Maternal NCLEX
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Question 1 of 5.
The nurse is conducting a physical assessment of the pregnant client. Which physiological cervical changes associated with pregnancy should the nurse expect to find? Select all that apply.
A. Formation of mucus plug
B. Chadwick's sign
C. Presence of colostrum
D. Goodell's sign
E. Cullen's sign
Explanation: Cervical changes associated with pregnancy include the formation of the mucus plug. Endocervical glands secrete a thick, tenacious mucus, which accumulates and thickens to form the mucus plug that seals the endocervical canal and prevents the ascent of bacteria or other substances into the uterus. This plug is expelled when cervical dilatation begins. Cervical changes associated with pregnancy include a bluish-purple discoloration of the cervix (Chadwick's sign) from increased vascularization. Cervical changes associated with pregnancy include the softening of the cervix (Goodell's sign) from increased vascularization and hypertrophy and engorgement of the vessels below the growing uterus. Colostrum does occur with pregnancy but is a physiological change associated with the breasts and not with a cervical change. Cullen's sign is a bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. It can occur with a ruptured ectopic pregnancy or acute pancreatitis.
Question 2 of 5.
The nurse correctly explains that the bleeding is the result of sloughing of which structure?
A. Endometrium
B. Myometrium
C. Epimetrium
D. None of the above
Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
Question 3 of 5.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
A. 5 months
B. 6 months
C. 7 months
D. 8 months
Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
Question 4 of 5.
The nurse correctly assists the client into which position?
A. Lithotomy
B. Prone
C. Sims'
D. Trendelenburg's
Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
Question 5 of 5.
Which response by the nurse is most accurate?
A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.
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