What physical changes should the nurse discuss with a client who is entering menopause? quizlet

Recommended textbook solutions

Clinical Reasoning Cases in Nursing

7th EditionJulie S Snyder, Mariann M Harding

2,512 solutions

Mecânica dos Materiais

8th EditionBarry J. Goodno, James M. Gere

1,037 solutions

Structural Kinesiology

18th EditionClem Thompson

456 solutions

Structural Kinesiology

20th EditionClem Thompson, R T Floyd

462 solutions

A 58-year-old female client is concerned that intercourse with her spouse has become increasingly painful. What should the nurse explain about the changes in this client's body?
A) Cervical mucus is thicker after menopause.
B) Estrogen levels increase after menopause.
C) Sexual desire diminishes after menopause.
D) Vaginal lubrication decreases after menopause.

D) Vaginal lubrication decreases after menopause.

Older women remain capable of multiple orgasms and may, in fact, experience an increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease with menopause and decreased estrogen, and phases of the sexual response cycle may take longer to occur. The client's concerns are not related to cervical mucus

A female client tells the nurse about having difficulty with sexual relations because of a recent weight gain. Which interventions should the nurse include when planning this client's care?
A) Sexual self-concept
B) Gender identity
C) Body image
D) Gender-role behavior

C) Body image is constantly changing. How people feel about their bodies is related to sexuality. People who have a poor body image may respond negatively to sexual arousal. This is what the client is experiencing. Sexual self-concept determines with whom one will have sex, the gender and kinds of people one is attracted to, and the values about when, where, with whom, and how one expresses sexuality. Gender identity is one's self-image as male or female. Gender-role behavior is the outward expression of a person's sense of maleness or femaleness as well as the expression of what is perceived as gender-appropriate behavior.

A female client tells the nurse about having no interest in sex since it has become painful. Which intervention(s) would be appropriate to help the client with this problem?
Select all that apply.
A) Ask when the last Pap smear was performed.
B) Discuss the need to be screened for sexually transmitted infections.
C) Instruct on the use of artificial lubrication.
D) Encourage the client to discuss with the healthcare provider because there are medications to help with this problem.
E) Suggest antibiotics to treat the pain.

C) Instruct on the use of artificial lubrication.
D) Encourage the client to discuss with the healthcare provider.
The client is describing a sexual arousal disorder, a subjective lack of sexual excitement that is linked with a lack of lubrication in the female. Interventions to help with this problem include using artificial lubrication and discussing medication options with the healthcare provider. Antibiotics, screening for sexually transmitted infections, and the last Pap smear would be interventions to address a sexual pain disorder, which involves pain that occurs during or immediately after intercourse.

During a physical assessment, a client tells the nurse that his penis "hurts" when the shaft is touched. What should the nurse suspect is occurring with this client?
A) Urethral stricture
B) Acute orchitis
C) Inflammatory disease
D) Acute epididymitis

A) Urethral stricture
Normally, palpation of the penis should not cause tenderness. The client's complaint of pain could indicate a urethral stricture. Redness or lesions on the penis could indicate inflammatory disease. Acute epididymis and acute orchitis are associated with a tender scrotum.

A female client complains of having a "strange discharge" from the vagina and "stinging" when voiding urine. Which diagnostic test(s) would be useful to aid in the diagnosis of this client's disorder?
Select all that apply.
A) Biopsy
B) Urinalysis
C) Complete blood count
D) Serum hormone levels
E) Papanicolaou smear

B) Urinalysis
E) Papanicolaou smear
The client is complaining of a strange discharge from her vagina. A Papanicolaou smear would be the most helpful in diagnosing the cause of that symptom. The client is also complaining of stinging with urination. A urinalysis would be helpful to rule out a urinary tract infection as the cause for the urinary pain. The other diagnostic tests may or may not help diagnose this client's health problem.

During a sexual history, a female client tells the nurse that because she is in a committed relationship, sexual relations are more satisfying and frequent. What should the nurse realize the client is describing?
A) Emptiness
B) A lack of intimacy
C) The feeling of connectedness
D) Disconnection

C) C) The feeling of connectedness
Fulfillment of sexuality depends on the ability to relate to a partner in an intimate and mutually pleasing manner that is compatible with one's values and chosen lifestyle. Lack of intimacy is related to satisfaction problems. If one has sex with a stranger, the body may function well, but there is often a sense of something missing after the sexual experience. Making love to one person while feeling more attracted to or in love with another person can result in feelings of emptiness or disconnection. Even couples in a committed relationship may complain of lack of intimacy. Dissatisfaction issues include lack of romance, love, tenderness, and nurturance.

An older client tells the nurse that he still has erections and wants to have sex with his wife, but she does not have the same interest as he does. What should the nurse do to assist this client?
A) Explain that women lose interest in sex as part of the aging process.
B) Suggest that he wait awhile and the urge to have sex will pass.
C) Ask what he has been doing to fulfill himself sexually.
D) Encourage the client to ask his wife to discuss the lack of interest with her physician.

D) Encourage the client to ask his wife to discuss the lack of interest with her physician.
The nurse's role with this client is counseling for sexual dysfunction. The nurse should encourage the client to ask his wife to discuss the lack of interest with her physician as a starting point. The other choices are inappropriate and should not be provided to the client.

A female client is prescribed an androgen medication to treat an estrogen-sensitive type of breast cancer. What should the nurse instruct this client about the medication?
Select all that apply.
A) There is an increased risk of multiple births.
B) Secondary male sex characteristics may develop.
C) Monitor weight weekly.
D) Report calf pain or dyspnea.
E) It must be taken with food.

B) Secondary male sex characteristics may develop.
C) Monitor weight weekly.
Androgen hormone replacements may be used to treat estrogen-dependent cancers. The nurse should instruct the client of the risk of developing secondary male sex characteristics when taking this medication. This medication also affects body weight so the nurse should instruct the client to monitor body weight weekly. Increased risk of multiple births is associated with female infertility medications. Reporting calf pain or dyspnea is associated with estrogen hormone replacement therapy. This medication does not need to be taken with food.

A nurse instructor is teaching a group of student nurses regarding problems of infertility and genetic inheritance of disease. Which statement made by the nurse indicates that teaching has been effective?
A) "A person's genotype is the observable expression of the traits."
B) "The total genetic makeup of an individual is referred to as the phenotype."
C) "In an autosomal recessive inherited disorder, the individual must have two abnormal genes to be affected."
D) "An individual is said to have an autosomal dominant inherited disorder if the disease trait is homozygous."

C) "In an autosomal recessive inherited disorder, the individual must have two abnormal genes to be affected."
In an autosomal recessive inherited disorder, the individual must have two abnormal genes to be affected. A person's phenotype is the observable expression of traits, and the total genetic makeup of an individual is referred to as genotype. An individual is said to have an autosomal dominant inherited disorder if the disease trait is heterozygous-that is, the abnormal gene overshadows the normal gene of the pair to produce the trait.

A nurse who is working at an obstetrics clinic is caring for a client who desires more information regarding fertility awareness-based contraceptive methods. Which statement made by the nurse provides the client with correct information?
A) "Maximum fertility for the woman occurs approximately 2 days before ovulation and decreases rapidly the day after."
B) "The calendar rhythm method is based on the assumption that ovulation tends to occur about 7 days before the start of the next menstrual period."
C) "To use the calendar rhythm method, the woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles."
D) "The calendar method is the most reliable of the fertility awareness methods."

C) "To use the calendar rhythm method, the woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles."
Fertility awareness-based methods, also known as natural family planning, are based on an understanding of the changes that occur throughout a woman's ovulatory cycle. Maximum fertility for the woman occurs approximately 6 days before ovulation and decreases rapidly the day after. The calendar rhythm method, also called the standard days method, is based on the assumption that ovulation tends to occur about 14 days before the start of the next menstrual period. To use this method, the woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles. The calendar method is the least reliable of the fertility awareness methods.

A female client tells the nurse about wanting to wait to start a family even though the spouse has been "hinting" about it for some time. What is the best response by the nurse?
A) "Maybe you should babysit a friend's child for a while to see if you really want children."
B) "You and your spouse need to discuss the decision to start a family."
C) "If you don't want to start a family then you don't have to."
D) "What would you do if you became pregnant now?"

B) "You and your spouse need to discuss the decision to start a family."
Making the decision to have children is the first step a couple makes in the process of conception. Sometimes one individual wishes to have a child but the other does not. In these situations, an open discussion is essential to reach a mutually acceptable decision. Telling the client that she does not need to start a family if she doesn't want to does not address the issue of the spouse hinting about starting a family. Asking what the client would do if she became pregnant now does not address the client's desire to wait to start a family. Suggesting the client babysit a friend's child would be a strategy to help a person decide if he or she wants to have a family but does not address the client and spouse's current issue.

A female client tells the nurse that she does not want to have children because there is a history of Down syndrome in the family. What should the nurse respond to this client?
A) "That is a common genetic defect caused by an extra chromosome."
B) "Babies born with Down syndrome do not live very long."
C) "It is probably best to not give birth to a baby with birth defects."
D) "Down syndrome only occurs in the babies of women who are over the age of 40."

A) "That is a common genetic defect caused by an extra chromosome."
Down syndrome is the most common trisomy abnormality seen in children. It is the product of the union of a normal egg or sperm with an egg or sperm that has an extra chromosome. This syndrome can occur at any time in a childbearing client of any age. Although children born with Down syndrome have a variety of physical ailments, advances in medical science have extended their life expectancy. The nurse should not provide an opinion about giving birth to a baby with birth defects.

During an evaluation for infertility, a male client is asked to provide a sperm sample. What information from the client's health history could impact the client's sperm?
Select all that apply.
A) Activity level
B) Smoking
C) Use of over-the-counter analgesics
D) Mumps after adolescence
E) Number of siblings

B) Smoking
C) Use of over-the-counter analgesics
D) Mumps after adolescence
The quality and effectiveness of sperm is affected by smoking history, use of over-the-counter pain medications, and experiencing mumps after adolescence. Activity level and number of siblings are not criteria to evaluate the quality and effectiveness of sperm.

During a health history, the nurse learns that a female client has been trying to conceive for 2 years and does not understand why she cannot become pregnant. For which causes of infertility should the nurse assess in this client?
Select all that apply.
A) Amount of alcohol consumed each day
B) Dietary eating pattern
C) Amount of exercise
D) Employment status
E) History of sexually transmitted infections

A) Amount of alcohol consumed each day
B) Dietary eating pattern
C) Amount of exercise
E) History of sexually transmitted infections

Risk factors for female infertility include excess alcohol consumption, poor diet, athletic training, or being infected with a sexually transmitted infection. Employment status is not a risk factor for female infertility.

A client is prescribed an oral contraceptive with estrogen and progesterone. What should the nurse instruct the client about this contraceptive?
Select all that apply.
A) An increase in appetite and weight gain is caused by the estrogen.
B) Headaches and nausea are caused by the progesterone.
C) Breast tenderness occurs because of the estrogen.
D) An increase in blood pressure is caused by the progesterone.
E) Acne and oily skin can occur because of the progesterone.

C) Breast tenderness occurs because of the estrogen.
E) Acne and oily skin can occur because of the progesterone.

There are possible side effects when taking oral contraceptives that contain both estrogen and progesterone. Headaches and nausea are caused by the estrogen. Breast tenderness occurs because of the estrogen. Acne and oily skin can occur because of the progesterone. An increase in appetite and weight gain is caused by the progesterone. An increase in blood pressure is caused by the estrogen.

The nurse is teaching a client with infertility about the medication clomiphene (Clomid). Which client statement indicates that teaching has been effective?
A) "This medication stimulates gonadotropin-releasing hormone."
B) "This medication stimulates follicle-stimulating hormone (FSH)."
C) "This medication stimulates luteinizing hormone (LH)."
D) "This medication increases my estrogen levels so I can ovulate."

C) "This medication stimulates luteinizing hormone (LH)."
Clomiphene (Clomid) stimulates LH, resulting in the maturation of more ovarian follicles than would normally occur. Clomiphene (Clomid) does not increase estrogen levels or stimulate FSH and gonadotropin-releasing hormone.

A client wants to use the vaginal sponge as a method of contraception. Which statement or statements indicate that the client needs further instruction?
Select all that apply.
A) "I need to leave it in no longer than 6 hours."
B) "I need to use a lubricant prior to insertion."
C) "I can insert the sponge no longer than 24 hours prior to having intercourse."
D) "I need to add spermicidal cream prior to intercourse."
E) "I need to moisten it with water prior to use."

A) "I need to leave it in no longer than 6 hours."
B) "I need to use a lubricant prior to insertion."
D) "I need to add spermicidal cream prior to intercourse."

A lubricant is not needed, as the sponge is moistened with water prior to insertion. Spermicidal cream is not needed, because it is already in the sponge. To activate the spermicide in the vaginal sponge, it must be moistened thoroughly with water. The sponge can be inserted and remain in place for 24 hours.

A nurse is caring for a client who is perimenopausal who states that she has recently had frequent bacterial vaginal infections. The nurse understands that the reason this has occurred is likely due to which of the following?
A) Decreased vaginal pH
B) Increased vaginal pH
C) Increased estrogen level
D) Decreased vasomotor stability

B) Increased vaginal pH

In the perimenopausal client, the vaginal pH increases, predisposing the client to bacterial vaginal infections. In perimenopause, estrogen levels decrease, not increase. Decreased vasomotor stability leads to hot flashes, not vaginal bacterial infections.

A nursing working in an outpatient women's health clinic is caring for a client in menopause. When discussing hormone replacement therapy (HRT) with the client, the nurse should include which statement?
A) "Most healthy, recently menopausal women should not use HRT for relief of hot flashes and vaginal dryness."
B) "HRT is the least effective treatment of menopausal hot flashes and vaginal dryness."
C) "If vaginal dryness and painful intercourse are the only symptoms, then low-dose vaginal estrogen is preferred."
D) "The risk of blood clots in the legs or lungs is further increased by using transdermal patches, gels, or sprays."

C) "If vaginal dryness and painful intercourse are the only symptoms, then low-dose vaginal estrogen is preferred."

If vaginal dryness and dyspareunia (painful intercourse) are the only symptoms, then low-dose vaginal estrogen is preferred. Most healthy, recently menopausal women may use HRT for relief of hot flashes and vaginal dryness. Risks for blood clots in the legs and lungs are increased with HRT, but occurrence is rare in women age 50-59. The risk is further lowered by using low-dose estrogen pills or transdermal patches, gels, or sprays.

A female client asks what causes the symptoms of menopause. On which hormonal function should the nurse focus when responding to this client's question?
A) Increased estrogen levels
B) Increased progesterone levels
C) Estrone as the major hormone
D) Increased luteinizing hormone levels

C) Estrone as the major hormone

As ovarian function decreases, the production of estrogen decreases and is replaced by estrone as the major ovarian estrogen. Estrone is produced in small amounts and has only about one-tenth the biological activity of estradiol. With decreased ovarian function, the second ovarian hormone, progesterone, which is produced during the luteal phase of the menstrual cycle, also is markedly reduced.

A client with a history of breast cancer who is entering menopause is seeking information about how to manage hot flashes. What information can be provided to the client?
A) Soy and black cohosh can be used to manage the hot flashes associated with menopause.
B) The client should be advised that she will have to wait until menopause has finished for the hot flashes to cease.
C) Estrogen is the only reliable method of treatment for hot flashes.
D) Olive oil and black cohosh are effective in the management of hot flashes.

A) Soy and black cohosh can be used to manage the hot flashes associated with menopause.

The hot flashes can be successfully managed with soy and black cohosh. Estrogen is not the only reliable method of treatment for hot flashes. Olive oil is not used to manage hot flashes. Advising the client to wait is inappropriate.

The nurse is assessing a postmenopausal client. Which client statement should indicate further assessment by the nurse?
A) "I use water-soluble lubricant to treat my vaginal dryness."
B) "For some reason, I have more sexual desire than ever."
C) "Sex certainly takes longer than it used to, but I'm getting used to that."
D) "I am so glad that I don't need to worry about sex anymore."

D) "I am so glad that I don't need to worry about sex anymore."

The nurse would further assess the client who made the statement, "I am so glad that I don't need to worry about sex anymore." This statement is unclear. Does it mean that the client is glad not to have to engage in sex anymore, or does it mean that she will not have to worry about getting pregnant anymore? The other statements reflect normal changes associated with aging and healthy responses to those changes.

A premenopausal client tells the nurse that she is not looking forward to menopause because it means her life is over. Which nursing diagnosis would be appropriate for the client at this time?
A) Ineffective Sexuality Pattern
B) Deficient Knowledge
C) Situational Low Self-Esteem
D) Disturbed Body Image

C) Situational Low Self-Esteem

The client believes that once menopause is reached, her life is over. The most appropriate nursing diagnosis for the client at this time would be Situational Low Self-Esteem because the client could have inadequate coping skills to aid with the aging process. There is no information to support the diagnosis of Ineffective Sexuality Pattern. The client may or may not have deficient knowledge or a disturbed body image.

A client approaching menopause is interested in oral hormone replacement therapy to manage the symptoms. Which should the nurse include in this client's teaching plans?
A) Hormone replacement therapy is linked to higher rates of deep vein thrombosis and colorectal cancer.
B) Estrogen is cardio-protective for women.
C) Hormone replacement therapy is useful for women who are at an increased risk for the development of osteoporosis.
D) Hormone replacement therapy is associated with a reduced incidence of breast cancer and pulmonary embolism.

C) Hormone replacement therapy is useful for women who are at an increased risk for the development of osteoporosis.
Osteoporosis is associated with the reduction of estrogen. Hormone replacement therapy is encouraged for those women who are at an increased risk for the development of this disease. Estrogen was once thought to be cardio-protective for women, but newer studies refute these claims. There is an increased risk for breast cancer and pulmonary embolism for those women who are taking hormone replacement therapy. Although the rates of deep vein thrombosis are increased, the rates of colorectal cancer are reduced in those taking hormone replacement therapy.

The nurse is evaluating care provided to a client experiencing menopause. Which observation indicates that the client is successfully managing menopausal symptoms?
A) Weight loss of 5 pounds in 4 months after starting an exercise program at the local gym
B) Client's stated desire to stay at home and limit social activities
C) Weight gain of 10 pounds in 3 months
D) Client's stated loss of interest in recreational activities

A) Weight loss of 5 pounds in 4 months after starting an exercise program at the local gym.

Evidence of successful outcomes for a client with menopause include: demonstrating a positive sense of self as evidenced by stable weight; participation in a regular exercise program; ability to manage stress; verbalizing feelings related to changes that have occurred; and describing strategies for maintaining health. A weight loss of 5 pounds in 4 months after starting an exercise program is evidence of successful management of menopause. The other observations are not evidence of successful management of menopause.

A client experiencing menopause voices an interest in using alternative and complementary therapies to manage symptoms. What initial response by the nurse is indicated?
A) "What types of therapies are of interest to you?"
B) "Those seldom work."
C) "Have you discussed this with your physician?"
D) "Many women report success with these measures."

A) "What types of therapies are of interest to you?"

Alternative and complementary therapies are used by many women to manage the manifestations associated with menopause. The nurse has a responsibility to collect data from the client. The nurse will need to determine which types of therapies are of interest to the client. The success of these remedies varies by user. It is inappropriate for the nurse to meet the client's request with negativity. Clients using alternative therapies are asked to report them to their physicians. This is not, however, the initial step for this scenario.

A client who is postmenopausal confides in the nurse about pain experienced during intercourse. What should the nurse instruct the client to do?
A) Use vaginal lubricants during intercourse.
B) Avoid intercourse.
C) Tolerate this problem because it is a normal part of aging.
D) Decrease the frequency of intercourse to decrease the pain.

A) Use vaginal lubricants during intercourse.

It is not uncommon for a postmenopausal female to report painful intercourse that is related to a decrease in vaginal lubrication. Vaginal lubricants can be very effective in reducing the pain experienced during intercourse. Although this is a normal change of aging, clients do not have to tolerate the discomfort. Avoidance and decreasing frequency of intercourse would not resolve the problem for the client. It is stereotypical to assume the client would have less of a desire for intercourse at an older age.

During an assessment, the nurse suspects a client is experiencing genital herpes. What did the nurse assess in this client?
Select all that apply.
A) Low blood pressure
B) Headache
C) Fever
D) Back pain
E) Vaginal discharge

B) Headache
C) Fever
D) Back pain
E) Vaginal discharge

Manifestations of genital herpes include headache, fever, vaginal discharge, and back pain. Low blood pressure is not a manifestation of genital herpes.

A client is experiencing dysuria, urinary frequency, and vaginal discharge. For which sexually transmitted infection(s) should the nurse prepare the client for testing?
Select all that apply.
A) Syphilis
B) Vaginitis
C) Chlamydia
D) Trichomoniasis
E) Gonorrhea

C) Chlamydia
E) Gonorrhea

Chlamydia invades the same target organs as gonorrhea, which include the cervix and male urethra, and creates the manifestations of dysuria, urinary frequency, and discharge. The other sexually transmitted infections target other organs.

A client diagnosed with a sexually transmitted infection reports having "no idea" how the illness was contracted. Which nursing diagnosis would be appropriate for the client at this time?
A) Anxiety
B) Knowledge Deficit
C) Ineffective Coping
D) Sexual Dysfunction

B) Knowledge Deficit

The client having no idea how the illness was contracted indicates a deficit in knowledge regarding the transmission of sexually transmitted infections. There is not enough information to determine if the client has sexual dysfunction, ineffective coping, or anxiety.

The nurse is planning care for a client with a history of sexually transmitted infections. What should be included in this plan of care?
A) Instruction to limit sexual contact until recovered from illness
B) Plan for the client to contact sexual partners regarding the diagnosis
C) Need to increase fluids and rest
D) Importance of adequate nutrition

B) Plan for the client to contact sexual partners regarding the diagnosis.

The client has a history of sexually transmitted infections. The nurse should discuss with the client a plan for sexual partners to be contacted regarding the diagnosis. The need to increase fluids, rest, and nutrition are important, but not as important as the client contacting sexual partners regarding the diagnosis. The nurse should instruct the client to avoid, not just limit, sexual contact until recovered from the illness.

A client with syphilis is allergic to penicillin. Which medication would the client need to be prescribed to treat the infection?
Select all that apply.
A) Doxycycline
B) Amoxicillin
C) Tetracycline
D) Gentamicin
E) Erythromycin

A) Doxycycline
C) Tetracycline

Clients allergic to penicillin are given oral doses of doxycycline or tetracycline for 14 days for the treatment of syphilis. Gentamicin, amoxicillin, and erythromycin are not prescribed for the treatment of syphilis.

The nurse is planning care to address pain in the client with genital herpes. Which intervention would be appropriate for this client?
A) Increase the intake of cranberry juice.
B) Clean lesions 2 or 3 times a day with warm water and soap.
C) Dry lesions with a hair dryer turned to the hot setting.
D) Wear tight cotton clothing.

B) Clean lesions 2 or 3 times a day with warm water and soap.
Measures to reduce the discomfort of herpes lesions include cleansing the lesions two or three times a day with warm water and soap. Lesions should be dried using a hair dryer turned to a cool setting. It is important to wear loose cotton clothing that will not trap moisture. Fluids that increase urine acidity such as cranberry juice should be avoided.

A public health nurse is educating a group of adults regarding sexually transmitted infections. Which is an appropriate statement by the nurse?
A) "Males have higher rates of gonorrhea and Chlamydia, whereas women have higher rates of syphilis."
B) "Men are disproportionately affected by STIs compared to women and infants."
C) "Women often experience few early manifestations of the infection, delaying diagnosis and treatment."
D) "The incidence of STIs is highest among young Caucasian females."

C) "Women often experience few early manifestations of the infection, delaying diagnosis and treatment."

Women often experience few early manifestations of sexually transmitted infection, delaying diagnosis and treatment. Women have higher rates of gonorrhea and Chlamydia, whereas men, especially men who have sex with men, have higher rates of syphilis. Women and infants are disproportionately affected by STIs. The incidence of STIs is highest among people of color.

A client at 8 weeks' gestation has been advised to have the embryo undergo genetic testing. The nurse instructs the client that the area of the embryo being tested is which of the following?
A) Chorion
B) Amnion
C) Ectoderm
D) Endometrium

A) The chorion is the outermost embryonic membrane and develops into chorionic villi, which can be used for early genetic testing of the embryo at 8 to 11 weeks' gestation by chorionic villi sampling. The endometrium is the lining of the uterus and will not be used for genetic testing of the embryo. The ectoderm is a germ layer and will develop into specific structures within the developing fetus. The amnion will develop into amniotic fluid, which can also be sampled for genetic testing but may not be developed by 8 weeks' gestation.

A client informs the nurse of a positive result from an early pregnancy test but wants to be sure that she is pregnant. Which response is the most appropriate for the nurse to make?
A) "Pregnancy can be detected 24 to 48 hours after conception, depending on the test."
B) "Pregnancy cannot be detected before 12 days after conception."
C) "Most early pregnancy tests are not reliable."
D) "Most pregnancy tests cannot differentiate between pregnancy and premenstrual hormone levels."

A) "Pregnancy can be detected 24 to 48 hours after conception, depending on the test." Early pregnancy factor, an immunosuppressant protein, is secreted by the trophoblastic cells of the developing embryo. This factor appears in the maternal serum within 24 to 48 hours after fertilization and forms the basis of a pregnancy test during the first 10 days of development. The nurse should respond that pregnancy can be detected 24 to 48 hours after conception, depending upon the test. It is not true that most early pregnancy tests are not reliable. Pregnancy can be detected before 12 days after conception. Early pregnancy tests assess for the presence of trophoblastic cells and not premenstrual hormone levels.

The nurse is instructing a client who is at 10 weeks' gestation on smoking cessation and avoiding substance abuse because these substances will:
A) Interfere with hormone excretion of the fetus.
B) Facilitate the transfer of viruses and other diseases into the developing fetus.
C) Pass into the developing fetus through the placenta very easily.
D) Stop the synthesis of protein in the developing fetus.

...

The nurse is instructing a client who is at 10 weeks' gestation on smoking cessation and avoiding substance abuse because these substances will:
A) Interfere with hormone excretion of the fetus.
B) Facilitate the transfer of viruses and other diseases into the developing fetus.
C) Pass into the developing fetus through the placenta very easily.
D) Stop the synthesis of protein in the developing fetus.

C) Pass into the developing fetus through the placenta very easily.
Byproducts of smoking and substance use pass from the mother to the fetus through the placenta via simple diffusion. These substances have adverse effects on the developing fetus. Smoking byproducts and abused substances do not interfere with hormone excretion of the fetus or stop the synthesis of protein in the fetus. They do not facilitate the transfer of viruses and other diseases into the developing fetus.

A client at 12 weeks' gestation with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work. The nurse realizes the client is describing a(n):
A) Father's reaction normally seen in the second trimester of pregnancy.
B) Father's reaction normally seen in the third trimester of pregnancy.
C) Father's reaction normally seen in the first trimester of pregnancy.
D) Atypical reaction of the father to pregnancy that should be further examined.

C) Father's reaction normally seen in the first trimester of pregnancy.

Pregnancy produces psychological changes in the mother and father of the child. A reaction seen in the father during the first trimester of pregnancy is a renewed interest in hobbies or activities outside of the family and is usually a sign of stress. This behavior is not seen in the second or third trimesters and is not an atypical reaction that should be further examined.

After learning that she is pregnant, an adolescent client asks for information that she needs to know about the pregnancy and the baby because she cannot afford to see a doctor. The nurse should do which of the following?
A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery.
B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery.
C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance.
D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery.

A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery.

Poverty and low education levels are associated with adolescent pregnancy. The nurse should support the client by providing information on resources to assist with medical care during the pregnancy and after delivery. The nurse should not instruct the client on all aspects of the pregnancy, including fetal development, labor, and delivery, as this can be overwhelming to the client. The nurse should not ask the client if the parents are aware of the pregnancy nor tell the client that the baby's father is responsible for her medical care; these actions do not address the client's needs.

An adolescent client at 34 weeks' gestation tells the nurse that she cannot wait for "all of this to be over" so she can resume her normal life. With which question should the nurse respond to this client?
A) "Are your friends excited about the baby coming and planning a shower for you?"
B) "Have you done anything to prepare for the baby coming home after delivery?"
C) "Do you miss school and spending time with your friends?"
D) "Have you been able to get enough rest while keeping up with your studies?"

B) "Have you done anything to prepare for the baby coming home after delivery?"

Developmental tasks of the third trimester include preparing for the baby with clothing and supplies. The nurse needs to assess what the client has done to prepare for the baby coming home after delivery. The nurse should not focus on the client missing school and friends because these are not developmental tasks associated with the pregnancy.

A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler. What does this assessment finding indicate to the nurse?
A) The mother is at 8 to 12 weeks' gestation.
B) The mother is at 16 weeks' gestation.
C) The mother is at 4 to 8 weeks' gestation.
D) The mother is at 20 weeks' gestation.

A) The mother is at 8 to 12 weeks' gestation.

The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is not available, a fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early as week 16 and almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks' gestation because the Doppler device detected fetal heartbeat. If the mother has not yet heard the fetal heartbeat, she must be at less than 16 or 20 weeks' gestation.

A client is surprised to learn of being pregnant because the home pregnancy test was negative when it was used a month ago. What should the nurse respond to this client?
A) "Home pregnancy tests are unreliable and should not be used without an ultrasound afterward to confirm pregnancy."
B) "Home pregnancy tests can provide a false negative and should be repeated in a week if your period has not yet started."
C) "Home pregnancy tests are unreliable and should not be used without a blood sample being drawn afterward."
D) "Home pregnancy tests lose their effectiveness after 6 months, and your kit was probably old."

B) "Home pregnancy tests can provide a false negative and should be repeated in a week if your period has not yet started."

False-negative results with home pregnancy tests are high, and so follow up is indicated if symptoms of pregnancy occur. If the results are negative, the woman should repeat the test in 1 week if she has not started her period. Home pregnancy tests do not lose their effectiveness for 2 years. Blood sampling and ultrasounds are not required to confirm the results of home pregnancy tests.

The nurse notes that a client who is 18 weeks pregnant is experiencing gum hyperplasia with areas of inflammation. What actions should the nurse take regarding this finding?
Select all that apply.
A) Encourage the use of dental floss to reduce gum overgrowth.
B) Do nothing because this is a normal finding with pregnancy.
C) Suggest seeing a dentist.
D) Discuss current dental habits.
E) Recommend flushing the mouth with hydrogen peroxide daily.

C) Suggest seeing a dentist.
D) Discuss current dental habits.

Hyperplasia of the gums can occur during pregnancy because of estrogen. However the client does have areas of inflammation. The nurse should discuss the client's current dental habits and suggest the client see a dentist. Doing nothing will not address the areas of inflammation. Flushing with hydrogen peroxide is not recommended for gum inflammation. Dental floss will not prevent gum hyperplasia

A client in the first trimester of pregnancy complains of a vaginal discharge and is concerned that the baby is infected. The nurse should instruct the client to do which of the following?
Select all that apply.
A) Avoid douching.
B) Keep the vaginal area clean and wear cotton underwear.
C) See the primary care physician to assess for a vaginal infection.
D) Limit bathing to 2 times a week.
E) Limit dairy products and use lactose-free products whenever possible.

A) Avoid douching.
B) Keep the vaginal area clean and wear cotton underwear.
One client discomfort seen in the first trimester of pregnancy is increased vaginal secretions. The nurse should instruct the client to keep the vaginal area clean and wear cotton underwear. The nurse should also instruct the client to avoid douching. The nurse should not instruct the client to limit bathing or dairy products; those actions will not decrease vaginal secretions and may offer other risks. The nurse should not suggest that the client has an infection because increased secretions are expected during the first trimester.

A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following?
A) Drink a glass of water every time nausea occurs.
B) Take a multivitamin without iron each day.
C) Take over-the-counter Benadryl for the nausea.
D) Take a multivitamin with iron each day.

B) Take a multivitamin without iron each day.
Multivitamins without iron will reduce the nausea associated with the first trimester of pregnancy. The nurse should not suggest taking the vitamin with iron, which can contribute to nausea. The nurse should not instruct the client to drink a glass of water every time nausea occurs because this could lead to the ingestion of high quantities of water. The nurse should also not instruct the client to ingest an over-the-counter medication without discussing this with her physician.

A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen a pregnant client in her second trimester has a hemoglobin of 10 g/dL and a serum ferritin level of 11 mg/L. The woman states that she has felt tired a lot, but otherwise feels fine. What actions would be expected in caring for this client?
Select all that apply.
A) Complete a further history and exam to carefully assess for any potential cause of bleeding.
B) Review a list of iron-rich foods and explore with the client how she can increase dietary iron.
C) Have the client continue her usual daily prenatal vitamin dose.
D) Stress the importance of complying with an increase in iron supplementation to 100 mg per day.
E) Ask the client to return in 2 months for a repeat check of her serum iron levels.
F) Order a screening for sickle cell anemia.

A) Complete a further history and exam to carefully assess for any potential cause of bleeding.
B) Review a list of iron-rich foods and explore with the client how she can increase dietary iron.
C) Have the client continue her usual daily prenatal vitamin dose.
D) Stress the importance of complying with an increase in iron supplementation to 100 mg per day.

Iron deficiency anemia is the most common medical complication of pregnancy; thus, low hemoglobin and ferritin levels during pregnancy suggest an inadequate intake of dietary iron as the probable cause of her anemia. Although the client otherwise reports feeling well, the nurse should review her history and physical findings for any other possible causes of decreased hemoglobin levels (e.g., tendency to bruise easily, uterine bleeding, dark stools) to help ensure that another cause is not missed. Given that the client's anemia is likely from iron deficiency, the nurse needs to emphasize the importance of eating iron-rich foods and complying with the increased iron supplementation (from the 27 mg/day typical in prenatal vitamins to between 60 and 120 mg/day) rather than continuing with her usual daily prenatal vitamin dose. A screening for sickle cell anemia is not indicated given the information presented. The client should return in 1 month for a re-check of her hemoglobin levels; if improvement is not seen, then further evaluation is indicated.

What is the test or measurement that provides an early indicator of fetal lung maturity in high-risk pregnancies?
A) Serum or urine human chorionic gonadotropin (hCG)
B) Fetal heartbeat by Doppler
C) Fetal heartbeat by fetoscope
D) Fetal movement

A) Serum or urine human chorionic gonadotropin (hCG)

The earliest indicator of fetal viability is the beta subunit of human hCG measured in maternal blood or urine. hCG normally rises at 10-12 weeks of gestation, and this initial elevation is important in monitoring high-risk pregnancies where viability has not been documented. A lack of increasing hCG levels, abnormally high levels of hCG, or an accelerated rise of hCG suggest the need for further investigation of the pregnancy and of fetal well-being. A fetal heartbeat is diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th week of gestation and by fetoscope at about the 17th to 20th week. Fetal movement, another objective sign of pregnancy, is palpable around 20 weeks' gestation by a trained examiner; pregnant women may experience movement subjectively, called quickening, around this same time.