Nurse Care Plan

Agnes, a 30 year old woman has just discovered she is pregnant for the first time. She missed her menstrual period 4 weeks ago and came to the office for a pregnancy test, which was positive.

1. Agnes' urine pregnancy test revealed a positive result. Which of the following statement about urine pregnancy test is true?
a. it is the detection of HCG in urine which is highly concentrated in the morning
b.presence of progesterone confirming pregnancy
c. there is shedding of endometrial lining
d. frequent micturition is a presumptive sign
2. Rebecca asked the nurse what structure will be supplying the fetus nourishment. Your answer will likely be?
a. choroinic villi c. trophoblast
b. uterus d. placenta
3. She further asked which of the following fetal structures are developing during this time. Which of the folloeing statement if made by the nurse denotes correct explanation?
a. The neural plates start to develop, and the heart beat can be detected by an ultrasonography by now
b.the alveolar sacs start producing surfactant
c. fetal movements is first felt by the mother
d. exchange of gases take place in fetal lungs
4. All are functions of amniotic fluids except?
a. protects the fetus from direct trauma
b. acts as urinary elimination system of the fetus
c. regulates intrauterine temperature
d. promotes muscoloskeletal movement of the fetus
5. Which of the folloein make up the fetal umbilical cord/
a. 2 veins; 1 artery; Whartons jelly and nerve endings
b. Wharton's jelly; 2 veins; 2 arteries
c. 1 vein; 1 artery; wharton's jelly
d. 1 vein; 2 arteries; wharton's jelly
6. The woman in her first trimester of pregnancy notices a change in the color of her vagina and perineum to bluish-purplish color. This is likely due to?
a. increased melanin formation
b.increased vasculization into the pelvic area
c. increased pituitary gland activity
d. in preparation for child birth
7. It is painless, intermittent uterine contraction of pregnacny?
a. labor contraction
b. low back pain
c. braxton kick contraction
d. braxton hick's contraction
8. The nurse is giving health information about normal hematologic changes of pregnancy. All are correct information regarding the risk for venous thrombosis EXCEPT?
a. some clothing factors, such as fibrinogen are increased
b. there is increased cardiovascular workload
d. hypercoagulability of the blood serves as protective functions during pregnancy
d. as the uterus enlarges, blood return from the lower extremities is inhibited and may cause venous stasis
9. The nurse advises the pregnant woman to avoid the supine position. And if the woman wishes to lie on her back, she must place a pillow under her right hip. This is to?
a. keep the uterus away from the great vessels
b. allow the woman to be more relaxed and breathe easier
c. keep the woman from hypertension.
d. allow the client to bemore comfortable and includes sound sleep.
10.When the woman lies flat on her back, the uterus and its contents compress the aorta and vena cava against the spine. This position will likely to cause?
a. pregnancy induced hypertension
b. hemodynamic changes
c. supine hypotension syndrome
d. nausea an dvomiting
11. A pregnant woman is concerned about her appearance especially hyperpigmentation on her face. To reassure her that this is a normal integumentary change of pregnancy, your statement will likely be?
a. this condition is not permanent, it tend to fade after pregnancy
b. tis condition is caused by increased pituitary activity
c. this condition can be stimulated by oral contraceptives
d. this condition is permanent and must use creams
12. " I cant sleep well at night; I often go to the toilet room and pee." Complained the pregnant woman. The nurse is aware that this physiologic change is due to?
a. dilatation of the uterus resulting from hormonal changes.
b. pressure of the expanding uterus in the bladder.
c. increased in kidney size, particularly the right side
d. decreased urinary peristalsis
13. It is a hormone secreted by the posterior pituitary gland that progressively increases during pregnancy that is crucial for lactation?
a.human placental lactogen
b. oxytocin
c. prolactin
d. progesterone
14. All are positive signs of pregnancy EXCEPT?
a. fetal heart beat
b. fetal outline
c. quickening
d. visible fetal movements
15. Olivia is 3 weeks delayed for her menstrual period. She complained of easy fatigability and is often nauseated in the morning. How do you classify this symptoms Olivia is experiencing?
a. positive
b. presumptive
c. probable
d. no clasification
16. Upon internal examination, the doctor noted that Olivia's lower uterine segment is soft. How is this classified an dhow is this called?
a. Chadwick's sign; presumptive
b.Chadwick's sign; probable
c. hegar's sign; presumptive
d. hegar's sign; probable
17. You are teaching Olivia about nutritional information. If Olivia understands your instructions, how will she reply when you ask her the importance of high folic acid in the diet and supplements?
a. prevents neural tube defects
b. promotes brain development
c. prevents osteoporosis
d. promotes cellular growth
18.Dina on her first trimester reports that she is feeling uncertain and other myriad of emotions towards her pregnancy. What psychological task is Dina experiencing?
a. acceptance of pregnancy
b. preparing for parenthood.
c. ambivalence and grief
d. acceptance of the baby
19. It is the persistent ingestion of nonfood substances, such as clay, laundry starch, or dirt.
a. vegetarianism
b. pica
c. lactose intolerance
d. food craving
20. Tess is often observed by her husband to be constantly binging on laundry starch. She is pale and looks weak. Based on the assesment gathered, what will be the priority nursing diagnosis/
a. risk for fetal injury related to unhealthy diet
b. alteration in nutrition less than body requirement related to perversion of eating
c. knowledge deficit related to pregnancy
d. fluid volume deficit realted to poor nutritional intake