metformin, menotropins, and human chorionic gonadotropin.What side effect should the nurse instruct the client to report immediately?

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

The nurse is providing preconception counseling.Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

A client informs the nurse that she believes she is pregnant. Which sign or symptom is the best indicator that the client is pregnant?

The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.What should the nurse do next?