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NurseDive Free Nursing Practice Question
A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?
A. Posterior neck flexion
Posterior neck flexion is not an expected change during pregnancy.
B. Increased abdominal muscle tone
Increased abdominal muscle tone is not an expected change during pregnancy. In fact, the abdominal muscles tend to stretch and may become less toned as the uterus expands.
C. Gradual lordosis
During pregnancy, the woman's center of gravity shifts due to the growing uterus, leading to an increased arch in the lower back known as lordosis. This change helps to maintain balance and reduce the strain on the back. The other options are not expected physiologic changes during pregnancy.
D. Decreased mobility of pelvic joints
Decreased mobility of pelvic joints is not an expected change during pregnancy. Some joint laxity may occur due to hormonal changes, but decreased mobility is not typical.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Exam - Proctored Exam 2. Take the full exam now
Full Explanation
Choice A: Posterior neck flexion is not an expected change during pregnancy.
Choice B: Increased abdominal muscle tone is not an expected change during pregnancy. In fact, the abdominal muscles tend to stretch and may become less toned as the uterus expands.
Choice C: During pregnancy, the woman's center of gravity shifts due to the growing uterus, leading to an increased arch in the lower back known as lordosis. This change helps to maintain balance and reduce the strain on the back. The other options are not expected physiologic changes during pregnancy.
Choice D: Decreased mobility of pelvic joints is not an expected change during pregnancy. Some joint laxity may occur due to hormonal changes, but decreased mobility is not typical.
Similar Questions
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when he observes which of the following patterns?
A. Variable decelerations
Variable decelerations on the fetal heart rate monitor tracing are suggestive of umbilical cord compression. These decelerations are often V, U, or Wshaped, and their onset, depth, and duration can vary. They are associated with cord compression, which can reduce blood flow to the fetus during contractions.
B. Late decelerations
Late decelerations are indicative of uteroplacental insufficiency and are not related to umbilical cord problems.
C. Accelerations
Accelerations are reassuring and suggest a responsive, healthy fetus.
D. Early decelerations
Early decelerations are usually benign and result from head compression during contractions, not umbilical cord issues.
Full Explanation
Choice A: Variable decelerations on the fetal heart rate monitor tracing are suggestive of umbilical cord compression. These decelerations are often V, U, or Wshaped, and their onset, depth, and duration can vary. They are associated with cord compression, which can reduce blood flow to the fetus during contractions. Other options are as follows:
Choice B: Late decelerations are indicative of uteroplacental insufficiency and are not related to umbilical cord problems.
Choice C: Accelerations are reassuring and suggest a responsive, healthy fetus.
Choice D: Early decelerations are usually benign and result from head compression during contractions, not umbilical cord issues.
A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. The nurse uses Naegele's Rule to calculate the correct EDD:
A. April 27, 2016
Choice A: April 27, 2016 Reason: This date is incorrect because it does not follow Naegele’s Rule. Naegele’s Rule involves adding 7 days to the first day of the last menstrual period (LMP) and then subtracting 3 months. Adding 7 days to May 4, 2015, gives us May 11, 2015. Subtracting 3 months from May brings us to February, not April.
B. April 11, 2016
Choice B: April 11, 2016 Reason: This date is also incorrect for the same reason as Choice A. It does not follow Naegele’s Rule. Adding 7 days to May 4, 2015, gives us May 11, 2015. Subtracting 3 months from May brings us to February, not April.
C. February 27, 2016
Choice C: February 27, 2016 Reason: This date is closer but still incorrect. Adding 7 days to May 4, 2015, gives us May 11, 2015. Subtracting 3 months from May brings us to February. However, the correct date should be February 11, not February 27.
D. February 11, 2016
Choice D: February 11, 2016 Reason: This is the correct date. Using Naegele’s Rule, we add 7 days to the first day of the last menstrual period (May 4, 2015), which gives us May 11, 2015. Then, we subtract 3 months, which brings us to February 11, 2016. This is the correct Estimated Due Date (EDD).
Full Explanation
The correct answer is: April 11, 2016
Choice A: April 27, 2016
Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 27, 2016, is incorrect because it does not follow the correct calculation steps.
Choice B: April 11, 2016
Reason: Following Naegele’s Rule:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 11, 2016, is the correct EDD as it accurately follows the calculation steps.
Choice C: February 27, 2016
Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.
Choice D: February 11, 2016
Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?
A. Immediately report the situation to the client's provider and prepare the client for induction of labor.
Reporting the situation and preparing the client for induction of labor is not the first action to take. Turning the client onto her left side is the initial intervention to stimulate fetal movements.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.
Encouraging the client to walk around without the monitoring unit is not appropriate in this situation, as the NST requires continuous monitoring of the fetal heart rate.
C. Turn the client onto her left side.
During a nonstress test (NST), the nurse monitors the fetal heart rate in response to fetal movements. Absence of fetal movements for 15 minutes can be concerning and might not provide adequate information for the NST. The first intervention should be to encourage fetal movement by turning the client onto her left side, which can improve blood flow to the uterus and increase fetal activity.
D. Offer the client a snack of orange juice and crackers
Offering the client a snack of orange juice and crackers might be done as a noninvasive intervention to encourage fetal movements, but turning the client onto her left side is more effective and should be done first.
Full Explanation
A. Immediately report the situation to the client's provider and prepare the client for induction of labor. This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.
C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.
D. Offer the client a snack of orange juice and crackers. This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.