Question

A 28-year-old G1P0 client at 10 weeks of gestation reports an increase in how often she needs to urinate, stating, "I feel like I'm going to the bathroom every hour, and it's starting to disrupt my sleep." Based on the nurse's understanding of physiologic changes during pregnancy, which statement is the most appropriate for the nurse to provide?

Answer 1

Correct Answers:

"This is expected due to an increase in blood volume, which cause your kidneys to process more fluid."

Rationale :

🤰Early pregnancy is associated with an increase in maternal blood volume and renal blood flow, which leads to an increased glomerular filtration rate (GFR) and more urine production, causing urinary frequency.

💧The growing uterus also begins to place pressure on the bladder, especially in the first trimester, further contributing to the feeling of needing to void more often.

🩺This urinary frequency is a normal physiologic change rather than an immediate sign of infection or gestational diabetes, particularly in a healthy client at 10 weeks’ gestation without other symptoms.

🧠Reassuring the client that this is an expected pregnancy change while assessing for other concerning signs helps reduce anxiety and supports therapeutic communication.

📌core message

Urinary frequency in early pregnancy is usually a normal result of increased blood volume, higher GFR, and mild uterine pressure on the bladder, so the nurse should provide reassurance and education.

Answer 2

Correct Answers:

Elevated levels of human chorionic gonadotropin (HCG) causing increased blood flow to the kidneys and more frequent urination.

Rationale :

🤰In early pregnancy, hCG levels are elevated, supporting the corpus luteum and contributing to systemic changes such as increased blood flow to the kidneys, which can cause frequent urination.

💤Fatigue and dizziness are common early-pregnancy symptoms related to a combination of hormonal shifts, vascular changes, and increased metabolic demands rather than decreased estrogen or progesterone.

🧪Estrogen levels generally rise, and progesterone also remains elevated to maintain the uterine lining, so the options describing decreased levels of these hormones are inaccurate for early pregnancy.

🩺Understanding that hormonal surges, especially hCG, underlie many first-trimester discomforts helps the nurse give accurate reassurance and explanations to the client.

📌core message

Early-pregnancy symptoms like fatigue, dizziness, and urinary frequency are strongly linked to elevated hCG and other normal hormonal changes, not to decreased estrogen or progesterone.

Answer 3

Correct Answers:

Administer an ordered dose of penicillin during the laboring process.

Rationale :

👶Group B streptococcus (GBS) colonization in pregnancy is managed by providing intrapartum antibiotic prophylaxis, typically IV penicillin, during labor to prevent neonatal infection.

🧬Administering antibiotics during labor, rather than immediately in pregnancy, reduces the risk of early-onset GBS sepsis in the newborn when exposure is greatest at birth.

🩺Simply explaining that an infection is occurring without a plan or using topical iodine does not effectively prevent vertical transmission from mother to baby.

📋A 24-hour urine collection is not indicated for GBS colonization; the key evidence-based intervention is IV penicillin during labor once GBS positive status is known.

📌core message

For a GBS-positive pregnant client, the correct intervention is intrapartum IV penicillin during labor to prevent neonatal GBS infection, not routine antenatal antibiotics or topical treatments.

Answer 4

Correct Answers:

A client in her first trimester who owns a cat and cares for it on her own.

Rationale :

🐱Handling a cat, especially cleaning the litter box, increases the risk of exposure to Toxoplasma gondii, which can cause toxoplasmosis, a recognized teratogenic infection in early pregnancy.

🧠Toxoplasmosis can lead to serious fetal effects such as neurologic damage, ocular defects, and miscarriage, making this a significant teratogenic concern in the first trimester.

🎧Being around friends smoking marijuana or taking supplements as directed is less directly teratogenic than exposure to cat feces contaminated with Toxoplasma.

🛡️Even with PPE at work, if properly used, teratogenic risk can be minimized, whereas litter box care remains a known and common risk that needs education and avoidance.

📌core message

A pregnant client who handles cat litter is at increased risk for toxoplasmosis, a significant environmental teratogen, especially dangerous in the first trimester.

Answer 5

Correct Answers:

"It provides adequate perfusion of the placenta."

Rationale :

🩸During pregnancy, maternal blood volume expands by about 30–50% to ensure adequate uteroplacental perfusion, supplying the placenta and fetus with sufficient oxygen and nutrients.

🤰This increased volume also supports the mother's increased metabolic demands and prepares her body to tolerate blood loss at delivery.

📊Although the expanded volume does help with waste elimination and maintaining hydration, the key physiologic reason in pregnancy is to support placental circulation and fetal development.

🩺Explaining the role in placental perfusion helps the client understand why cardiovascular changes like increased blood volume are both normal and necessary during pregnancy.

📌core message

The 30–50% increase in blood volume during pregnancy primarily ensures adequate perfusion of the placenta, supporting fetal growth and preparing for delivery blood loss.

Answer 6

Correct Answers:

Abdominal pain

Rationale :

🤰Mild ankle edema, some shortness of breath when climbing stairs, and slightly decreased appetite can be normal third-trimester discomforts due to uterine size and fluid shifts.

⚠️However, abdominal pain in late pregnancy can signal complications such as preterm labor, placental abruption, preeclampsia with epigastric pain, or other acute conditions.

🩺This symptom warrants immediate, focused assessment of location, quality, timing, and associated signs like vaginal bleeding or uterine contractions.

📋Identifying abdominal pain as a potentially abnormal cue helps prioritize safety, differentiating it from more common, benign late-pregnancy discomforts.

📌core message

At 35 weeks, abdominal pain is a concerning cue needing further assessment, unlike mild edema or exertional dyspnea, which are often normal third-trimester changes.

Answer 7

Correct Answers:

Requires the use of an ultrasound and helps determine fetal oxygenation.

Rationale :

🖥️A biophysical profile (BPP) combines ultrasound assessment and sometimes NST data to evaluate fetal well-being, including movement, tone, breathing, amniotic fluid volume, and reactivity.

💨These parameters reflect fetal oxygenation and central nervous system function, helping clinicians determine whether the fetus is well-oxygenated or at risk for hypoxia.

🩺The procedure is noninvasive and does not require a signed consent like an invasive test such as amniocentesis would.

📋It does not directly decrease the risk of membrane rupture or require maternal blood sampling; its main purpose is fetal assessment via ultrasound-based scoring.

📌core message

A biophysical profile is a noninvasive ultrasound-based test that evaluates fetal oxygenation and well-being by scoring movement, tone, breathing, and fluid volume.

Answer 8

Correct Answers:

Administer Rho(D) immune globulin as prescribed

Rationale :

🩸An Rh-negative client experiencing pregnancy loss is at risk for Rh sensitization if exposed to Rh-positive fetal blood, which can threaten future pregnancies through hemolytic disease of the fetus/newborn.

💉Administering Rho(D) immune globulin promptly prevents the mother's immune system from forming anti-D antibodies, thereby reducing complications in subsequent pregnancies.

🩺Monitoring vital signs, providing emotional support, and obtaining consent for procedures are all important, but they do not specifically address the future sensitization risk.

📋Because the question focuses on reducing risk of complications in future pregnancies, Rho(D) immune globulin is the priority intervention.

📌core message

After a spontaneous abortion in an Rh-negative client, the nurse should promptly administer Rho(D) immune globulin to prevent Rh sensitization and protect future pregnancies.

Answer 9

Correct Answers:

drink a quart of water 1-2 hours before the procedure

Rationale :

✅A full bladder is needed for a first-trimester transabdominal ultrasound because it helps lift the uterus out of the pelvis and provides a better acoustic window for imaging.

📋Teaching the client to drink about a quart of water 1–2 hours before the procedure and avoid voiding allows the bladder to fill and improves visualization of the fetus.

🧪Frequent emptying of the bladder or restricting fluids would interfere with achieving a full bladder, reducing the quality of the ultrasound images.

🤰Monitoring fetal movement for 24 hours is associated with kick counts, not with preparation for a diagnostic ultrasound.

📌core message

For an early transabdominal ultrasound, the client should drink fluid and maintain a full bladder before the test to improve uterine and fetal visualization.

Answer 10

Correct Answers:

Continue the NST for another 20 minutes and offer the mother juice or a snack to stimulate fetal activity.

Rationale :

✅A non-stress test (NST) is considered reactive when there are adequate accelerations in fetal heart rate with fetal movement; however, sometimes the fetus is sleeping or less active in the first 20 minutes.

🧃Standard practice is to extend the NST for an additional 20 minutes and use stimulation such as offering juice or a snack to increase fetal activity before labeling the test as nonreactive.

🩺The fetal baseline of 135 bpm with moderate variability and no decelerations is reassuring, so immediate emergency cesarean or advanced testing is not yet indicated.

📋Only if the NST remains nonreactive after extended monitoring and stimulation would further testing, such as biophysical profile or contraction stress test, be considered.

📌core message

With a normal baseline and variability but no accelerations at 20 minutes, the nurse should extend the NST and stimulate fetal activity, often with juice, before escalating care.

3 :
A pregnant client is positive for Group B streptococcus. Which is the appropriate action for the nurse to take at this time?

4 :
A nurse is caring for pregnant clients in the community setting. You are doing a risk assessment for your potential clients' exposure to environmental teratogens. Which client is at the greatest risk for exposure to teratogens impacting fetal development?

5 :
The maternity nurse understands that vascular volume increases 30% to 50% during pregnancy. What response by the nurse supports this?

6 :
Which cue from the client at 35 weeks of gestation requires additional assessment?

7 :
The health care provider has ordered a biophysical profile (BPP) test on a pregnant client. How would the nurse explain the procedure to the patient?

9 :
A pregnant client in her first trimester is scheduled for a transabdominal ultrasound. Which of the following should be included in the client's teaching plan?

3 : A pregnant client is positive for Group B streptococcus. Which is the appropriate action for the nurse to take at this time?

4 : A nurse is caring for pregnant clients in the community setting. You are doing a risk assessment for your potential clients' exposure to environmental teratogens. Which client is at the greatest risk for exposure to teratogens impacting fetal development?

5 : The maternity nurse understands that vascular volume increases 30% to 50% during pregnancy. What response by the nurse supports this?

6 : Which cue from the client at 35 weeks of gestation requires additional assessment?

7 : The health care provider has ordered a biophysical profile (BPP) test on a pregnant client. How would the nurse explain the procedure to the patient?

9 : A pregnant client in her first trimester is scheduled for a transabdominal ultrasound. Which of the following should be included in the client's teaching plan?

3 :
A pregnant client is positive for Group B streptococcus. Which is the appropriate action for the nurse to take at this time?

4 :
A nurse is caring for pregnant clients in the community setting. You are doing a risk assessment for your potential clients' exposure to environmental teratogens. Which client is at the greatest risk for exposure to teratogens impacting fetal development?

5 :
The maternity nurse understands that vascular volume increases 30% to 50% during pregnancy. What response by the nurse supports this?

6 :
Which cue from the client at 35 weeks of gestation requires additional assessment?

7 :
The health care provider has ordered a biophysical profile (BPP) test on a pregnant client. How would the nurse explain the procedure to the patient?

9 :
A pregnant client in her first trimester is scheduled for a transabdominal ultrasound. Which of the following should be included in the client's teaching plan?