Question

A woman in her third trimester reports heartburn. What nursing advice is most appropriate?

Answer 1

Correct Answers:

Avoid spicy foods and eat small, frequent meals.

Rationale :

🍽️Heartburn in late pregnancy is mainly caused by progesterone-induced relaxation of the lower esophageal sphincter and uterine pressure on the stomach, which makes reflux more likely.

🔥Avoiding spicy, fatty, and acidic foods helps reduce gastric irritation and minimizes the likelihood of acid reflux episodes.

🥗Eating small, frequent meals instead of large meals decreases gastric volume, which lowers the chance of stomach contents being pushed back into the esophagus.

🛌Teaching these nonpharmacologic lifestyle measures is a key nursing intervention to promote comfort and reduce pregnancy-related dyspepsia safely.

📌Core Message

In pregnancy-related heartburn, nurses should promote dietary modification like avoiding irritant foods and using small, frequent meals to reduce reflux symptoms safely.

Answer 2

Correct Answers:

Category III - Abnormal, requires immediate intervention

Rationale :

📉Absent variability in the fetal heart rate indicates a loss of beat-to-beat fluctuation, which is a key sign of compromised fetal autonomic regulation.

⚠️Recurrent late decelerations reflect uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygenation during contractions.

📑Together, absent variability and recurrent late decelerations meet criteria for Category III fetal heart rate tracing, which is considered abnormal and suggests potential fetal acidemia.

🚨A Category III tracing requires immediate intrauterine resuscitation and rapid provider notification, as well as possible emergent delivery to prevent fetal injury.

📌Core Message

A tracing with absent variability and recurrent late decelerations is Category III, signaling fetal compromise and the need for immediate intervention.

Answer 3

Correct Answers:

G4 T1 P1 A1 L1

Rationale :

🤰Gravida counts all pregnancies, so with one term birth, one preterm birth, one abortion, and the current pregnancy, the client is G4.

👶A birth at 41 weeks is a term delivery, giving T1 in the GTPAL system.

🍼A birth at 36 weeks is preterm, and the elective abortion at 10 weeks counts as an abortion, resulting in P1 and A1.

❤️Only the living boy is included in the living category, giving L1, because the preterm girl died at birth.

📌Core Message

Using GTPAL, this client’s history equals G4 T1 P1 A1 L1, based on all pregnancies, gestational ages, and living children.

Answer 4

Correct Answers:

"Your fear and tension can slow labor by decreasing uterine contractions."

Rationale :

🧠High anxiety and fear increase catecholamines, which interfere with oxytocin’s effect on the uterus.

⚙️Increased tension can reduce uterine perfusion, leading to weaker and less effective contractions.

💤If the client cannot relax between contractions, the uterus may not fully recoil, making subsequent contractions less coordinated.

👩‍⚕️Explaining this physiologic effect of stress helps motivate the client to use relaxation techniques to support labor progress.

📌Core Message

Maternal anxiety and tension raise catecholamines, which can decrease uterine contraction effectiveness and slow labor, so relaxation is crucial.

Answer 5

Correct Answers:

Perform a fundal massage and assess for bleeding

Rationale :

🩺A soft, boggy fundus indicates uterine atony, the leading cause of postpartum hemorrhage.

✋Fundal massage stimulates uterine contraction, helping the uterus become firm and limiting blood loss.

🩸Assessing lochia for amount, color, and clots after massage helps determine the extent of bleeding and detect hemorrhage early.

🚑This immediate nursing intervention is the priority action before escalating care or notifying the provider if atony persists.

📌Core Message

A boggy postpartum uterus suggests uterine atony, so the nurse must massage the fundus and assess bleeding promptly to prevent hemorrhage.

Answer 6

Correct Answers:

"Skin-to-skin helps the baby maintain body temperature and promotes bonding."

Rationale :

🌡️Skin-to-skin contact supports thermoregulation, helping the newborn maintain a stable body temperature.

💞Placing the baby on the mother’s chest enhances bonding and attachment, supporting healthy emotional development.

🍼This practice facilitates early breastfeeding, stimulating oxytocin release and promoting both milk let-down and uterine involution.

🏥It is an evidence-based practice for healthy term newborns, improving physiologic stability and family-centered care.

📌Core Message

Immediate skin-to-skin contact promotes thermoregulation, bonding, and breastfeeding, making it a key aspect of newborn care.

Answer 7

Correct Answers:

Assess for polyhydramnios or macrosomia

Rationale :

📏At 36 weeks, the fundal height is usually close to the gestational age in centimeters, so 40 cm is larger than expected.

🌊An increased fundal height may reflect polyhydramnios, which is an excess of amniotic fluid associated with potential maternal and fetal complications.

⚖️It may also indicate macrosomia, where the fetus is larger than average, often related to diabetes or growth abnormalities.

🔍The priority is to further evaluate the cause, often with ultrasound, rather than simply reassuring or proceeding to delivery without assessment.

📌Core Message

A fundal height that is significantly greater than gestational age warrants assessment for polyhydramnios or macrosomia, not automatic reassurance.

Answer 8

Correct Answers:

Accurately monitor the amount of fluid infused and the amount returning from the uterus

Rationale :

💧During amnioinfusion, tracking the infused fluid volume is essential to avoid uterine overdistension.

🚰Monitoring the amount of fluid returning ensures that fluid is draining and not being excessively retained in the uterine cavity.

⚠️If inflow exceeds outflow, intrauterine pressure can rise, increasing risk of uterine hypertonus, uterine rupture, or fetal compromise.

📊Accurate intake and output documentation is a critical nursing responsibility for maintaining maternal-fetal safety during amnioinfusion.

📌Core Message

Safe amnioinfusion depends on precise monitoring of infused and returned fluid to prevent uterine overdistension and protect mother and fetus.

Answer 9

Correct Answers:

Gynecoid

Rationale :

🦴The gynecoid pelvis has a rounded inlet and generous pelvic dimensions, making it the most favorable for vaginal birth.

🚼Its wide subpubic angle and roomy midpelvis support effective fetal engagement, descent, and rotation.

📚Other pelvic types, such as android or platypelloid, can present narrower diameters and increase risk of labor dystocia.

👩‍⚕️Knowing the gynecoid shape is ideal helps explain why some labors may progress more smoothly than others.

📌Core Message

The gynecoid pelvis provides the most favorable dimensions for vaginal delivery, supporting smoother fetal descent and rotation.

Answer 10

Correct Answers:

"Avoid cleaning the cat's litter box or wear gloves and wash hands thoroughly."

Rationale :

🐱Toxoplasmosis is frequently transmitted through cat feces, especially in litter boxes, making this a key risk during pregnancy.

🧤Avoiding litter box cleaning, or using gloves and washing hands well afterward, prevents ingestion of Toxoplasma gondii oocysts.

👶Maternal infection in pregnancy can cause congenital toxoplasmosis, leading to serious neurologic and ocular complications in the fetus.

📖Providing clear infection-prevention teaching about cat litter and soil handling is a vital nursing intervention to reduce fetal risk.

📌Core Message

To prevent toxoplasmosis in pregnancy, avoid direct cat litter exposure or use gloves and strict hand hygiene to protect the developing fetus.

Examplify NURS226 DFD Exam-2

No.

1 :
A woman in her third trimester reports heartburn. What nursing advice is most appropriate?

2 :
Nurse is monitoring a laboring client. The fetal heart rate tracing shows absent variability and recurrent late decelerations. How should the nurse interpret this finding?

3 :
A client is now pregnant. Her obstetric history includes:
Delivered a boy at 41 weeks, living
Delivered a girl at 36 weeks, who died at birth
One elective abortion at 10 weeks
What is the client's GTPAL?

4 :
On labor A laboring client is extremely anxious and tense. She reports fear about the labor process and is unable to relax between contractions. The nurse explains the effects of anxiety. Which statement by the nurse is most accurate?

5 :
A nurse is assessing a client 1 hour after a vaginal birth. The client's fundus feels soft and boggy. The nurse's priority action should be

6 :
A nurse is caring for a client immediately after a full-term vaginal birth. The newborn is healthy, vigorous, and crying. The nurse plans to place the baby skin-to-skin on the mother's chest. Which statement best explains the primary benefit of this intervention?

7 :
A client at 36 weeks has a fundal height of 40 cm. What is the priority nursing action?

8 :
A nurse is caring for a laboring client receiving an amnioinfusion to relieve variable decelerations. Which nursing action is most important during this procedure?

9 :
Which pelvic type is most favorable for vaginal delivery?

10 :
A pregnant client asks the nurse how to avoid toxoplasmosis during pregnancy. Which instruction should the nurse provide?

Examplify NURS226 DFD Exam-2

No.

1 : A woman in her third trimester reports heartburn. What nursing advice is most appropriate?

2 : Nurse is monitoring a laboring client. The fetal heart rate tracing shows absent variability and recurrent late decelerations. How should the nurse interpret this finding?

3 : A client is now pregnant. Her obstetric history includes:Delivered a boy at 41 weeks, livingDelivered a girl at 36 weeks, who died at birthOne elective abortion at 10 weeksWhat is the client's GTPAL?

4 : On labor A laboring client is extremely anxious and tense. She reports fear about the labor process and is unable to relax between contractions. The nurse explains the effects of anxiety. Which statement by the nurse is most accurate?

5 : A nurse is assessing a client 1 hour after a vaginal birth. The client's fundus feels soft and boggy. The nurse's priority action should be

6 : A nurse is caring for a client immediately after a full-term vaginal birth. The newborn is healthy, vigorous, and crying. The nurse plans to place the baby skin-to-skin on the mother's chest. Which statement best explains the primary benefit of this intervention?

7 : A client at 36 weeks has a fundal height of 40 cm. What is the priority nursing action?

8 : A nurse is caring for a laboring client receiving an amnioinfusion to relieve variable decelerations. Which nursing action is most important during this procedure?

9 : Which pelvic type is most favorable for vaginal delivery?

10 : A pregnant client asks the nurse how to avoid toxoplasmosis during pregnancy. Which instruction should the nurse provide?

1 :
A woman in her third trimester reports heartburn. What nursing advice is most appropriate?

2 :
Nurse is monitoring a laboring client. The fetal heart rate tracing shows absent variability and recurrent late decelerations. How should the nurse interpret this finding?

3 :
A client is now pregnant. Her obstetric history includes:
Delivered a boy at 41 weeks, living
Delivered a girl at 36 weeks, who died at birth
One elective abortion at 10 weeks
What is the client's GTPAL?

4 :
On labor A laboring client is extremely anxious and tense. She reports fear about the labor process and is unable to relax between contractions. The nurse explains the effects of anxiety. Which statement by the nurse is most accurate?

5 :
A nurse is assessing a client 1 hour after a vaginal birth. The client's fundus feels soft and boggy. The nurse's priority action should be

6 :
A nurse is caring for a client immediately after a full-term vaginal birth. The newborn is healthy, vigorous, and crying. The nurse plans to place the baby skin-to-skin on the mother's chest. Which statement best explains the primary benefit of this intervention?

7 :
A client at 36 weeks has a fundal height of 40 cm. What is the priority nursing action?

8 :
A nurse is caring for a laboring client receiving an amnioinfusion to relieve variable decelerations. Which nursing action is most important during this procedure?

9 :
Which pelvic type is most favorable for vaginal delivery?

10 :
A pregnant client asks the nurse how to avoid toxoplasmosis during pregnancy. Which instruction should the nurse provide?