Contemporary Maternal-Newborn Nursing Care 8th Edition By Ladewig, London, Davidson TEST BANK

(Contemporary Maternal Newborn Nursing 8e Patricia Ladewig, Marcia London, Michele) (Test Bank all Chapters)

Chapter 01 Question 1 Type: MCSA During a prenatal visit, a patient expresses interest in accessing community-based care and services. Which response allows the registered nurse to best describe services that are offered by way of community-based care?

1. "Most healthcare services provided to childbearing women and their families take place in a hospital setting."

2. "Community-based care can provide a patient with certain primary care services."

3. "Nurses are the sole providers of services related to home care."

4. "Due to lack of support from third-party payers, community-based care has decreased."

Correct Answer: 2 Rationale 1: The majority of health care provided to childbearing women and their families takes place outside of hospital in clinics, offices, community-based organizations, and private homes.

Rationale 2: Primary care includes health promotion and illness prevention, and it features services that are best provided in community-based settings.

Rationale 3: While nurses are the major providers of home care services, healthcare providers in various other fields, such as physical therapy, also offer home care services.

Rationale 4: As third-party payers begin to recognize the importance of primary care in containing costs and maintaining health, community-based care has increased.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Describe the use of community-based nursing care in meeting the needs of childbearing families.

Question 2 Type: MCSA The labor and delivery nurse and a nurse new to the labor and delivery unit are admitting a laboring patient. The patient is making groaning guttural sounds during contractions and answering questions with one-word answers.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The labor and delivery nurse simultaneously is quickly setting up the instruments and sterile field for this delivery while asking the admission questions between contractions. The experienced labor and delivery nurse has not yet completed a pelvic exam. The nurse new to labor and delivery understands that this is an example of: 1. An expert nurse assessing advanced labor and imminent delivery in the patient.

2. The correct order of steps when admitting a laboring patient.

3. Inconsistencies in an individual nurse’s approach to patient care.

4. Advanced nurse practice.

Correct Answer: 1 Rationale 1: An expert nurse utilizes multiple aspects of a patient’s behavior (including the length of each response to a question and sounds the patient produces during contractions) in addition to the more objective findings of the pelvic exam (including dilation of the cervix) in the assessment of a laboring patient. The expert nurse has identified that the grunting and guttural sounds during contractions are involuntary pushing and that the patient is very close to delivery.

Rationale 2: Although most nurses have a routine when admitting a patient, the order of the steps will vary according to the situation at hand.

Rationale 3: Changing the order of the steps of admission is not being inconsistent; changing the order of the steps of admission is responsive to the needs of the patient at that point in time.

Rationale 4: Advanced nurse practice describes educational and certification achievement and is not used to describe the continuum from novice to expert.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Distinguish among the education, qualifications, and scopes of practice in nurses caring for childbearing families.

Question 3 Type: MCSA Currently, one-third of children under 20 years old come from families of minority populations. The new nurse is observing her preceptor assess the patient’s communication pattern, religious beliefs, level of education, and support system. The new nurse understands that the best reason for her preceptor to assess these areas is to increase the: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Patient’s cooperation with the plan of care.

2. Hospital’s compliance with the Joint Commission on Accreditation of Healthcare Organizations JCAHO standards.

3. Nurse’s knowledge of cultural beliefs.

4. Patient’s satisfaction with her care.

Correct Answer: 1 Rationale 1: Gaining cooperation with the plan of care increases the outcome desired at discharge. When a patient’s value system is not included in the plan of care, it will decrease compliance with the treatment plan and possibly increase the length of stay and decrease the desired outcome at discharge.

Rationale 2: Although compliance with JCAHO standards is very important, it is more important to gain patient cooperation with the plan of care.

Rationale 3: The nurse’s knowledge of cultural beliefs increases the ability to care for the patient, but without patient cooperation with the plan of care, the nurse’s knowledge is lost.

Rationale 4: Patient satisfaction with care is important, but the prime reason for the satisfaction is the nurse’s taking time to gain patient cooperation with the plan of care.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Distinguish among the education, qualifications, and scopes of practice in nurses caring for childbearing families.

Question 4 Type: MCSA The patient at 30 weeks’ gestation expresses a desire for the registered nurse to independently manage her perinatal care and the birth of her baby. When the nurse explains she is not credentialed to independently manage the patient's perinatal care and delivery, the nurse is recognizing principles related to: 1. Standards of care.

2. Scope of practice.

3. Right to privacy.

4. Informed consent.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 2 Rationale 1: Standards of care pertain to established minimum criteria for competent, proficient actions related to delivery of nursing care.

Rationale 2: Scope of practice is defined as the limits of nursing practice set forth in state statutes.

Rationale 3: Right to privacy involves the legal right of a person to keep her or his person and property free from public scrutiny.

Rationale 4: Informed consent is a legal concept that protects a patient’s right to autonomy and self-determination in terms of his or her care.

Global Rationale: Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Distinguish among the education, qualifications, and scopes of practice in nurses caring for childbearing families Question 5 Type: MCMA The certified nurse–midwife (CNM) role includes which of the following?

Standard Text: Select all that apply.

1. Is prepared to manage independently the care of women at low risk for complications during pregnancy and birth 2. Gives primary care for high-risk patients who are in hospital settings 3. Gives primary care for healthy newborns 4. Obtains a physician consultation for any technical procedures at delivery 5. Is educated in two disciplines of nursing Correct Answer: 1,3,5 Rationale 1: A CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth.

Rationale 2: CNMs cannot give primary care for high-risk patients who are in hospital settings. The physician provides the primary care for high-risk patients who are in hospital settings.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: A CNM is prepared to manage independently the care of healthy newborns.

Rationale 4: The CNM does not need to obtain a physician consultation for any technical procedures at delivery.

Rationale 5: The CNM is educated in the disciplines of nursing and midwifery.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify the nursing roles available to the maternal–newborn nurse.

Question 6 Type: MCMA The new graduate is learning about advanced practice nursing. Which of the following situations best illustrates an advanced practice nursing role?

Standard Text: Select all that apply.

1. An experienced registered nurse who is the manager of a large obstetrical unit 2. A registered nurse who is the circulating nurse at surgical (cesarean) deliveries 3. A clinical nurse specialist who is working as a staff nurse on a mother–baby unit 4. A nurse practitioner who is consulting with a physician in the newborn nursery 5. A nurse–midwife attending vaginal deliveries of uncomplicated pregnancies Correct Answer: 4,5 Rationale 1: Management roles are often held by professional nurses.

Rationale 2: Unit-specific skills such as circulating during cesarean births do not require additional formal education.

Rationale 3: An advanced practice nurse working as a staff nurse is not working in the role of advanced practice.

Rationale 4: Advanced practice nurses have received additional specialized education beyond registered nursing and tend to have a clinical focus. Nurse practitioners make clinical judgment and begin treatment and consult a physician as needed.

Rationale 5: It is within the scope of practice for certified nurse–midwives to attend deliveries of essentially normal patients with essentially normal pregnancies.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify the nursing roles available to the maternal–newborn nurse.

Question 7 Type: MCSA The major focus of the nurse practitioner is on: 1. Leadership.

2. Physical and psychosocial clinical assessment.

3. Independent care of the high-risk, pregnant patient.

4. Tertiary prevention.

Correct Answer: 2 Rationale 1: Leadership might be a quality of the NP, but it is not the major focus.

Rationale 2: Physical and psychosocial clinical assessment is the major focus of the nurse practitioner (NP), who provides care in many different clinical settings.

Rationale 3: NPs cannot provide independent care of the high-risk pregnant patient but must work under a physician’s supervision.

Rationale 4: The NP cannot do tertiary prevention as a major focus.

Global Rationale: Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify the nursing roles available to the maternal–newborn nurse.

Question 8 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is reviewing charts for quality improvement. A patient experienced a complication during labor. The nurse is uncertain if the labor nurse took the appropriate action during the situation. What is the best method for the quality improvement nurse to determine what the appropriate action by the nurse should have been?

1. Call the nurse manager of the labor and delivery unit and ask what the nurse should have done.

2. Ask the departmental chair of the obstetrical physicians what the best nursing action should have been.

3. Examine other charts to find cases of the same complication, and determine how it was handled in those situations.

4. Look in the policy and procedure book, and examine the practice guidelines published by a professional nursing organization.

Correct Answer: 4 Rationale 1: The nurse should find the standards herself and not rely on another person, such as the labor and delivery nurse manager, to determine appropriateness of care.

Rationale 2: Physician care and nursing care are very different; physicians might not be up to date on nursing standards of care or nursing policies and procedures.

Rationale 3: What nursing action was undertaken in a different situation might not be based on the policies and procedures or other standards of care. The quality improvement nurse will obtain the most accurate information by examining the policies, procedures, and standards of care.

Rationale 4: Agency policies, procedures, and protocols contain guidelines for nursing action in specific situations. Professional organizations such as the Association of Women’s Health, Obstetrical, and Neonatal Nurses (AWHONN) also publish standards of practice that should guide nursing care.

Global Rationale: Cognitive Level: Evaluating Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Identify legal and ethical principles in the practice of maternal–newborn nursing.

Question 9 Type: MCSA According to the 1973 U.S. Supreme Court decision in Roe v. Wade, abortion is legal if induced: 1. At a federally funded clinic.

2. Before the period of viability.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. To provide tissue for therapeutic research.

4. At a military hospital overseas.

Correct Answer: 2 Rationale 1: At a federally funded clinic, abortions can be provided legally if under United States laws.

Rationale 2: Abortion can be performed legally until the period of viability; after viability, the rights of the fetus take precedence.

Rationale 3: Abortion cannot be used to provide tissue for therapeutic research.

Rationale 4: At a military hospital overseas, abortions can be provided legally if under United States laws.

Global Rationale: Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 -Identify legal and ethical principles in the practice of maternal–newborn nursing.

Question 10 Type: MCSA The nurse is caring for a patient who has delivered her first child. The patient states, “My mother said that I have to have a bowel movement before I can go home, but my girlfriend said that isn’t true anymore. What caused this change?” Which response by the nurse is best?

1. “Doctors just want patients to go home sooner these days.”

2. “It really doesn’t matter. Don’t worry about it.”

3. “Research indicates it is normal for bowel function to slow for a few days.”

4. “We used to give all patients laxatives, but now they cost too much.”

Correct Answer: 3 Rationale 1: Cost containment and managed care are the driving forces behind some changes in care compared to a generation ago, not physician preference.

Rationale 2: Always address a patient’s questions and avoid saying “don’t worry about it” to keep communication therapeutic.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Evidence-based practice is the use of research findings to guide nursing actions, policies, and procedures. Often research findings contradict care that used to be the norm, leading to changes in policies and procedures.

Rationale 4: Although laxatives are low-cost medications, there is no evidence indicating that all patients should receive them after childbirth. The evidence indicates that bowel function slows slightly after birth and normally resumes in a few days.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Identify the impact of evidence-based practice in improving the quality of nursing care for childbearing families.

Question 11 Type: MCMA Which of the following practices characterize the basic competencies related to evidence-based practice?

Standard Text: Select all that apply.

1. Clinical practice supported by good evidence 2. Clinical practice supported by intuitive evidence 3. Clinical practice supported by data 4. Clinical practice that promotes quality 5. Clinical practice that provides a useful approach to problem solving Correct Answer: 1,3,4,5 Rationale 1: Clinical practice supported by good evidence is one of the hallmark characteristics of the basic competencies related to evidence-based practice.

Rationale 2: Clinical practice supported by intuitive evidence does not provide valid evidence and data for the proper actions.

Rationale 3: Clinical practice supported by data is one of the hallmark characteristics of the basic competencies related to evidence-based practice.

Rationale 4: Clinical practice that promotes quality is one of the hallmark characteristics of the basic competencies related to evidence-based practice.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 5: Clinical practice that provides a useful approach to problem solving is one of the hallmark characteristics of the basic competencies related to evidence-based practice.

Global Rationale: Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Identify the impact of evidence-based practice in improving the quality of nursing care for childbearing families.

Question 12 Type: MCSA The nurse is preparing a report on the number of births by three service providers at the facility (certified nurse– midwives, family practitioners, and obstetricians). This would be an example of: 1. Inferential statistics.

2. Descriptive statistics.

3. Evidence-based practice is the use of conclusions of research to improve nursing care.

4. Secondary use of data.

Correct Answer: 2 Rationale 1: Inferential statistics allow the investigator to draw conclusions from data to either support or refute causation.

Rationale 2: Descriptive statistics concisely describe phenomena such as births by providers.

Rationale 3: Evidence-based practice.

Rationale 4: Secondary use of data is analyzing data a different way than the original data analysis was undertaken or looking at different variables from a data set.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Explain how nurses can use descriptive and inferential statistics in clinical practice in maternal–child health nursing.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 13 Type: MCSA An example of descriptive statistics is: 1. A positive correlation between breastfeeding and infant weight gain.

2. The infant mortality rate in the state of Oklahoma.

3. A causal relationship between the number of sexual partners and sexually transmitted diseases.

4. The total number of spontaneous abortions in drug-abusing women as compared with non-drug-abusing women.

Correct Answer: 2 Rationale 1: A positive correlation between two or more variables is an example of inferential statistics.

Rationale 2: The infant mortality rate in the state of Oklahoma is an example of a descriptive statistic because it describes or summarizes a set of data.

Rationale 3: A causal relationship between the number of sexual partners and sexually transmitted diseases is an example of inferential statistics.

Rationale 4: The total number of spontaneous abortions in drug-abusing women also would be an inferential statistic.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Explain how nurses can use descriptive and inferential statistics in clinical practice in maternal–child health nursing.

Question 14 Type: MCSA The 2011 estimated infant mortality rate in the United States exceeds the infant mortality rate of several other developed countries, including Sweden, Japan, France, Germany, and Canada. Which research question most effectively explores variables that may potentially influence these statistics?

1. What is the average age of healthcare providers in each country?

2. What is the level of racial diversity in each country?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. What is the average age of children in each country?

4. What is the level of awareness related to contraception in each country?

Correct Answer: 2 Rationale 1: The age of healthcare providers does provide insight as to national infant mortality rates.

Rationale 2: Racial background can impact infant mortality rates.

Rationale 3: The average age of children does not provide insight as to the rate of infant mortality.

Rationale 4: Awareness related to contraception has no direct impact on the survival of infants after birth.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Discuss how available statistical data can be used to formulate further research questions.

Question 15 Type: MCSA The nurse knows the birth rate by age group in the state. Which research question could be developed for further study from this data?

1. What is the average number of children per family in the United States?

2. How does educational level affect the incidence of unplanned pregnancy?

3. What is the overall nutritional status of adolescents?

4. Which high schools provide day care for student parents?

Correct Answer: 2 Rationale 1: Determining the average number of children nationally will not yield additional information about this state.

Rationale 2: Research questions often come from a nurse’s desire to further understand an issue. How educational level affects the incidence of unplanned pregnancy is a question that flows from the known data of birth rate by age group.

Rationale 3: Studying the nutritional status of adolescents will not yield additional information about this state.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Schools that provide student parent day care might indicate the incidence of teen pregnancy in the population served by the school but not pregnancy rates of those who are not in high school.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Discuss how available statistical data can be used to formulate further research questions.

Question 16 Type: MCSA The major focus of the clinical nurse specialist (CNS) involves: 1. Conducting physical and psychosocial assessments, including history, physical examination, and certain diagnostic tests and procedures.

2. Independently managing the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns.

3. Generating new research relevant to topics such as health care and administrative issues.

4. Demonstrating leadership within his or her specialty and working to improve inpatient care both directly and indirectly.

Correct Answer: 4 Rationale 1: Physical and psychosocial clinical assessment is the major focus of the nurse practitioner (NP), who provides care in many different clinical settings.

Rationale 2: The certified nurse-midwife (CNM) is qualified to provide independent care of the low-risk pregnant client while seeking physician consultation as needed.

Rationale 3: Nurse researchers have an advanced doctoral degree, typically a PhD, and assume a leadership role in generating new research.

Rationale 4: The CNS assumes a leadership role within his or her specialty and works to improve inpatient care both directly and indirectly.

Global Rationale: Cognitive Level: Understanding Client Need: Safe Effective Care Environment Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Identify the nursing roles available to the maternal-newborn nurse.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 02 Question 1 Type: MCSA While conducting a family assessment, the nurse determines that a particular family's structure is binuclear. Some potential challenges inherently faced by binuclear families include: 1. Challenges related to co-parenting and joint custody, including negotiation and compromise between the parents about childrearing decisions.

2. Issues related to both parents being employed, including child care, household chores, and spending time together.

3. Challenges related to children interacting with peers and when revealing their parents’ sexual orientation.

4. Issues related to single parenting, including lack of social and emotional support, need for assistance with childrearing, and financial strain.

Correct Answer: 1 Rationale 1: Because both parents have equal responsibility and legal rights regarding their biologic child, binuclear families may inherently face challenges related to co-parenting and joint custody, including negotiation and compromise between the parents about childrearing decisions.

Rationale 2: Issues inherently faced by the dual-career/dual-earner family include child care, household chores, and spending time together.

Rationale 3: Children raised in gay and lesbian families may face challenges related to interacting with peers and when revealing their parents’ sexual orientation.

Rationale 4: Binuclear families incorporate co-parenting, whereas with single parenting, one parent is responsible for child care. Issues inherently related to single parenting may include lack of social and emotional support, need for assistance with childrearing, and financial strain.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe how family type may influence nursing care of the childbearing family.

Question 2 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is preparing a community presentation on family development. Which of the following statements should the nurse include?

1. The youngest child’s age determines the family’s current stage.

2. A family does not experience overlapping of stages.

3. Family development ends when the youngest child leaves home.

4. The stages describe the family’s progression over time.

Correct Answer: 4 Rationale 1: The oldest child’s age is the marker for which stage the family is in, except for the two last stages, which occur after the children have left home.

Rationale 2: Families with more than one child can experience multiple stages simultaneously.

Rationale 3: Families with more than one child can experience multiple stages simultaneously.

Rationale 4: Family development stages describe the changes and adaptations that a family goes through over time as children are added to the family.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Explain the changes that a childbearing family will undergo based on the developmental tasks to be completed.

Question 3 Type: MCSA The nurse is preparing to assess the development of a family new to the clinic. The nurse understands that the primary use of a family assessment tool is to: 1. Obtain a comprehensive medical history of family members.

2. Determine which clinic the patient should be referred to.

3. Predict how a family will likely change with the addition of children.

4. Understand the physical, emotional, and spiritual needs of members.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 4 Rationale 1: The focus of a family assessment is the family as one entity. Health of the family is one area that is explored using a family assessment tool.

Rationale 2: The family assessment tool facilitates understanding of the physical, emotional, and spiritual needs of members. Although referrals might take place as a result of the family assessment findings, understanding of the family is the primary reason the tool is used.

Rationale 3: The family assessment tool facilitates understanding of the physical, emotional, and spiritual needs of members. Family development models help predict how a family will likely change with the addition of children.

Rationale 4: This is the main reason for using a family assessment tool.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify information that would be useful to collect when performing a family assessment.

Question 4 Type: MCSA The registered nurse is caring for a pregnant Muslim patient who is anticipating delivery within the next few days.

The nurse asks if she and her husband have chosen a name for their baby. The patient quietly shakes her head, "no." Based upon the patient's response, the nurse understands that: 1. The patient is not happily anticipating the arrival of her baby.

2. Cultural beliefs may require the couple to choose the baby's name following the birth.

3. The patient does not speak English.

4. Cultural beliefs may require that the baby's name be kept secret until after the delivery.

Correct Answer: 2 Rationale 1: There is no evidence to support that the patient is not happily anticipating her baby's arrival.

Rationale 2: In the Muslim culture, it is common to avoid naming the baby until after the baby is born.

Rationale 3: The patient has been conversing with the nurse; no prior interaction suggested a language barrier.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Rather than keeping the baby's name secret, in the Muslim culture, it is common to avoid naming the baby until the baby is born.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO04 - Integrate the prevalent cultural norms that affect childbearing and childrearing when providing care to that family.

Question 5 Type: MCSA A woman of Korean descent has just given birth to a son. Her partner wishes to give her sips of hot broth from a thermos he brought from home. The patient has refused your offer of ice chips or other cold drinks. The nurse should: 1. Explain to the patient that she can have the broth if she will also drink cold water or juice.

2. Encourage the partner to feed the patient sips of broth. Ask if the patient would like you to bring her some warm water to drink as well.

3. Explain to the couple that food can’t be brought from home but that the nurse will make hot broth for the patient.

4. Encourage the patient to have the broth after the nurse takes it to the kitchen and boils it first.

Correct Answer: Rationale 1: Explaining to the patient that she can have broth if she will drink cold water or juice first does not show cultural sensitivity and does not respect the patient’s beliefs.

Rationale 2: Encouraging the partner to feed the patient sips of broth and asking if the patient would like you to bring her some warm water to drink as well is an approach that shows cultural sensitivity. The equilibrium model of health, based on the concept of balance between light and dark, heat and cold, is the foundation for this belief and practice.

Rationale 3: Explaining to the couple that the hospital does not allow food brought from home but that you will make hot broth for them is an incorrect response.

Rationale 4: Encouraging the patient to have broth after you take it the kitchen and boil it first is an incorrect response because boiling first would make the broth too hot to drink.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Integrate the prevalent cultural norms that affect childbearing and childrearing when providing care to that family.

Question 6 Type: MCSA The nurse works in a facility that cares for patients from a broad range of racial, ethnic, cultural, and religious backgrounds. Which statement should the nurse include in a presentation for nurses new to the facility on the patient population of the facility?

1. “Our patients come from a broad range of backgrounds, but we have a good interpreter service.”

2. “Many of our patients come from backgrounds different from your own, but it doesn’t cause problems for the nurses.”

3. “Because most of the doctors are bilingual, we don’t have to deal with the differences in cultural backgrounds of our patients.”

4. “Understanding the common values and health practices of our diverse patients will facilitate better care and health outcomes.”

Correct Answer: 4 Rationale 1: The role of a foreign language interpreter is to facilitate communication. The interpreter might or might not be able to interpret the cultural practices of patients. An example is a Spanish interpreter: The interpreter might be from Spain but interprets language for patients from Guatemala and Nicaragua, countries about which the interpreter might know virtually nothing.

Rationale 2: Racial, ethnic, cultural, and religious backgrounds of patients have significant implications for how they perceive health, illness, and health care. It is important for nurses to understand the backgrounds of the patient population that attend that facility.

Rationale 3: Bilingual physicians, like all physicians, have very busy schedules and often do not understand nursing care. It is the responsibility of the nurse to become familiar with the backgrounds of the patient population.

Rationale 4: Because of the implications for care based on cultural background, it is important for nurses to understand the backgrounds of the patient population that attend the facility.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Explain the importance of cultural competency in providing nursing care to the childbearing family.

Question 7 Type: MCSA The nurse manager in a hospital with a large immigrant population is planning an in-service. The nurse manager is aware of how ethnocentrism affects nursing care. Which statement should the nurse manager include? “The belief that one’s own values and beliefs are the only or the best values: 1. “Means that newcomers to the United States should adopt U.S. norms and values.”

2. “Can create barriers to communication through misunderstanding.”

3. “Leads to an expectation that patients will exhibit pain the same way.”

4. “Improves the quality of care provided to culturally diverse patient bases.”

Correct Answer: 2 Rationale 1: Although acculturation involves adoption of some of the majority culture’s practices and beliefs, each cultural group will continue to hold and express its own set of values and beliefs.

Rationale 2: Ethnocentrism is the conviction that one’s own values and beliefs either are the only ones that exist or are the best. When the nurse assumes that a patient has the same values and beliefs as the nurse, misunderstanding will frequently occur, which in turn can negatively impact nurse–patient communication.

Rationale 3: Expression of pain is one area that varies greatly from one culture to another.

Rationale 4: The belief that one’s own values and beliefs are the best will not improve the quality of care provided to culturally diverse patient bases.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Explain the importance of cultural competency in providing nursing care to the childbearing family.

Question 8 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

When preparing to teach a culturally diverse group of childbearing families about hospital birthing options, in order to be culturally competent, the nurse should: 1. Understand that the families have the same values as the nurse.

2. Teach the families how childbearing takes place in the United States.

3. Insist that the clients answer questions instead of their husbands.

4. Learn about the cultural groups that are likely to attend the class.

Correct Answer: 4 Rationale 1: Assuming that the families have the same values is ethnocentrism.

Rationale 2: Although it is important to explain health care during pregnancy and childbearing, this is not the top priority.

Rationale 3: The husband’s answering questions might be a cultural norm, and insisting that the patient answer could decrease the family’s trust in the healthcare system.

Rationale 4: Cultural competence is the development of skills and knowledge necessary to appreciate, understand, and work with individuals from other cultures than the culture of the nurse. Through gaining knowledge of the cultures that are likely to be encountered professionally, the nurse is able to understand the aspects of the patient’s culture that might impact how care should best be given to be accepted by the patient.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Explain the importance of cultural competency in providing nursing care to the childbearing family.

Question 9 Type: MCSA The nurse is admitting a Mexican woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask?

1. “What other treatments have you used for your abdominal pain?”

2. “What is your country of origin; where were you were born?”

3. “When you talk to family members, how close do you stand?”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “How would you describe your role within your family?”

Correct Answer: 1 Rationale 1: This question is most important because some traditional or folk remedies include the use of herbs.

Because some herbs have medication interactions, this physiologic question is imperative to ask.

Rationale 2: Although this information is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.

Rationale 3: Although understanding the patient’s perception of appropriate personal space is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.

Rationale 4: Although understanding the patient’s family roles is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Interpret the information collected from a cultural assessment to provide culturally sensitive care.

Question 10 Type: MCSA The labor and delivery nurse is caring for a laboring patient who has asked for a priest to visit her during labor.

The patient’s mother died during childbirth, and although there are no complications during the patient’s pregnancy, she is fearful of her own death during labor. What is the best response of the nurse?

1. “Nothing is going to happen to you. We’ll take very good care of you during your birth.”

2. “Would you like to have an epidural so that you won’t feel the pain of the contractions?”

3. “The priest won’t be able to prevent complications and might get in the way of your providers.”

4. “Would you like me to contact your parish or our hospital chaplain to come see you?”

Correct Answer: 4 Rationale 1: Avoid statements of false reassurance, as there are no guarantees in the outcomes during health care.

Using these statements shuts down effective communication, as the patient’s concern is downplayed.

Rationale 2: The patient’s expressed concern is not about pain; it is a fear of death and a desire to see a priest.

Address the patient’s concerns directly.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Although this statement is true, it is not therapeutic. It downplays the patient’s concerns and will shut down effective communication. Address the concerns the patient expresses.

Rationale 4: When the patient states she wants to see a priest, the nurse should attempt to make arrangements for this visit to occur in a timely manner. Most hospitals have a chaplaincy department that can provide assistance in obtaining the services of a wide variety of religious leaders. Depending on the day of the week and the time of day, the patient’s own home parish church might be able to provide a priest for pastoral care at the bedside.

Global Rationale: Cognitive Level: Evaluating Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Identify ways a nurse might accommodate the religious rituals and practices of the childbearing family.

Question 11 Type: MCSA A pregnant patient reports experiencing occasional gastroesophageal reflux. She explains that she relieves her symptoms through acupressure treatments, as well as by taking an over-the-counter medication recommended by her obstetrician. The nurse recognizes acupressure to be a form of: 1. Homeopathy.

2. Alternative therapy.

3. Biofeedback.

4. Complementary therapy.

Correct Answer: 4 Rationale 1: Homeopathy entails using diluted amounts of substances that, if ingested in larger amounts, would produce effects similar to the symptoms of the disorder being treated.

Rationale 2: Alternative therapy involves the use of a procedure or substance in place of conventional medicine.

Rationale 3: Biofeedback control pertains to using the mind to control physiologic responses based on the concept that the mind controls the body.

Rationale 4: Complementary therapy incorporates the use of a procedure or product as an adjunct to conventional medical treatment.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Distinguish among complementary and alternative therapies.

Question 12 Type: MCSA A patient reports using "homeopathic remedies" to ease her back pain. In order to more fully explore the patient's use of complementary and alternative medicine (CAM), the nurse should ask: 1. "Will you tell me more about the homeopathic remedies you're using?"

2. "Are you aware that some complementary and alternative therapies can be dangerous?"

3. "Does your physician approve of your use of homeopathic remedies?"

4. "Have you prioritized your need for comfort above your concern for your baby's health?"

Correct Answer: 1 Rationale 1: The nurse should ask direct, nonjudgmental questions when seeking to gain information about a patient's use of CAM. Rationale 2: While tactful warnings regarding the use of CAM may be appropriate, the nurse should first explore the patient's use of CAM in a nonjudgmental manner.

Rationale 3: Patients may be reluctant to discuss their use of CAM with their healthcare providers; the nurse should explore the topic using nonjudgmental language.

Rationale 4: Additional information is needed in order to evaluate the patient's use of CAM, and the topic should be approached without use of disparaging comments.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Distinguish between complementary and alternative therapies.

Question 13 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The patient pregnant with her first child reports that her husband wants her to visit a homeopath for help with her nausea and vomiting. The patient asks what the nurse’s opinion of homeopathy is. The best response by the nurse is: 1. “Homeopathy is unproven and potentially dangerous. Avoid using homeopathic remedies.”

2. “The FDA has approved homeopathic remedies, and practitioners undergo education and certification.”

3. “I can’t give you advice about what alternatives to try. Go online and do some research to get information.”

4. “Homeopathy is the same as herbal remedies. Some are safe during pregnancy and some are not.”

Correct Answer: 2 Rationale 1: Homeopathic remedies are not dangerous. Homeopathic remedies are FDA-approved and have been proven to be effective in treating a wide range of chronic and acute illnesses and conditions.

Rationale 2: Homeopathic remedies are FDA-approved and have been proven to be effective in treating a wide range of chronic and acute illnesses and conditions.

Rationale 3: It is appropriate for the nurse to provide factual information to educate a patient who has asked a question. Not all patients have access to computers, nor do they know how to do an internet search.

Rationale 4: Herbalism and homeopathy are not the same. Herbs are available in many stores and preparations; some have been proven to be dangerous during pregnancy. Homeopathy is a system of “like curing like,” in which the symptom being treated would be a symptom of taking too much of the substance in a non-homeopathic form.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO09 - Describe the benefits and risks of the various complementary and alternative therapies to the childbearing family.

Question 14 Type: MCMA Complementary and alternative therapies have many benefits for the childbearing family and others. However, many of these remedies have associated risks. Which of the following situations would be considered risks?

Standard Text: Select all that apply.

1. Getting a massage from a licensed massage therapist for back pain, prescribed by the primary caregiver Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Trying out a homeopathic medicine from a friend to reduce swelling in the legs 3. Getting a chiropractic treatment for low back pain due to discomforts of pregnancy without telling the primary health care provider 4. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain 5. Joining a group that practices tai chi weekly to help with physical fitness and movement Correct Answer: 2,3,4 Rationale 1: Getting a massage from a licensed massage therapist for back pain, prescribed by the primary caregiver, is a perfectly good use of complementary therapies.

Rationale 2: Trying out a homeopathic medicine from a friend to reduce swelling in your legs is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

Rationale 3: Getting a chiropractic treatment for low back pain due to discomforts of pregnancy without telling the primary health care provider is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

Rationale 4: Taking an herbal preparation suggested by a health food store worker for treatment of leg pain is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

Rationale 5: Joining a group that practices tai chi weekly to help with physical fitness and movement is a perfectly good use of complementary therapies.

Global Rationale: Cognitive Level: Evaluating Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO09 - Describe the benefits and risks of the various complementary and alternative therapies to the childbearing family.

Question 15 Type: MCSA The labor and delivery unit nurse manager is incorporating complementary and alternative therapies into the unit’s policies and procedures. Which statement should the nurse manager include during an in-service educational presentation for the nursing staff?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “Policies have been developed for using massage and aromatherapy.”

2. “When patients ask questions you don’t know, tell them to look online.”

3. “Because herbs are dangerous during pregnancy, we will not use them.”

4. “Be sure to ask patients what alternative therapies they have used.”

Correct Answer: 1 Rationale 1: The development of written policies and procedures facilitates safe nursing practice, which in turn promotes patient safety.

Rationale 2: Online information can vary in its accuracy. Reputable sources (electronic or print) should be recommended for further patient education.

Rationale 3: This statement is false. Many herbs can be safely used during pregnancy.

Rationale 4: What the patient has used in the past does not predict what she is open to using at present. It is more important to develop written policies and procedures.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO10 - Formulate nursing care within the nurse practice act and with the informed consent of the patient when using appropriate complementary therapies with childbearing families.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 03 Question 1 Type: MCSA A nurse is teaching a classroom of teenage girls about the female reproductive system. After teaching, the nurse asks the students to describe the release of an ovum during ovulation. Which student's response suggests she correctly understood the nurse's teaching?

1. “During ovulation, an egg is released from the ovary and enters the fallopian tube.”

2. "Around the middle of the menstrual cycle, one of the fallopian tubes releases an egg."

3. "Ovulation is when the uterus releases an unfertilized egg or ovum."

4. "The endometrium is where the eggs are formed and released into the fallopian tube."

Correct Answer: 1 Rationale 1: The egg is formed in the ovary and once released, it enters the fallopian tube.

Rationale 2: The egg is formed in the ovary and then released near the fimbria of the fallopian tube.

Rationale 3: The egg is formed in the ovary and travels by way of the fallopian tube to the uterus.

Rationale 4: The uterine endometrium is the site of implantation of a fertilized egg.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO01 - Identify the structures and functions of the female reproductive system.

Question 2 Type: MCSA The clinic nurse is caring for a young woman seeking contraception because she has recently married and become sexually active. The teen states, “The opening of my husband’s penis isn’t at the tip; it’s around the corner below the tip. He tells me that he was born that way. Will that cause problems if we want to have children?” What is the best response for the nurse to give? “This variation is called: 1. “Epispadias. It is not likely to impact his fertility.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. “Epispadias. It will likely cause him to be infertile.”

3. “Hypospadias. It is not likely to impact his fertility.”

4. “Hypospadias. It will likely cause him to be infertile.”

Correct Answer: 3 Rationale 1: Epispadias is the condition where the urethral opening is on the upper aspect of the penis. The patient is describing hypospadias, when the urethral opening is on the lower side of the penis. Mild hypospadias, when the urethral opening is on the glans of the penis, does not impact fertility.

Rationale 2: Epispadias is the condition where the urethral opening is on the upper aspect of the penis. The patient is describing hypospadias, when the urethral opening is on the lower side of the penis. Mild hypospadias, when the urethral opening is on the glans of the penis, does not impact fertility.

Rationale 3: The patient is describing hypospadias, which is the urethral opening on the lower aspect of the penis.

Mild hypospadias, when the urethral opening is on the glans of the penis, does not impact fertility.

Rationale 4: The patient is describing hypospadias, where the urethral opening is on the lower side of the penis.

Mild hypospadias, where the urethral opening is on the glans of the penis, does not impact fertility.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Identify the structures and functions of the male reproductive system.

Question 3 Type: MCSA A prenatal patient states, "The doctor said he might have to cut my cervix so the baby can get out during delivery." Based upon this statement, the nurse should provide teaching related to episiotomy, which includes defining: 1. The perineal body.

2. The labia majora.

3. The mons pubis.

4. The vaginal vestibule.

Correct Answer: 1 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: The perineal body, which is located between the lower part of the vagina and the anus, is often the site of an episiotomy or lacerations during childbirth.

Rationale 2: The labia majora are longitudinal, raised folds of pigmented skin located on either side of the vulvar cleft.

Rationale 3: The mons pubis is a softly rounded mound of subcutaneous fatty tissue that covers the front portion of the symphysis pubis.

Rationale 4: The vaginal vestibule contains the vaginal opening, which is the border between the external and internal genitals.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Explain the significance of specific female reproductive structures during childbirth.

Question 4 Type: MCSA A pregnant patient asks, "What's the difference between the true pelvis and the false pelvis?" The nurse's best response is: 1. "The true pelvis doesn't affect fetal passage during labor and childbirth."

2. "The false pelvis consists of the inlet, the pelvic cavity, and the outlet."

3. "The true pelvis helps direct the presenting fetal part into the false pelvis."

4. "The false pelvis helps support the weight of the pregnant uterus."

Correct Answer: 4 Rationale 1: The size and shape of the true pelvis must be adequate for normal fetal passage during labor and childbirth.

Rationale 2: The true pelvis consists of the inlet, the pelvic cavity, and the outlet.

Rationale 3: The false pelvis helps direct the presenting fetal part into the true pelvis.

Rationale 4: The false pelvis helps support the weight of the pregnant uterus.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Explain the significance of specific female reproductive structures during childbirth.

Question 5 Type: MCSA A pregnant adolescent asks the nurse, “Why does the physician call measuring my uterus a ‘fundal height’?” The nurse’s answer is based on the fact that the fundus of the uterus is located: 1. In the elongated portion where the fallopian tubes enter.

2. In the lower third area.

3. At the uppermost (dome-shaped top) portion.

4. Between the internal cervical os and the endometrial cavity.

Correct Answer: 3 Rationale 1: The elongated portion where the fallopian tubes enter the uterus is called the cornua.

Rationale 2: The lower third of the uterus is called the cervix or neck.

Rationale 3: The rounded, uppermost (dome-shaped top) portion of the uterus that extends above the points of attachment of the fallopian tubes is called the fundus.

Rationale 4: The isthmus is the portion of the uterus between the internal cervical os and the endometrial cavity.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Explain the significance of specific female reproductive structures during childbirth.

Question 6 Type: MCSA A nurse teaches newly pregnant patients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is: 1. Estrogen.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Human chorionic gonadotropin (hCG).

3. Progesterone.

4. Luteinizing hormone.

Correct Answer: 2 Rationale 1: Estrogen is an ovarian hormone.

Rationale 2: When the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete human chorionic gonadotropin (hCG) hormone to maintain the corpus luteum.

Rationale 3: Progesterone is an ovarian hormone.

Rationale 4: Luteinizing hormone is excreted by the anterior pituitary.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Summarize the actions of the hormones that affect reproductive functioning.

Question 7 Type: MCSA A school nurse is teaching a health class to middle school children. The nurse explains that follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are secreted by the: 1. Hypothalamus.

2. Ovaries and testes.

3. Posterior pituitary.

4. Anterior pituitary.

Correct Answer: 4 Rationale 1: The hypothalamus secretes gonadotropin-releasing hormone to the pituitary gland in response to signals from the central nervous system.

Rationale 2: The ovaries secrete the female hormones estrogen and progesterone, and the testes secrete testosterone.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: The posterior pituitary gland secretes oxytocin and anti-diuretic hormone.

Rationale 4: The anterior pituitary secretes FSH and LH, which are primarily responsible for maturation of the ovarian follicle.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Summarize the actions of the hormones that affect reproductive functioning.

Question 8 Type: MCSA The nurse is presenting a community education session on female hormones. Which statement from a participant indicates the need for further information?

1. “Estrogen is what causes females to look female.”

2. “The presence of some hormones causes other to be secreted.”

3. “Progesterone is present at the end of the menstrual cycle.”

4. “Prostaglandin is responsible for achieving conception.”

Correct Answer: 4 Rationale 1: This is a true statement. The question is asking for an incorrect statement. Estrogen causes secondary sex characteristics, such as enlarged breasts and widened hips.

Rationale 2: This is a true statement. The question is asking for an incorrect statement. One example is that the production of gonadotropin-releasing hormone (GnRH) causes the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH).

Rationale 3: This is a true statement. The question is asking for an incorrect statement. Progesterone is present in large quantities during the secretory phase of the menstrual cycle.

Rationale 4: Prostaglandin is not related to conception. Prostaglandin is called the hormone of pregnancy because it maintains pregnancy.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Summarize the actions of the hormones that affect reproductive functioning.

Question 9 Type: MCSA A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone?

1. Estrogen 2. Progesterone 3. FSH (follicle-stimulating hormone) 4. LH (luteinizing hormone) Correct Answer: 2 Rationale 1: Estrogen primarily assists in maturation of the ovarian follicles and causes endometrial mucosa to proliferate.

Rationale 2: Progesterone is the likely cause because it decreases uterine motility and contractibility caused by estrogens, thereby preparing the uterus for implantation.

Rationale 3: FSH is a hormone secreted by the pituitary gland.

Rationale 4: LH is a hormone secreted by the pituitary gland.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Summarize the actions of the hormones that affect reproductive functioning.

Question 10 Type: MCSA The nurse is explaining the menstrual cycle to a group of women. The teaching on phases of the menstrual cycle should include the fact that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and the blood supply to the endometrium is reduced in which phase?

1. Menstrual phase Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Proliferative phase 3. Secretory phase 4. Ischemic phase Correct Answer: 4 Rationale 1: The menstrual phase is the menses.

Rationale 2: The proliferative phase is characterized by proliferation of the endometrium.

Rationale 3: The secretory phase involves glycogen secretion by the endometrium after ovulation.

Rationale 4: The ischemic phase is characterized by ischemia of the endometrium.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Identify the two phases of the ovarian cycle and the changes that occur in each phase.

Question 11 Type: MCSA Which statement best indicates that the patient understands the differences in the follicular and luteal phases of the ovarian cycle?

1. “My period will be every 28 days.”

2. “The first part of my period might vary in length, but not the second.”

3. “The follicular phase is the second half of my cycle.”

4. “The follicular phase is when the egg is fertilized.”

Correct Answer: 2 Rationale 1: The follicular phase can vary, resulting in cycle length other than 28 days.

Rationale 2: For a female with a 28-day cycle, the follicular phase comprises days 1–14 of the menstrual cycle, and the luteal phase comprises days 15–28. The luteal phase does not vary.

Rationale 3: The luteal phase is the second half of the cycle.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: The follicular phase comprises days 1–14 of the menstrual cycle, not when the egg is fertilized.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Identify the two phases of the ovarian cycle and the changes that occur in each phase.

Question 12 Type: MCSA The nurse is preparing a handout on the ovarian cycle to a group of middle school girls. Which information should the nurse include?

1. There are two phases of the ovarian cycle: luteal and follicular.

2. Irregular menstrual cycles have varying lengths of the follicular phase.

3. The ovum travels from the ovary to the tube during the luteal phase.

4. The hormone human chorionic gonadotropin stimulates ovulation.

Correct Answer: 1 Rationale 1: The two phases of the ovarian cycle are follicular (days 1–14 of the menstrual cycle) and luteal (days 15–28 of the menstrual cycle).

Rationale 2: Menstrual cycles that are irregular in length have a consistent follicular phase but a varying luteal phase.

Rationale 3: The ovum is released from the graafian follicle of the ovary and travels to the fallopian tube during the follicular phase of the ovarian cycle.

Rationale 4: Human chorionic gonadotropin (hCG) is secreted by a fertilized ovum and does not stimulate ovulation.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Identify the two phases of the ovarian cycle and the changes that occur in each phase.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 13 Type: MCSA The nurse is preparing a presentation on the menstrual cycle for a group of high school students. Which statement should the nurse include in this presentation?

1. “The menstrual cycle has five distinct phases that occur during the month.”

2. “One hormone controls the phases of the menstrual cycle.”

3. “The secretory phase occurs when a woman is most fertile.”

4. “Menstrual cycle phases vary in order from one woman to another.”

Correct Answer: 3 Rationale 1: There are four phases of the menstrual cycle: menstrual, proliferative, secretory, and ischemic phases.

Rationale 2: Four hormones control ovulation and therefore the menstrual cycle: progesterone, estrogen, folliclestimulating hormone (FSH), and luteinizing hormone (LH).

Rationale 3: During the secretory phase, the endometrium is thickest, and glycogen is produced to nourish a fertilized ovum.

Rationale 4: Although the length of the menstrual cycle might vary, the phases of the menstrual cycle always occur in the same order.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Describe the phases of the menstrual cycle, their dominant hormones, and the changes that occur in each phase.

Question 14 Type: MCSA In preparation for teaching a women's community center class about physiologic changes during menopause, the nurse is preparing a handout for students. Which information should the nurse include in her teaching?

1. The ovaries remain small after puberty, but they increase in size following menopause.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Ovarian secretion of estrogen decreases between the ages of 45 to 55, after which point ovulatory activity ceases.

3. Due to changes in estrogen levels, the labia minora increase in size after menopause.

4. After menopause, the endometrium continues to undergo monthly degeneration and renewal.

Correct Answer: 2 Rationale 1: The ovaries of girls are small, but they become larger after puberty and then decrease in size following menopause.

Rationale 2: Between the ages of 45 and 55, a woman’s ovaries secrete decreasing amounts of estrogen.

Eventually, ovulatory activity ceases and menopause occurs.

Rationale 3: The labia minora decrease in size after menopause because of changes in estrogen levels.

Rationale 4: From menarche to menopause, the endometrium undergoes monthly degeneration and renewal in the absence of pregnancy.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Summarize the actions of the hormones that affect reproductive functioning.

Question 15 Type: MCSA A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0° F) for the past 36 hours. This most likely indicates that: 1. Menstruation is about to begin.

2. Ovulation will occur soon.

3. Ovulation has occurred.

4. She is pregnant and will not menstruate.

Correct Answer: 3 Rationale 1: A temperature increase does not occur when menstruation is about to begin.

Rationale 2: A temperature increase does not occur before ovulation has occurred.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Signs that ovulation has occurred include: pain associated with rupture of the ovum (mittelschmerz), increased vaginal discharge, and a temperature increase of 0.6°C over the past 36 hours.

Rationale 4: Pregnancy can be detected only through testing the urine or serum for the presence of human chorionic gonadotropin hormone.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Describe the phases of the menstrual cycle, their dominant hormones, and the changes that occur in each phase.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 04 Question 1 Type: MCMA The nurse is explaining the difference between meiosis and mitosis. Which statement does the nurse include?

Standard Text: Select all that apply.

1. Meiosis is the division of a cell into two exact copies of the original cell.

2. Mitosis is splitting one cell into two, each with half the chromosomes of the original cell.

3. Meiosis is the process by which gametes, or the sperm and ova, are formed.

4. Mitosis occurs in most of the cells of the body.

5. Meiotic division leads to cells that halve the original genetic material.

Correct Answer: 3,5 Rationale 1: Meiosis creates two cells that have half of the chromosomes of the original cell.

Rationale 2: Mitosis creates two cells that are exact copies of the original cell.

Rationale 3: Both sperm and ova are created through meiosis.

Rationale 4: Mitosis is how the majority of cells reproduce so that the new cells have the same structure and function as the original. Meiosis only occurs in gametes.

Rationale 5: Meiosis creates two cells that have half of the chromosomes of the original cell.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Differentiate between meiotic cellular division and mitotic cellular division.

Question 2 Type: MCSA The nurse has completed a presentation on reproduction. Which participant’s statement indicates that the teaching has been successful?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “A male is born with all the sperm he will ever produce.”

2. “Females create new ova throughout their reproductive life.”

3. “Ova separate into two unequally sized cells.”

4. “Each primary spermatocyte divides into four haploid cells.”

Correct Answer: 3 Rationale 1: Males begin spermatogenesis at puberty and continue throughout their life. Each sperm divides into four haploid cells.

Rationale 2: Females are born with all the ova they will ever produce. The ova begin to be formed in early fetal life. One ovum is released each month during the reproductive life of a female, from menarche to menopause.

Rationale 3: Each ovum undergoes meiotic division just prior to being released from the graafian follicle. Each cell created by this meiosis has the same number of chromosomes, but the cytoplasm does not split equally. This causes a polar body to be produced along with a secondary oocyte.

Rationale 4: Primary spermatocytes contain 46 chromosomes (46XY). Each primary spermatocyte undergoes meiotic division into two haploid secondary spermatocytes (22X or 22Y). Haploid cells each contain half of the genetic material of the original cell. Then each secondary spermatocyte undergoes a second meiotic division into two haploid spermatids (remaining either 22X or 22Y.) Spermatids mature into spermatozoa. Thus, a primary spermatocyte eventually becomes four haploid spermatozoa.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Compare the processes by which ova and sperm are produced.

Question 3 Type: MCSA After teaching a class about the female reproductive system, the nurse asks the attendees to describe the process of meiosis. Which student response suggests successful comprehension of the material?

1. "Completion of the second meiotic division results in formation of three polar bodies and one ovum."

2. "At the time of ovulation, the first meiotic division begins."

3. "Completion of the first meiotic division produces three polar bodies and one primary oocyte."

4. "At the time of puberty, the second meiotic division begins."

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: Completion of the second meiotic division produces three polar bodies and one ovum.

Rationale 2: The first meiotic division of oocytes begins before the female fetus is born.

Rationale 3: Completion of the first meiotic division produces one polar body and one secondary oocyte.

Rationale 4: The second meiotic division begins at the time of ovulation.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Compare the processes by which ova and sperm are produced.

Question 4 Type: MCSA You are counseling a young woman regarding contraception. When asked if she currently uses any form of contraception, she replies, "I can't get pregnant because I don't have intercourse on the day I ovulate." Based upon her response, what information should you include in your teaching?

1. Refraining from intercourse on the day of ovulation will effectively prevent pregnancy.

2. Sperm are believed to be healthy and highly fertile for at least five days.

3. After ovulation, ova are considered fertile for about 72-96 hours.

4. Sperm survive 48-72 hours in the female reproductive tract.

Correct Answer: 4 Rationale 1: Because sperm survive 48-72 hours in the female reproductive tract, avoidance of intercourse for 24 hours will not reliably prevent pregnancy from occurring.

Rationale 2: Sperm are believed to be most fertile for the first 24 hours following entry into the female reproductive tract.

Rationale 3: Ova are considered fertile for about 12-24 hours after ovulation.

Rationale 4: Sperm survive 48–72 hours in the female reproductive tract.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Describe the components of the fertilization process and how each impacts fertilization.

Question 5 Type: MCSA When evaluating information taught about conception and fetal development, the patient verbalizes understanding about transportation time of the zygote through the fallopian tube and into the cavity of the uterus with which statement?

1. “It will take at least three days for the egg to reach the uterus.”

2. “It will take eight days for the egg to reach the uterus.”

3. “It will only take 12 hours for the egg to go through the fallopian tube.”

4. “It will take 18 hours for the fertilized egg to implant in the uterus.”

Correct Answer: 1 Rationale 1: It takes at least three days for the egg to reach the uterus.

Rationale 2: “It will take eight days for the egg to reach the uterus” is an incorrect interpretation of the information on conception.

Rationale 3: “It will only take 12 hours for the egg to go through the fallopian tube” is an incorrect interpretation of the information on conception.

Rationale 4: “It will take 18 hours for the fertilized egg to implant in the uterus” is an incorrect interpretation of the information on conception.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Describe the components of the fertilization process and how each impacts fertilization.

Question 6 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA If only a small volume of sperm is discharged into the vagina, an insufficient amount of enzymes might be released when sperm encounters the ovum. In that case, pregnancy would probably not result because: 1. Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus.

2. The block to polyspermy (cortical reaction) would not occur.

3. The fertilized ovum would be unable to implant in the uterus.

4. Sperm would be unable to penetrate the zona pellucida of the ovum.

Correct Answer: 4 Rationale 1: “Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus” is an incorrect statement.

Rationale 2: The answer choice of the block to polyspermy (cortical reaction) not occurring is incorrect because it is mediated by release of materials from cortical granules below the ovum’s surface and not the result of low sperm count.

Rationale 3: The fertilized ovum would be unable to implant in the uterus because fertilization is unlikely to occur with a low sperm count.

Rationale 4: Sperm would be unable to penetrate the zona pellucida of the ovum because it takes hundreds of acrosomes (the result of the acrosomal reaction) to rupture and release enough hyaluronic acid to clear the way for a single sperm to penetrate the ovum’s zona pellucida successfully.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Describe the components of the fertilization process and how each impacts fertilization.

Question 7 Type: MCSA The nurse is caring for a patient who is pregnant with twins. Which statement indicates the patient needs additional information?

1. “Because both of my twins are boys, I know that they are identical.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. “If my twins came from one fertilized egg that split, they are identical.”

3. “If I have one boy and one girl, I will know they came from two eggs.”

4. “It is rare for twins to both be within the same amniotic sac.”

Correct Answer: 1 Rationale 1: Not all same-sex twins are identical or monozygotic, because fraternal, or dizygotic, twins can be the same gender or different genders.

Rationale 2: When the zygote splits, identical twins share the same genotype result.

Rationale 3: The only way to have twins of different genders is if they came from two separate fertilized ova.

Monozygotic twins are identical and are the same gender.

Rationale 4: Monoamnionic-monochorionic twins are very rare and occur as a result of the zygote splitting seven or more days after fertilization.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed.

Question 8 Type: MCSA A pregnant patient asks you to describe the differences between monozygotic and dizygotic twins. Which statement should you include in your teaching?

1. Dizygotic twinning occurs less frequently than does monozygotic twinning.

2. Monozygotic twins originate from division of the fertilized ovum at different stages.

3. Dizygotic twins share one placenta and one chorion.

4. Monozygotic twins are also referred to as "fraternal" twins.

Correct Answer: 2 Rationale 1: Dizygotic twinning occurs more frequently than does monozygotic twinning.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Monozygotic twins originate from division of the fertilized ovum at different stages of early development.

Rationale 3: Dizygotic twins each have a separate chorion and amnion.

Rationale 4: Monozygotic twins are also referred to as "identical" twins.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed.

Question 9 Type: MCSA Which statement by a pregnant patient would indicate that additional teaching was necessary?

1. “Because of their birth relationship, fraternal twins are more similar to each other than if they had been born singly.”

2. “Identical twins can be the same or different sex.”

3. “Congenital abnormalities are more prevalent in identical twins.”

4. “Identical twins occur more frequently than fraternal twins.”

Correct Answer: 3 Rationale 1: Fraternal twins are not more similar to each other than if they had been born singly.

Rationale 2: Identical or monozygotic twins have identical chromosomal structures and therefore are always the same sex.

Rationale 3: Due to variations in the timing of the splitting of the embryo, congenital abnormalities such as conjoining are more common in monozygotic twins.

Rationale 4: Dizygotic, or fraternal, twins occur more frequently than do monozygotic twins.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed.

Question 10 Type: MCSA The nurse is creating a poster for pregnant mothers. Which description of fetal development does the nurse include?

1. Four layers of cells form after the embryo is at the ball stage.

2. After fertilization, the cells only become larger for several weeks.

3. Most organs are formed by 8 weeks after fertilization.

4. The embryonic stage is from fertilization until 5 months.

Correct Answer: 3 Rationale 1: Three primary germ layers form from the ball of undifferentiated cells called the blastocyst: ectoderm, mesoderm, and endoderm.

Rationale 2: After fertilization, the cells reproduce by mitosis, resulting in more cells, not larger cells.

Rationale 3: Most organs are formed during the embryonic stage, which lasts from the 15th day after fertilization until the end of the 8th week after fertilization.

Rationale 4: The embryonic stage begins on the 15th day after fertilization and ends at the completion of the 8th week after fertilization.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Summarize the processes that occur during the cellular multiplication and differentiation stages of intrauterine development and their effect on the structures that form.

Question 11 Type: MCSA The nurse is presenting an early pregnancy class to a group of pregnant women. Which statement indicates a need for further education? “The placenta: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “Develops and grows larger until about 20 weeks’ gestation.”

2. “Creates hormones and enzymes that are necessary during pregnancy.”

3. “Ages and becomes less permeable during the last month of pregnancy.”

4. “Floats in the amniotic sac and filters waste products from the fetus.”

Correct Answer: 4 Rationale 1: The chorionic villi of the placenta become more differentiated with time. The placenta grows in size until about 20 weeks. After this point, the placenta thickens but does not increase in size.

Rationale 2: The placenta creates glycogen, cholesterol, hormones such as human chorionic gonadotropin (hCG), and enzymes such as sulfatase and insulinase.

Rationale 3: The placenta is designed to last for 40 weeks, the average length of human gestation. The permeability to nutrients and oxygen begins to decrease starting at about 36 weeks as a part of the aging of the placenta.

Rationale 4: The placenta is attached to the uterine wall, and does not float in the amniotic sac. One function of the placenta is to filter metabolic waste products from the baby’s blood so that they can be excreted by the mother.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Describe the development, structure, and functions of the placenta and umbilical cord during intrauterine life (embryonic and fetal development).

Question 12 Type: MCSA The nurse is working with a patient who has experienced a fetal death in utero at 20 weeks. The patient asks what her baby will look like when it is delivered. Which statement by the nurse is the best response?

1. “Your baby will be covered in fine hair called lanugo.”

2. “Your child will have arm and leg buds, but not fully formed limbs.”

3. “A white, cheesy substance called vernix caseosa will be on the skin.”

4. “The genitals of the baby will be ambiguous.”

Correct Answer: 1 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Downy fine hair called lanugo covers a 20-week fetus.

Rationale 2: Limb buds have developed by 35 days post-fertilization. At 20 weeks, the fetus will have well developed well differentiated arms and legs.

Rationale 3: Vernix caseosa forms at about 24 weeks. This fetus is only 20 weeks and will not have vernix.

Rationale 4: The genitals are apparent by 12 weeks after fertilization. This fetus would have had specifically male or female genitals 8 weeks ago.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO07 - Contrast the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 36, and 40 weeks’ gestation.

Question 13 Type: MCSA At her first prenatal visit, the patient states, "I'm five weeks' pregnant now and I would like to hear my baby's heartbeat today." How should the nurse respond?

1. Prepare to assist with auscultation of the fetal heartbeat using a fetoscope.

2. Explain to the patient that the fetal heart does not begin to beat until approximately 7 weeks' gestation.

3. Anticipate that the patient will be scheduled for Doppler ultrasound.

4. Explain to the patient that the fetal heartbeat is not yet detectable at 5 weeks' gestation.

Correct Answer: 4 Rationale 1: Fetal heart tones can be identified through use of a fetoscope at approximately the 20th week of pregnancy.

Rationale 2: The fetal heart begins to beat by the 4th week of gestation.

Rationale 3: Generally, fetal heart tones cannot be heard until approximately the 8th week of pregnancy by ultrasound Doppler device.

Rationale 4: While the tubular heart begins to form during the 3rd week, fetal heart tones generally are not be detectable until at least 7 weeks' gestation.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Contrast the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 36, and 40 weeks’ gestation.

Question 14 Type: MCSA The patient at 18 weeks’ gestation thinks she might have been exposed to a toxin at work that could affect fetal development. The patient asks the nurse what organs might be affected at this point in pregnancy. The best response of the nurse is: 1. “The brain is developing now and could be affected.”

2. “Because you are in the second trimester, there is no danger.”

3. “The internal organs like the heart and lungs could be impacted.”

4. “It’s best to not worry about possible problems with your baby.”

Correct Answer: 1 Rationale 1: Maximum brain growth and myelination are occurring at this point in fetal development.

Rationale 2: Although the greatest danger from teratogens is during the embryonic stage (the first 8 weeks of pregnancy), the fetus at 20 weeks is still vulnerable to exposure to teratogens.

Rationale 3: The heart, lungs, and other internal organs form during the embryonic state, or the first 8 weeks of pregnancy. During their formation is when they are most likely to be affected by a teratogen.

Rationale 4: Avoid telling patients to not worry. Doing so indicates to the patient that you don’t care about their concerns and will end effective communication.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO08 - Compare the vulnerable periods during which malformations of the various organ systems may occur, resulting in congenital malformations.

Question 15 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCMA The nurse is preparing a preconception information class. Information about causes of fetal organ malformation in the first trimester will be presented. What prenatal influences on the intrauterine environment should be included in the instruction?

Standard Text: Select all that apply.

1. The use of saunas or hot tubs 2. The use of drugs 3. The quality of the sperm or ovum 4. Maternal nutrition 5. Age of the mother at conception Correct Answer: 1,2,4 Rationale 1: The use of saunas or hot tubs is associated with maternal hyperthermia and neural tube defects.

Rationale 2: Many drugs can have teratogenic effects.

Rationale 3: The quality of the sperm or ovum can affect fertility but not organ formation.

Rationale 4: Maternal nutrition, if deficient, can cause damage to the fetus. Vitamins and folic acid taken prior to and during the pregnancy can have beneficial effects.

Rationale 5: A maternal age of 35 or older is associated with genetic defects that occur at conception, not with first-semester organ malformation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO08 - Compare the vulnerable periods during which malformations of the various organ systems may occur, resulting in congenital malformations.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 05 Question 1 Type: MCSA The clinic nurse is returning phone calls. Which call should the nurse return first?

1. 22-year-old reporting that she has menstrual cramps and vomiting every month 2. 17-year-old asking if there is a problem with using one tampon for a whole day 3. 46-year-old mother of a teen wondering if her daughter should be on birth control 4. 34-year-old requesting information on douching after intercourse Correct Answer: 2 Rationale 1: Because vomiting can lead to dehydration, this patient will require further assessment. Because her symptoms are not life-threatening, this patient’s assessment is not the first priority.

Rationale 2: Using a single tampon for an entire day can lead to toxic shock syndrome, a potentially lifethreatening condition. This patient needs education on the danger of using one tampon more than 3–6 hours.

Rationale 3: A sexually active teen could be at risk for unintended pregnancy, as well as sexually transmitted infections. However, it is unclear whether the daughter is sexually active. This call is a low priority.

Rationale 4: Douching is not recommended, because the practice causes a change in the pH of the vagina and impacts the normal flora, predisposing patients to candidiasis and bacterial vaginosis. This patient requires education but is not the first priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Identify appropriate nursing care based on the results of the patient’s sexual history.

Question 2 Type: MCSA When taking a sexual history from a patient, the nurse should: 1. Ask questions that the patient can answer with a “yes” or “no.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Ask mostly open-ended questions.

3. Have the patient fill out a comprehensive questionnaire and review it after the patient leaves.

4. Try not to make much direct eye contact.

Correct Answer: 2 Rationale 1: “Yes-or-no” answers indicate closed-ended questions that will not encourage the patient to share the necessary information.

Rationale 2: Open-ended questions are often useful in eliciting information because they encourage more than a one-word answer.

Rationale 3: Filling out a questionnaire and reviewing it after the patient leaves is not appropriate. It should be reviewed in the presence of the patient, encouraging conversation regarding the results.

Rationale 4: It is helpful to use direct eye contact as much as possible, unless culturally unacceptable. Eye contact encourages a connection between the involved parties and shows care and concern.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Identify appropriate nursing care based on the results of the patient’s sexual history.

Question 3 Type: MCSA Which patient would the nurse document as exhibiting signs and symptoms of primary dysmenorrhea?

1. 17-year-old, has never had a menstrual cycle 2. 16-year-old, had regular menses for 4 years, but has had no menses in four months 3. 19-year-old, regular menses for 5 years that have suddenly become painful 4. 14-year-old, irregular menses for one year, experiences cramping every cycle Correct Answer: 4 Rationale 1: This is primary amenorrhea, or the lack of menses.

Rationale 2: Secondary amenorrhea is the term used when a patient has had regular cycles that cease.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Secondary dysmenorrheal is the sudden onset of pain and discomfort with menses.

Rationale 4: Primary dysmenorrhea is when menstruation has been painful from the first menstrual cycle and consistently continues to be painful each month.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO02 - Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation.

Question 4 Type: MCSA A patient asks her nurse, "Is it okay for me to use a vaginal douche each day when I'm on my period?" The nurse's correct response is: 1. "Douching should be avoided when you're on your period."

2. "Using a douche each day will help prevent vaginal infections from occurring."

3. "During your period, douching will help promote the flow of menstrual secretions."

4. "Regular douching is necessary in order to promote good hygiene."

Correct Answer: 1 Rationale 1: Women should avoid douching during menstruation because the cervix is dilated to permit the downward flow of menstrual fluids from the uterine lining.

Rationale 2: Douching washes away the natural mucus and upsets the vaginal flora, which can make the vagina more susceptible to infection.

Rationale 3: During menstruation, douching may interfere with downward flow of menstrual fluids from the uterine lining.

Rationale 4: Douching as a hygiene practice is unnecessary because the vagina cleanses itself.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO02 - Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation.

Question 5 Type: MCSA What should the gynecology clinic nurse recommend for the patient experiencing premenstrual syndrome?

1. “Eat more chocolate and drink more caffeine beginning a week prior to when your menstrual cycle bleeding should begin.”

2. “Engage in aerobic activity often throughout the month, and continue exercising when your symptoms begin.”

3. “Decrease your dietary intake of dairy and soy slightly during the month, and especially during your days of bleeding.”

4. “Increase your consumption of red meat when you feel symptoms, and eat three large meals per day.”

Correct Answer: 2 Rationale 1: Chocolate and caffeine contain methylxanthines; therefore, intake of chocolate, coffee, and colas should be limited throughout the month.

Rationale 2: Regular aerobic activity helps to decrease PMS symptoms.

Rationale 3: 1,200 mg of calcium per day can help decrease PMS symptoms. The calcium can either come from supplements or be obtained through dietary intake of dairy and soy products.

Rationale 4: Decreased red meat consumption can be beneficial to reduce PMS symptoms, as will eating several small meals per day rather than three large meals.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Discriminate between the signs, symptoms, and nursing management of women with dysmenorrhea and premenstrual syndrome.

Question 6 Type: MCSA A patient comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for two years. The most likely cause for the patient’s complaint is: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Primary dysmenorrhea.

2. Secondary dysmenorrhea.

3. Menorrhagia.

4. Hypermenorrhea.

Correct Answer: 2 Rationale 1: Primary dysmenorrhea is defined as cramps without underlying disease.

Rationale 2: Secondary dysmenorrhea is associated with pathology of the reproductive tract and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device.

Rationale 3: Menorrhagia is excessive, profuse flow.

Rationale 4: Hypermenorrhea is an abnormally long menstrual flow.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Discriminate between the signs, symptoms, and nursing management of women with dysmenorrhea and premenstrual syndrome.

Question 7 Type: MCMA Which issues should the nurse consider when counseling a patient on contraceptive methods?

Standard Text: Select all that apply.

1. Cultural perspectives on menstruation and pregnancy 2. Efficacy of the method 3. Future childbearing plans 4. Whether the patient is a vegetarian 5. Age at menarche Correct Answer: 1,2,3 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Cultural and religious beliefs, practices, and sanctions must be considered when discussing contraception with patients in order to avoid insulting a patient for whom a particular type of contraceptive method is prohibited by her background.

Rationale 2: Efficacy of contraceptive methods varies and must be considered when discussing contraception with patients. When pregnancy is medically contraindicated, high-efficacy methods (such as an IUD, hormonal methods, or sterilization) should be discussed with the patient. When the patient would like to avoid pregnancy at this time, but pregnancy is not medically contraindicated, lower-efficacy methods (such as diaphragm, cervical cap, or Today sponge) could be discussed.

Rationale 3: If a patient desires children in the future, sterilization methods would be inappropriate to discuss.

Rationale 4: Vegetarianism has no impact on contraceptive method use.

Rationale 5: Age at menarche has no impact on contraceptive method use.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

Question 8 Type: MCSA A patient has decided to use the NuvaRing vaginal contraceptive ring as her method of contraception. Which statement suggests the patient needs further instruction?

1. "I do not need to be examined in order to determine the contraceptive ring size that is correct for me."

2. "Every three months, I will need to remove the contraceptive ring and replace it with a new one."

3. "When I store my replacement rings, I should keep them in my refrigerator."

4. "The contraceptive ring provides a sustained release of low-dose contraceptive."

Correct Answer: 2 Rationale 1: One size of the NuvaRing fits virtually all women.

Rationale 2: The ring is left in place for 3 weeks and then removed for 1 week to allow for withdrawal bleeding.

Rationale 3: Replacement rings should be kept in the refrigerator to maintain integrity.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: The contraceptive ring provides a low-dose, sustained-release hormonal contraceptive.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

Question 9 Type: MCSA Which patient is not a good candidate for Depo-Provera (DMPA)?

1. One who wishes to get pregnant within three months 2. One who wishes to breastfeed 3. One with a vaginal prolapse 4. One who weighs 200 pounds Correct Answer: 1 Rationale 1: Return of fertility after the use of Depo-Provera takes an average of nine months.

Rationale 2: Studies have proven there is no harm to a breastfed baby when a woman uses Depo-Provera.

Rationale 3: There is no correlation between a vaginal prolapse and use of Depo-Provera.

Rationale 4: There is no correlation between one’s weight and use of Depo-Provera.

Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

Question 10 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The Public Health Nurse receives a phone call from a 16-year-old girl who asks, "Do I need to have a Pap smear just because I'm sexually active?" What is the nurse's correct response?

1. "Yes, all sexually active females should be screened for both cervical cancer and HPV.” 2. "No, you do not need to be screened for cervical cancer until you are 21 years old."

3. "Yes, all women under the age of 29 should be screened for both cervical cancer and HPV." 4. "No, but you will need to begin your screenings for both cervical cancer and HPV when you are 18 years old."

Correct Answer: 2 Rationale 1: Engaging in sexual activity is not an indication for routine cervical cancer or for HPV screening.

Rationale 2: 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend initiating cervical cancer screening at age 21.

Rationale 3: 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend cervical cancer screening without HPV co-testing in women ages 21 to 29.

Rationale 4: 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend initiating cervical cancer screening at age 21.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Delineate basic gynecologic screening procedures indicated for well women.

Question 11 Type: MCMA A nurse is providing a patient with instructions regarding breast self-examination (BSE). Which of the following statements by the patient would indicate the likelihood that she understands how to detect changes such as lumps in her breast?

Standard Text: Select all that apply.

1. “I should perform BSE one week prior to the start of my period.”

2. “When I reach menopause, I will perform BSE every two months.”

3. “Knowing the texture and feel of my breasts is important.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “I should inspect my breasts in a circular manner.”

5. “I should inspect my breasts while in a supine position, with my arms at my sides.”

Correct Answer: 3,4 Rationale 1: BSE should be performed one week after the start of each menstrual period because hormonal levels are lowest and allow closer exam of softer breast tissue.

Rationale 2: BSE should be performed monthly, on the same day each month, during menopause.

Rationale 3: A woman who knows the texture and feel of her own breasts is far more likely to detect changes that develop.

Rationale 4: Checking breasts in a circular manner, feeling all parts of the breast, provides adequate palpation and possible detection of lumps.

Rationale 5: The breasts should be inspected while standing with arms at sides.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Delineate basic gynecologic screening procedures indicated for well women.

Question 12 Type: MCSA What is the best indicator that the patient is experiencing menopause?

1. No menses for 8 consecutive months 2. Hot flashes and night sweats 3. High serum FSH with low serum estrogen 4. Diagnosed with osteoporosis 4 months ago Correct Answer: 3 Rationale 1: Menopause is defined as 12 months of amenorrhea.

Rationale 2: Although hot flashes and night sweats are common in menopause, lab values or twelve months of amenorrhea are better indicators.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Examining serum levels of the hormones FSH and estrogen is a very accurate indication of menopause.

Rationale 4: Menopause is not the only cause of osteoporosis; therefore, the diagnosis of osteoporosis 4 months ago is not an indicator of menopause.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Explain the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women.

Question 13 Type: MCSA A 63-year-old female patient requests information about complementary and alternative therapies that promote wellness during menopause. Which therapies should the nurse recommend?

1. Non-weight-bearing exercise, such as swimming.

2. Increased consumption of phytoestrogens (i.e., plant products with estrogen properties) for women with a history of endometeriosis or fibroids.

3. Calcium intake of 600 mg per day to help prevent osteoporosis.

4. Soy for reducing insomnia symptoms.

Correct Answer: 4 Rationale 1: Weight-bearing exercises such as walking, jogging, tennis, and low-impact aerobics are encouraged in order to increase bone mass and decrease the risk of osteoporosis.

Rationale 2: Women who have endometriosis or fibroids should be cautioned on the use of phytoestrogens Rationale 3: Peri- and postmenopausal women are advised to have a calcium intake of at least 1200 mg per day.

Most women require supplements to achieve this level.

Rationale 4: Research suggests that isoflavones, which are found in soy, are effective in reducing symptoms of insomnia in postmenopausal women.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Explain the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women.

Question 14 Type: MCSA The nurse is presenting a session on intimate partner violence. Which statement indicates a need for further education?

1. “My daughter is not to blame for the violence in her marriage.”

2. “Everyone experiences anger and hitting in a relationship.”

3. “Abusers can be either husbands or boyfriends or girlfriends.”

4. “The ‘honeymoon period’ follows an episode of violence.”

Correct Answer: 2 Rationale 1: The victims of violence are not the cause of the violence. Abusers are responsible for their violent behavior. Avoiding blaming and shaming of victims of domestic violence is important to establish a therapeutic relationship.

Rationale 2: Violence is not a normal part of intimate relationships. This statement indicates that the patient has likely been a victim of domestic violence.

Rationale 3: Abusers can be spouses or boyfriends or girlfriends. Intimate partner violence can be experienced in any intimate relationship, regardless of whether the couple is straight, gay, or lesbian, and both within marriage and outside of marriage.

Rationale 4: An acute episode of battering is followed by the tranquil phase, or honeymoon period, when the abuser is often repentant and promising never to abuse the victim again. In some cases, the honeymoon period is the only time there is a lack of building tension.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Examine the nurse’s role in screening and caring for women who have experienced domestic violence or rape.

Question 15 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA When a woman who has been raped is admitted to the emergency department, which nursing intervention has priority?

1. Explain exactly what will need to be done to preserve legal evidence.

2. Assure the woman that everything will be all right.

3. Create a safe, secure atmosphere for the woman.

4. Contact family members.

Correct Answer: 3 Rationale 1: Explaining exactly what will need to be done to preserve legal evidence is not the top priority.

Rationale 2: Assuring the woman that everything will be all right is not the top priority and is giving false promise.

Rationale 3: The first priority in caring for a survivor of a sexual assault is to create a safe, secure atmosphere that will allow the woman to process what has happened.

Rationale 4: Contacting family members is not the top priority and can wait until a safe environment is established.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Examine the nurse’s role in screening and caring for women who have experienced domestic violence or rape.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 06 Question 1 Type: MCSA The nurse is teaching a class to women who were recently diagnosed with benign breast disease (BBD), commonly known as fibrocystic breast disease. One of the participants reports increased swelling, pain, and pressure in her breasts just before menstruation. What is the best response by the nurse?

1. “Consider asking your nurse practitioner about adding a mild diuretic to your regimen.”

2. “The pain may be caused by thinning of the normal breast tissue.”

3. “Breast swelling and pressure are expected symptoms, but pain is abnormal and should be evaluated by your physician.”

4. “It's best to make an appointment with an oncologist.”

Correct Answer: 1 Rationale 1: Treatment of BBD may include taking a mild diuretic during the week prior to the onset of menses to counteract fluid retention, relieve pressure in the breast, and help decrease pain.

Rationale 2: The pathology of BBD involves fibrosis, which is a thickening of the normal breast tissue.

Rationale 3: Common symptoms associated with BBD include cyclical breast pain, tenderness, and swelling.

Rationale 4: Cyclical breast pain, swelling, and tenderness are common symptoms associated with BBD. Generally fibrocystic changes are not a risk factor for breast cancer.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Contrast the contributing factors, signs and symptoms, treatment options, and nursing care management of women with common benign breast disorders.

Question 2 Type: MCSA The nurse is caring for a patient diagnosed with endometriosis. Which statement by the patient requires immediate follow-up?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “I am having many hot flashes since I had the Lupron injection.”

2. “The pain I experience with intercourse is becoming more severe.”

3. “My leg has become painful and swollen since I started taking birth control pills.”

4. “I’ve noticed my voice is lower since I started taking danazol.”

Correct Answer: 3 Rationale 1: Leuprolide acetate (Lupron) is a GnRH agonist and causes symptoms of a hypo-estrogenic state (hot flashes, vaginal dryness, decreased libido, and bone density loss). Hot flashes are expected and not a complication.

Rationale 2: Dyspareunia is a common symptom of endometriosis and therefore is not a complication.

Rationale 3: Combination oral contraceptive pills contain estrogen. A painful, swollen lower extremity can be a sign of deep vein thrombosis, which can cause thromboembolus, which is potentially life threatening. This is a complication and must be addressed immediately.

Rationale 4: Danocrine (danazol) is a testosterone derivative that suppresses GnRH and has high-androgen and low-estrogen effects. A lowered voice is one side effect of danazol. This patient is not experiencing a complication.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Explain the signs and symptoms, medical therapy, and implications for fertility of endometriosis.

Question 3 Type: MCSA The nurse is creating a care plan for a patient who is unable to conceive as a consequence of endometriosis.

Which statement accurately reflects a nursing diagnosis that may apply to the care of this patient?

1. Acute pain related to dysuria and renal pain secondary to endometriosis 2. Hyperandrogenism related to elevated serum androgen levels secondary to endometriosis 3. Compromised family coping related to depression secondary to infertility 4. Infertility related to endometrial inflammation and adhesions secondary to endometriosis Correct Answer: 3 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Pelvic pain is a frequent symptom of endometriosis, while dysuria and renal pain are more commonly associated with conditions such as upper urinary tract infections (UTI).

Rationale 2: Hyperandrogenism is a medical diagnosis that pertains to elevated serum androgen levels.

Hyperandrogenism is associated with polycystic ovarian syndrome (PCOS).

Rationale 3: Infertility may lead to depression and subsequent compromised family coping, which is a nursing diagnosis.

Rationale 4: Although associated with the medical condition of endometriosis, infertility is a medical diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO02 - Explain the signs and symptoms, medical therapy, and implications for fertility of endometriosis Question 4 Type: MCSA The patient has been diagnosed with endometriosis. She asks the nurse if there are any long-term health risks associated with this condition. The nurse should include which statement in the patient teaching about endometriosis?

1. “There are no other health risks associated with endometriosis.”

2. “Pain with intercourse rarely occurs as a long-term problem.”

3. “You are at increased risk for ovarian and breast cancer.”

4. “Most women with this condition develop fibromyalgia.”

Correct Answer: 3 Rationale 1: There are long-term health risks associated with endometriosis, including increased risk for cancer of the ovary and breast, melanoma, non-Hodgkins lymphoma, and an increased incidence of fibromyalgia.

Rationale 2: Dyspareunia is a common symptom of endometriosis.

Rationale 3: An increased risk for cancer of the ovary and breast is associated with endometriosis.

Rationale 4: There is a risk of increased incidence of fibromyalgia.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Explain the signs and symptoms, medical therapy, and implications for fertility of endometriosis.

Question 5 Type: MCSA A patient diagnosed with polycystic ovarian disease (PCOS) asks her nurse why her treatment regimen includes spironolactone (Aldactone). How should the nurse respond?

1. "Spironolactone may be used to decrease symptoms associated with PCOS, such as excessive hair growth and acne."

2. "Menstrual irregularities related to polycystic ovarian disease are treated using spironolactone."

3. "Spironolactone is often used to reduce complications associated with PCOS, including rectocele."

4. "Condylomata acuminata, which are sometimes caused by polycystic ovarian disease, are treated with spironolactone."

Correct Answer: 1 Rationale 1: Spironolactone may be used to treat symptoms of hyperandrogenism that are secondary to PCOS, including excessive hair growth and acne.

Rationale 2: Combined oral contraceptive (COC) or cyclic progesterone are used to treat menstrual irregularities associated with PCOS. Rationale 3: A rectocele, which may develop when the posterior vaginal wall is weakened, is associated with pelvic relaxation.

Rationale 4: Condylomata acuminata, also called genital or venereal warts, is a sexually transmitted condition unrelated to PCOS. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Discuss the signs and symptoms, diagnosis criteria, treatment options, and health implications of polycystic ovarian syndrome (PCOS).

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 6 Type: MCMA The nurse is planning a group session for parents who are beginning infertility evaluation. Which statement should be included in this session?

Standard Text: Select all that apply.

1. “Infertility can be stressful for a marriage.”

2. “The doctor will be able to tell why you have not conceived.”

3. “Your insurance will pay for the infertility treatments.”

4. “Keep communicating with one another through this process.”

5. “Taking a vacation usually results in pregnancy.”

Correct Answer: 1,4 Rationale 1: Infertility is often stressful on a marriage, as a result of the need to schedule intercourse and pay for treatments and the societal expectation to have children.

Rationale 2: Some infertility cannot be explained, despite extensive treatments.

Rationale 3: Insurance often does not pay for infertility treatment.

Rationale 4: Communication is important to help cope with stress. A nurse should always encourage patients to ask questions.

Rationale 5: A common myth is that taking a vacation or just relaxing will result in conception.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Explain the signs and symptoms, medical therapy, and implications for fertility of endometriosis.

Question 7 Type: MCSA Which patient in the gynecology clinic should the nurse see first?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. 22-year-old, using tampons, T=102°F, P=122, BP=70/55 2. 15-year-old, no menses for past four months 3. 18-year-old seeking information on contraception methods 4. 31-year-old, reports increasing dyspareunia Correct Answer: 1 Rationale 1: A patient using tampons who is febrile, tachycardic, and hypotensive might have toxic shock syndrome. Hypotension is life-threatening; this patient should be seen immediately.

Rationale 2: Secondary amenorrhea can be caused by pregnancy. Teen pregnancy is a high risk, but no indication is given that the patient is exhibiting a life-threatening condition.

Rationale 3: Unplanned pregnancy and sexually transmitted infections can be problematic in the future, but this patient exhibits no signs or symptoms of a life-threatening condition at this time.

Rationale 4: Although this patient might have endometriosis, dyspareunia is not a life-threatening condition.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Identify the risk factors, treatment options, and nursing interventions for a woman with toxic shock syndrome.

Question 8 Type: MCSA Which statement indicates that patient teaching has been effective?

1. “I should douche weekly to prevent a recurrence of my bacterial vaginosis.”

2. “I can use this anti-yeast medication weekly to prevent another infection.”

3. “My diabetes is unrelated to the frequency of my vaginal yeast infections.”

4. “The fishy vaginal odor I have is caused by a bacterial infection.”

Correct Answer: 4 Rationale 1: Douching disrupts normal flora by washing out desirable bacteria; douching is not recommended.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Medication for vaginal yeast infections should be used as treatment, not prophylaxis. Using medication as prescribed is important patient education. Medication should not be saved for future use.

Rationale 3: Yeast vaginitis is more common in diabetic and pre-diabetic women. Four episodes or more per year of yeast vaginitis are an indication to screen a woman for diabetes.

Rationale 4: Bacterial vaginosis is characterized by a fishy vaginal odor and greenish discharge with a vaginal pH over 4.5.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Compare the causes, signs and symptoms, treatment options, and nursing care for women with vulvovaginal candidiasis versus bacterial vaginosis.

Question 9 Type: MCSA Which patient is at greatest risk for developing Chlamydia trachomatis infection?

1. 16-year-old, sexually active, using no contraceptive 2. 22-year-old mother of two, developed dyspareunia 3. 35-year-old woman on oral contraceptives 4. 48-year-old woman with hot flashes and night sweats Correct Answer: 1 Rationale 1: Teens have the highest incidence of sexually transmitted infections, especially Chlamydia. A patient not using contraceptives is not using condoms, which decrease the risk of contracting a STI. Rationale 2: Dyspareunia sometimes develops with Chlamydia infection, but dyspareunia is not a symptom specific to Chlamydia.

Rationale 3: There is no correlation between oral contraceptive use and an increased rate of Chlamydia infection.

Additionally, Chlamydia is more commonly seen in young women Rationale 4: This patient is experiencing signs of menopause, not Chlamydia infection.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Compare the prevention, causes, treatment, signs and symptoms, treatment options, and nursing care of women for the common sexually transmitted infections.

Question 10 Type: MCSA The physician has prescribed metronidazole (Flagyl) for a woman diagnosed with trichomoniasis. The nurse’s instructions to the woman should include: 1. “Both partners must be treated with the medication.”

2. “Alcohol does not need to be avoided while taking this medication.”

3. “It will turn your urine orange.”

4. “This medication could produce drowsiness.”

Correct Answer: 1 Rationale 1: Both partners should be treated with the medication.

Rationale 2: Alcohol should be avoided.

Rationale 3: Metronidazole does not turn the urine orange.

Rationale 4: Metronidazole does not cause drowsiness.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare the prevention, causes, treatment, signs and symptoms, treatment options, and nursing care of women for the common sexually transmitted infections.

Question 11 Type: MCMA The couple demonstrates understanding of the consequences of not treating Chlamydia when they state: Standard Text: Select all that apply.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “She could become pregnant.”

2. “She could have severe vaginal itching.”

3. “He could get an infection in the tube that carries the urine out.”

4. “It could cause us to develop rashes.”

5. “She could develop a worse infection of the uterus and tubes.”

Correct Answer: 3,5 Rationale 1: Chlamydia does not cause a woman to become pregnant.

Rationale 2: Chlamydia does not cause vaginal itching.

Rationale 3: Chlamydia is a major cause of nongonococcal urethritis (NGU) in men.

Rationale 4: Chlamydia does not cause a rash.

Rationale 5: Chlamydia cervicitis can ascend and become pelvic inflammatory disease, or infection of the uterus, fallopian tubes, and sometimes ovaries.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Compare the prevention, causes, treatment, signs and symptoms, treatment options, and nursing care of women with common sexually transmitted infections.

Question 12 Type: MCSA Which of the following patients should be treated with ceftriaxone (Rocephin) IM and doxycycline (Vibramycin) orally?

1. A pregnant patient with gonorrhea and a yeast infection 2. A non-pregnant patient with gonorrhea and Chlamydia 3. A pregnant patient with syphilis 4. A non-pregnant patient with Chlamydia and trichomoniasis Correct Answer: 2 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Doxycycline is contraindicated during pregnancy.

Rationale 2: This combined treatment provides dual treatment for gonorrhea and Chlamydia because the two infections frequently occur together.

Rationale 3: Syphilis is treated with penicillin.

Rationale 4: Trichomoniasis is treated with metronidazole.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare the prevention, causes, treatment, signs and symptoms, treatment options, and nursing care of women for the common sexually transmitted infections.

Question 13 Type: MCSA The nurse is preparing a brochure that compares and contrasts cystitis and pyelonephritis. Which information should be included in the brochure?

1. Both conditions usually present with sudden onset of chills, high temperature, and flank pain.

2. Dysuria, especially at the end of urination, is often the initial symptom of both conditions.

3. Both conditions are associated with pregnancy complications including increased risk of preterm birth and of intrauterine growth restriction.

4. Urine culture is included in the evaluation of both cystitis and pyelonephritis.

Correct Answer: 4 Rationale 1: Acute pyelonephritis has a sudden onset, with chills, high temperature, and flank pain (either unilateral or bilateral).

Rationale 2: The initial symptom of cystitis is often dysuria, specifically at the end of urination.

Rationale 3: Pyelonephritis during pregnancy is associated with an increased risk of preterm birth and intrauterine growth restriction.

Rationale 4: Diagnosis of cystitis is made with a urine culture. Women with acute pyelonephritis should have a urine culture and sensitivity done to determine the appropriate antibiotic.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO09 - Contrast the causes, signs and symptoms, treatment options, and nursing care for women with cystitis versus pyelonephritis.

Question 14 Type: MCMA The nurse is discharging a patient after hospitalization for pelvic inflammatory disease (PID). Which statements indicate that teaching was effective?

Standard Text: Select all that apply.

1. “I might have infertility because of this infection.”

2. “It is important for me to finish my antibiotics.”

3. “Tubal pregnancy could occur after PID.” 4. “My PID was caused by a yeast infection.”

5. “I am going to have an IUD placed for contraception.”

Correct Answer: 1,2,3 Rationale 1: Women sometimes become infertile because of scarring in the fallopian tubes as a result of the inflammation of PID. Rationale 2: Antibiotic therapy should always be completed when a patient is diagnosed with any infection.

Rationale 3: The tubal scarring that occurs from tubal inflammation during PID can prevent a fertilized ovum from passing through the tube into the uterus, causing an ectopic or tubal pregnancy.

Rationale 4: PID is caused by bacteria, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae. Yeast infections do not ascend and become upper reproductive tract infections.

Rationale 5: An intrauterine device (IUD) in place increases the risk of developing PID; a patient who has a history of PID is not a good candidate for an IUD. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathology, signs and symptoms, treatment, and nursing care.

Question 15 Type: MCSA Which of the following diagnostic tests would the nurse question when ordered for a patient diagnosed with pelvic inflammatory disease (PID)?

1. CBC (complete blood count) with differential 2. Vaginal culture for Neisseria gonorrhoeae 3. Throat culture for Streptococcus A 4. RPR (rapid plasma reagin) Correct Answer: 3 Rationale 1: CBC with differential will give an indication of the severity of the infection.

Rationale 2: Gonorrhea is a common cause of PID, and the patient should be tested for this.

Rationale 3: Streptococcus of the throat is not associated with PID. Rationale 4: RPR is a test for syphilis, another cause of PID. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathology, signs and symptoms, treatment, and nursing care.

Question 16 Type: MCSA The nurse is to tell a patient that her Pap smear result was abnormal. Which statement should the nurse include?

1. “The Pap smear is used to diagnose cervical cancer.”

2. “A loop electrosurgical excision procedure (LEEP) is needed.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “Colposcopy to further examine your cervix is the next step.”

4. “Your cervix needs to be treated with cryotherapy.”

Correct Answer: 3 Rationale 1: The Pap smear is a screening tool for cervical abnormalities; it is not diagnostic.

Rationale 2: Although LEEP (the removal of the surface tissue of the cervix) might be performed to treat cervical dysplasia or carcinoma in situ, this patient has not had a diagnostic examination yet.

Rationale 3: Colposcopy is an examination of the cervix through a magnifying device. Solutions are often painted onto the cervix and surrounding tissue and observed for changes secondary to the application of the solution.

Biopsy samples are taken of suspected abnormal tissue and sent for pathologic examination and diagnosis.

Endocervical canal biopsy is often undertaken with colposcopy.

Rationale 4: Cryotherapy, or freezing of the cervix, is one treatment option for precancerous cervical lesions.

However, this patient does not yet have a diagnosis; she has only had an abnormal screening test.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Compare the cause and implications of an abnormal finding during a pelvic examination in the provision of nursing care.

Question 17 Type: MCSA The nurse is preparing an education session for women on prevention of urinary tract infections (UTIs). Which statement should be included?

1. Lower urinary tract infections rarely occur in women.

2. The most common causative organism of cystitis is E. coli.

3. Wiping from back to front after a BM will help prevent a UTI. 4. Back pain often develops with a lower urinary tract infection.

Correct Answer: 2 Rationale 1: About 60% of women will experience an episode of cystitis during their lifetime.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Because E. coli is a common bacterium in the bowel and the female urethra is short and close to the anus, cross-contamination of bowel bacteria into the female urinary tract is common.

Rationale 3: Wiping from back to front increases the risk of UTIs because the E. coli of the bowel is being drawn towards the urethra. Women should be instructed always to wipe from front to back.

Rationale 4: Low back or flank pain is a sign of pylonephritis, which is an upper urinary tract infection. Signs of a lower UTI include dysuria, urinary frequency, and urinary urgency.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO09 - Contrast the causes, signs and symptoms, treatment options, and nursing care for women with cystitis versus pyelonephritis.

Question 18 Type: MCSA The nurse is caring for a patient who underwent a total abdominal hysterectomy with bilateral salpingooophorectomy several hours ago. The highest priority for the nurse is to: 1. Monitor blood pressure and pulse.

2. Assess the patient’s acceptance of not being able to have children.

3. Teach the patient how to splint her abdomen while taking deep breaths.

4. Verify that the IV pump is working correctly.

Correct Answer: 1 Rationale 1: A post-surgical patient is at risk for internal bleeding at the site of the surgery. Monitoring blood pressure and pulse is necessary to verify that the patient is hemodynamically stable.

Rationale 2: Although this patient will not be able to become pregnant because of the surgery, acceptance is a psychosocial issue and a lower priority than is physiologic stability.

Rationale 3: Splinting while deep-breathing is a comfort measure to facilitate oxygenation and prevent atelectasis.

But hemodynamic stability is a higher priority.

Rationale 4: The patient needs IV fluids to replace blood loss during surgery and until oral intake is adequate. But hemodynamic stability is a higher priority.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO10 - Describe the nursing care management of a woman requiring a hysterectomy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 07 Question 1 Type: MCSA A patient who has been unable to conceive asks the nurse if it is her fault or her husband’s fault that they have not been able to become pregnant. The best response by the nurse is: 1. “The male infertility factors are more common than female.”

2. “Female infertility issues are more common than male issues.”

3. “The testing the doctor will order will determine who is at fault.”

4. “We will know more about what is causing your infertility after some tests are done.”

Correct Answer: 4 Rationale 1: This statement is not true. Because of the complexity of ovulation and maintaining a pregnancy, it is more likely that a female issue is causing the infertility. Regardless, using the term “at fault” is blaming and should be avoided.

Rationale 2: Although this statement is true because of the complexity of ovulation and maintaining a pregnancy, using the term “at fault” is blaming and should be avoided.

Rationale 3: Testing will determine what the infertility issue is, but using the term “at fault” is blaming and should be avoided.

Rationale 4: This is a factual answer that avoids using the term “at fault.” This statement is therapeutically worded and therefore is the best answer.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Compare the essential components of fertility with the possible causes of infertility.

Question 2 Type: MCSA The patient experiencing infertility is to complete three months of documenting her basal body temperatures.

Which statement by the patient indicates a need for additional teaching?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “I should check my temperature with this special thermometer before I get out of bed each day.”

2. “I will track my temperatures and the consistency of my cervical mucus for the next three months.”

3. “If I am ovulating, my temperature will be a smooth, even line on the graph that does not go up or down.”

4. “The point of checking my basal body temperature is to determine whether I am ovulating regularly.”

Correct Answer: 3 Rationale 1: The basal body temperature is most accurate prior to arising each day. A thermometer with larger spaces between tenths of a degree is used to facilitate accurate recording.

Rationale 2: Taking the temperature each morning will help detect ovulation. Checking cervical mucus daily for changes in consistency and stretchiness is another method to detect ovulation. Combining the two methods gives better information on when ovulation is occurring than one method does alone.

Rationale 3: A flat line on the graph is a monophasic cycle indicating a lack of ovulation. An ovulating woman will have a biphasic pattern to her basal body temperature. The temperature will drop slightly prior to ovulation, and rise about .5–1.0°F as ovulation occurs, remaining elevated if conception occurs or dropping just prior to onset of menses.

Rationale 4: Basal body temperatures are less predictive of when ovulation occurs, but an increase in the latter half of the cycle indicates that ovulation has occurred.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Describe the elements of the preliminary investigation of infertility and the nurse’s role in supporting/teaching patients during this phase.

Question 3 Type: MCSA A 31-year-old woman with normal ovaries, a normal prolactin level, and an intact pituitary gland is undergoing initial pharmacologic treatment of anovulation. Which medication would the nurse anticipate being prescribed for this patient?

1. Clomiphene citrate (Clomid or Serophene) 2. Glucophage (Metformin) 3. Human menopausal gonadotropins (hMGs) Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Bromocriptine (Parlodel) Correct Answer: 1 Rationale 1: Clomiphene citrate (Clomid or Serophene) is a common first-line therapy for inducing ovulation in women with normal ovaries, normal prolactin level, and intact pituitary gland.

Rationale 2: Oral hypoglycemic agents such as glucophage (Metformin) are used for inducing ovulation in women with polycystic ovary disease (PCOS).

Rationale 3: Human menopausal gonadotropins (hMGs) is a second line of therapy in women who fail to ovulate or conceive with clomiphene citrate therapy.

Rationale 4: Bromocriptine (Parlodel) is used to treat hyperprolactinemia accompanied by anovulation.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Compare the indications for the tests with the associated treatments, including assisted reproductive technologies, that are done in an infertility workup.

Question 4 Type: MCSA A nurse is reviewing the basal body temperature method with a couple. Which of the following statements would indicate that the teaching has been successful?

1. “I have to go buy a special type of thermometer.”

2. “I need to wait five minutes after smoking a cigarette before I take my temperature.”

3. “I need to take my temperature before I get out of the bed in the morning.”

4. “I need to take my temperature for at least two minutes every day.”

Correct Answer: 3 Rationale 1: The temperature can be taken with a standard oral or rectal thermometer.

Rationale 2: In the basal body temperature method, the woman takes her temperature every day before starting any activity, including smoking.

Rationale 3: In the basal body temperature method, the woman takes her temperature every day before arising.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: In the basal body temperature method, the woman takes her temperature every day for five minutes.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Compare the indications for the tests and associated treatments, including assisted reproductive technologies, that are done in an infertility workup.

Question 5 Type: MCSA A patient calls his urologist's office to clarify instructions about semen analysis. The nurse should instruct the patient to: 1. Remain abstinent for 3 days prior to collecting the specimen.

2. Use a lubricant while obtaining the semen specimen.

3. Immediately refrigerate the specimen for a maximum of 8 hours.

4. Deliver the specimen to the laboratory within 1 hour of collection.

Correct Answer: 1 Rationale 1: To obtain accurate results of a semen analysis, the specimen is collected after 3 days of abstinence.

Rationale 2: Most lubricants also are spermicidal and should not be used unless approved by the andrology laboratory.

Rationale 3: If the specimen is obtained at home, it needs kept at body temperature and delivered to the lab within 1 hour so as not to impair motility.

Rationale 4: If the specimen is obtained at home, it needs to be delivered to the lab within 1 hour so as not to impair motility.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Compare the indications for the tests with the associated treatments, including assisted reproductive technologies that are done in an infertility workup.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 6 Type: MCMA The patient undergoing infertility treatment reports to the nurse that her partner is angry all of the time since beginning treatment and is very negative in comments made about the likelihood of their achieving pregnancy.

The patient states, “I was angry and depressed, but now I am dedicated to following through with treatment and hoping we get pregnant.” What is the best interpretation of these comments? The partner is: Standard Text: Select all that apply.

1. Exhibiting signs of the anger stage of grieving the loss of their dreams of having children.

2. In a different stage of grief than the patient.

3. Having difficulty accepting the reality of their infertility.

4. Showing that he will not be a good parent.

5. Feeling guilty about not being able to father a child.

Correct Answer: 1,2 Rationale 1: The patient’s description of her partner correlates with the anger stage of grief. Couples often experience the stages of grief when infertility is diagnosed because childbearing is an expected outcome in marriage; the inability to become pregnant is the loss of the dream of parenthood.

Rationale 2: The patient is in acceptance stage of grief, while the partner is in the anger stage. It is common and normal for families to be in different stages of the grieving process.

Rationale 3: The partner is in the anger stage of grief. Lack of acceptance would manifest as not believing that the diagnosis is correct.

Rationale 4: Being in the anger stage of grief is expected and normal and has no bearing on parenting ability.

Rationale 5: Guilt would manifest as feelings that it is his fault that pregnancy has not yet occurred. The patient is describing anger.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO04 - Explain the physiologic and psychologic effects of infertility on a couple to the nursing care management of the couple.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 7 Type: MCSA The nurse manager is interviewing nurses for a position in an infertility clinic. Which statement best indicates that the interviewee understands the role of the nurse when working with infertile patients?

1. “My job will be teaching patients how to take their medications and scheduling tests.”

2. “Much of my duties will involve forming therapeutic relationships with patients struggling with infertility.”

3. “This position is an assistant to the physician during diagnostic testing for infertility.”

4. “I will both teach and support families struggling with emotions as they attempt to become pregnant.”

Correct Answer: 4 Rationale 1: Although teaching and facilitating scheduling are important, the emotions that families deal with during treatment for infertility must also be addressed.

Rationale 2: Although this response addresses the emotional aspects of infertility, it does not mention providing support or teaching, which are also major components of the job.

Rationale 3: Some assisting might be a part of this position; the role of the RN in an infertility clinic involves much teaching and providing emotional support to infertile patients.

Rationale 4: This answer addresses the two main aspects of the RN working with infertile patients: emotional support and education.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Describe the nurse’s role as counselor, educator, and advocate for couples during infertility evaluation and treatment.

Question 8 Type: MCSA Which patient(s) should the nurse refer to a genetics practitioner prior to attempting pregnancy?

1. 32-year-old woman and 29-year-old man with 3-year-old twins 2. 22-year-old woman whose sister has Tay-Sachs disease Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. 30-year-old woman whose husband has AIDS 4. 19-year-old woman whose sister has primary infertility Correct Answer: 2 Rationale 1: This patient has no indication of having a genetic problem.

Rationale 2: Tay-Sachs disease is an autosomal recessive condition; therefore, if the patient’s sister has the disease, the patient could be a carrier for the condition.

Rationale 3: The risk for this patient is becoming infected with HIV while attempting conception. This couple has no indication of a genetic condition.

Rationale 4: Primary infertility is not likely to be caused by a genetic defect that could be carried by a sibling.

This patient has no indication of a genetic condition.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Identify couples who may benefit from preconceptual chromosomal analysis and prenatal testing when providing care to couples with special reproductive concerns.

Question 9 Type: MCSA The nurse has presented an in-service to nurses new to the maternal–child health care unit. Which statement indicates that teaching on genetic disorders has been successful?

1. “Down syndrome is an autosomal recessive condition. If both parents carry the gene, there is a 1-in-4 chance that a child will be affected.”

2. “Galactosemia is a sex-linked condition. Both parents must carry the gene, and more girls than boys will be affected by this condition.”

3. “Sickle-cell disease is a trisomy; the affected patient has three copies of a gene. Trisomies are more common in pregnancies of young women than those of older women.”

4. “Huntington’s disease is an autosomal dominant condition. Only one parent carries the gene, and males and females are equally affected by the disease.”

Correct Answer: 4

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Down syndrome is a trisomy and most likely to occur in parents over age 35. Autosomal recessive conditions are passed along to offspring when both parents carry the affected gene and pass the affected gene to the child.

Rationale 2: Galactosemia is not a sex-linked disorder; it is an autosomal recessive disorder. Both parents must carry the gene and pass that gene on to the child. Males and females are equally affected. Sex-linked disorders are carried on the X chromosome; therefore, males are more likely to have the condition because they only have one copy of the X chromosome.

Rationale 3: Trisomies are three copies of a specific gene and occur most often in parents over age 35. Sickle-cell disease is not a trisomy; it is an autosomal recessive condition. Both parents must carry the gene; there is a 1-in-4 chance that their child will be affected.

Rationale 4: Huntington’s disease is an autosomal dominant disease, meaning that the affected person inherited the condition from only one affected parent. A child has a 50% chance of inheriting an autosomal dominant condition if one parent is affected. Males and females are equally affected by autosomal dominant disorders.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Identify the characteristics of autosomal dominant, autosomal recessive, and Xlinked (sex-linked) recessive disorders.

Question 10 Type: MCSA A 45-year-old mother gave birth to a baby boy two days ago. The nurse assesses a single palmar crease, poor muscle tone, and low-set ears on the newborn. The nurse understands that these signs most likely indicate the infant has which autosomal abnormalities?

1. Trisomy 13 2. Trisomy 18 3. Trisomy 21 4. Trisomy 26 Correct Answer: 3 Rationale 1: A single palmar crease and low-set ears are not characteristics of trisomy 13.

Rationale 2: A single palmar crease and low-set ears are not characteristics of trisomy 18.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: A single palmar crease and low-set ears are characteristics of trisomy 21 (Down syndrome).

Rationale 4: Trisomy 26 is not an autosomal abnormality.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Identify the characteristics of autosomal dominant, autosomal recessive, and Xlinked (sex-linked) recessive disorders.

Question 11 Type: MCSA A nurse counsels a couple regarding their concerns about an X-linked disorder. Both parents are carriers of the disorder. They ask the nurse how this disorder will affect any children they might have. What is the nurse’s best response?

1. “If you have a daughter, she will not be a carrier.”

2. “If you have a daughter, she will not be affected.”

3. "If you have a son, he will be a carrier."

4. "If you have a son, he will not be affected.”

Correct Answer: 2 Rationale 1: Fathers affected with an X-linked disorder cannot pass the disorder to their sons, but all their daughters become carriers of the disorder.

Rationale 2: An X-linked disorder is manifested in a male who carries the abnormal gene on his only X chromosome.

Rationale 3: There is no male-to-male transmission of an X-linked disorder. An X-linked disorder is manifested in a male who carries the abnormal gene on his only X chromosome.

Rationale 4: There is a 50% chance that a carrier mother will pass the abnormal gene to each of her sons, who will thus be affected.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO07 - Identify the characteristics of autosomal dominant, autosomal recessive, and Xlinked (sex-linked) recessive disorders.

Question 12 Type: MCSA A child with suspected Down syndrome has been born to 32-year-old parents. The parents ask the nurse how the diagnosis will be made and if there was a way that the diagnosis could have been made during the pregnancy. The best response by the nurse is: 1. “The baby’s genes could have been tested during pregnancy by doing an amniocentesis.”

2. “The doctor will check the baby’s genes by doing a 24-hour urine collection on your child.”

3. “Mom’s blood could have been tested during the pregnancy to check for genetic problems with the baby.”

4. “A swab of the baby’s cheek or a stool sample will be used to check your baby’s chromosomes.”

Correct Answer: 1 Rationale 1: A genetic amniocentesis is the removal of a small amount of amniotic fluid obtained by inserting a needle through the abdominal wall into the uterus. The amniotic fluid is then processed to examine the chromosomes.

Rationale 2: Suspected genetic conditions in newborns are diagnosed by examining the baby’s chromosomes either from a blood sample or from a swab of the inside of the cheek.

Rationale 3: Mom’s blood would contain the mother’s chromosomes, not the baby’s. Prenatal genetic testing is accomplished through genetic amniocentesis. A small amount of amniotic fluid is obtained by inserting a needle through the abdominal wall into the uterus. The amniotic fluid is then processed to examine the chromosomes.

Rationale 4: Although a cheek swab can be used for genetic testing, stool samples cannot. Because part of the answer is incorrect, the whole answer is incorrect.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Compare prenatal and postnatal diagnostic procedures used to determine the presence of genetic disorders and the nursing considerations for each.

Question 13 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA The couple has had an ultrasound at 19 weeks’ gestation, and their fetus was found to have anencephaly. The nurse is completing counseling for the couple on the ultrasound findings. Which statement indicates that additional teaching is needed?

1. “We won’t know if something is wrong until the baby’s chromosomes are tested.”

2. “This problem is not caused by one of us having a genetic problem.”

3. “Our baby has an incomplete brain and might not be born alive.”

4. “Waiting until our 30s did not cause this problem to develop.”

Correct Answer: 1 Rationale 1: Anencephaly is clearly visualized with an ultrasound and does not require genetic testing to verify a diagnosis.

Rationale 2: Genetic abnormalities in either parent are not related to anencephaly.

Rationale 3: Anencephaly is a condition in which the skull does not cover the brain completely, and the brain consists mostly of brainstem with little other brain development.

Rationale 4: The age of either parent is not related to anencephaly.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Compare prenatal and postnatal diagnostic procedures used to determine the presence of genetic disorders and the nursing considerations for each.

Question 14 Type: MCSA A male infant was born two days ago, and the nurse assessed the infant as having single palmar crease, poor muscle tone, and low-set ears. Genetic testing of the infant has been ordered by the physician. Which statement should the nurse include when explaining this plan to the parents?

1. “We will draw blood from both of you to check for abnormal genes.”

2. “Your son will have his chromosomes sampled and then studied.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “When your son is 2 years old, he will need a blood test.”

4. “After your breast milk is in, we will draw blood from your son.”

Correct Answer: 2 Rationale 1: The parents’ chromosomes do not need to be assessed in order to diagnose the infant.

Rationale 2: A single palmar crease, poor muscle tone, and low-set ears could indicate trisomy 18. This diagnosis is confirmed by chromosomal analysis of the infant, using either a buccal smear or a blood specimen.

Rationale 3: The chromosome studies will be undertaken as soon as possible.

Rationale 4: It is not necessary to wait until the breast milk has come in.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Compare prenatal and postnatal diagnostic procedures used to determine the presence of genetic disorders and the nursing considerations for each.

Question 15 Type: MCSA The family of a 3-day-old child has just been informed that their child has cystic fibrosis. Which statement to the family should the nurse make?

1. “I can see that you are adjusting well. I’ll leave you alone for a while.”

2. “This must be difficult news for you. What questions do you have?”

3. “Do you have family members or clergy you would like me to call?”

4. “Why didn’t you have an amniocentesis during your pregnancy?”

Correct Answer: 2 Rationale 1: When a patient is given bad news, the grieving process begins. The family is grieving the loss of a normal child. This family is most likely in the shock/disbelief stage of grief.

Rationale 2: This response uses therapeutic communication techniques and portrays a caring attitude towards the family. Asking if the family has questions further facilitates communication.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Although it is good to have supportive family members or a clergy person called if the family desires, it is better for the nurse to take the initiative and establish therapeutic communication and to portray caring.

Rationale 4: It is not therapeutic to ask “why” questions. In addition, although cystic fibrosis is diagnosable prenatally, a patient opposed to abortion often will not seek prenatal diagnosis, because the pregnancy would not be terminated if the child were affected by a chromosomal abnormality.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO09 - Examine the emotional impact on a couple undergoing genetic testing or coping with the birth of a baby with a genetic disorder.

Question 16 Type: MCSA The couple at 12 weeks’ gestation has been told that their fetus has sickle-cell disease. Which statement by the couple indicates that they are adequately coping?

1. “We knew we were both carriers of sickle cell. We shouldn’t have tried to have a baby.”

2. “If we had been healthier when we conceived, our baby wouldn’t have this disease now.”

3. “Taking vitamins before we got pregnant would have prevented this from happening.”

4. “The doctor told us there was a 25% chance that our baby would have sickle disease.”

Correct Answer: 4 Rationale 1: Self-blame and judgment do not indicate coping.

Rationale 2: Preconception health does not affect transmission of an autosomal recessive trait.

Rationale 3: Nutrition does not affect transmission of an autosomal recessive trait.

Rationale 4: A true statement indicates coping. When both the mother and father are carriers of an autosomal recessive disease like sickle-cell, there is a 25% chance of a normal child, a 25% chance of a child with sickle-cell disease, and a 50% chance of a child with sickle-cell trait.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO09 - Examine the emotional impact on a couple undergoing genetic testing or coping with the birth of a baby with a genetic disorder.

Question 17 Type: MCSA The parents of a child with cystic fibrosis are attending genetic counseling. After their initial visit, they ask the nurse what will happen next. How should the nurse respond?

1. "Your genetic counseling is a medical matter that can only be discussed with your physician."

2. “You will have one more appointment with your genetic counselor and that will conclude your genetic counseling."

3. "You will receive a letter from your primary care physician that explains the results of your genetic counseling session.”

4. "You will have a follow-up visit with your genetic counselor and you will receive additional information at that time."

Correct Answer: 4 Rationale 1: The nurse should act as a liaison between the family and genetic counselor.

Rationale 2: After a follow-up visit, the family may return to the genetic counselor to ask questions and express concerns, especially if the couple is considering having more children, or if siblings want information about their affected brother or sister.

Rationale 3: Upon completion of genetic counseling, the genetic counselor sends the parent(s) and their certified nurse–midwife or physician a letter detailing the contents of the sessions.

Rationale 4: After the initial genetic counseling session, a follow-up visit is scheduled in order for the genetic counselor to provide the parents with all available information and offer additional counseling.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO10 - Explain the nurse’s role in supporting the family undergoing genetic counseling.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 08 Question 1 Type: MCSA The nurse in the obstetrical clinic is setting appointments for patients seeking preconceptual care. Which patient should be seen first?

1. 36-year-old, has never been pregnant, takes medication for a seizure disorder 2. 15-year-old, smokes one pack per day, had a miscarriage four months ago 3. 22-year-old, runs long distances, has been on the pill for six years 4. 29-year-old, has had two abortions, takes a multiple-vitamin supplement Correct Answer: 1 Rationale 1: This patient is the top priority because she has multiple risk factors: She is over the age of 35 and therefore is at risk for trisomies; some medications are teratogenic and are contraindicated during pregnancy; and pregnancy is not recommended for women with some conditions. This patient needs to see the specialist who prescribes her anti-seizure medication, as well with an obstetric provider, to discuss the risks her age presents to a possible pregnancy.

Rationale 2: Although this patient has the risks of being young and a smoker, she is not the highest priority.

Rationale 3: The only risk factor this patient has is a need to increase folic acid intake due to being on the pill for six years.

Rationale 4: This patient has no risk factors for pregnancy. A history of more than three abortions increases the risks of preterm labor and infertility, but this patient has only had two abortions.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe the most appropriate nursing care for couples during preconception counseling to help ensure their best possible health state.

Question 2 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

A primigravida is admitted to the labor unit with contractions every 7–8 minutes. She is 3 cm dilated, 70% effaced, and at 0 station. She is very anxious, is having difficulty coping with contractions, and states that she did not attend prenatal classes. Which of the following would be the most effective nursing intervention?

1. Instruct the patient in abdominal breathing and progressive relaxation.

2. Instruct the patient in patterned, paced breathing and touch relaxation.

3. Instruct the patient in pelvic tilt and pelvic rock exercises.

4. Call the physician and request a sedative.

Correct Answer: 1,3 Rationale 1: Abdominal breathing and progressive relaxation assist the patient in relaxing and allow the uterine muscles to work more efficiently.

Rationale 2: Patterned, paced breathing and touch relaxation are exercises that are taught in childbirth preparation classes and involve the use of a partner.

Rationale 3: Pelvic tilt and rock exercises are body-conditioning exercises.

Rationale 4: Providing sedatives would not allow the patient to participate actively in the process.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Describe the most appropriate nursing care for couples during preconception counseling to help ensure their best possible health state.

Question 3 Type: MCSA The nurse is assisting an expectant couple in developing a birth plan. Which of the following instructions would the nurse include in the teaching plan?

1. The birth plan includes only patient choices and does not take into account standard choices of the health care provider.

2. The birth plan allows the patient to make choices about the birth process; however, these choices cannot be altered.

3. The birth plan is a legally binding contract between the patient and the health care provider.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. The birth plan is a communication tool between the patient and the health care provider.

Correct Answer: 4 Rationale 1: The birth plan is used as a tool for communication among the expectant parents, the health care provider, and the health care professionals at the birth setting.

Rationale 2: The written plan identifies options that are available; thus, it can be altered.

Rationale 3: It is not a legal document.

Rationale 4: The birth plan is used as a tool for communication among the expectant parents, the health care provider, and the health care professionals at the birth setting.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Describe the most appropriate nursing care for couples during preconception counseling to help ensure their best possible health state.

Question 4 Type: MCSA A couple would like their 5-year-old to attend the birth. Which statement by the nurse would assist in the family’s plan to include their 5-year-old in the birth?

1. “You should let your child stay home because you will be focusing on the birth.”

2. “Children under 12 are not allowed to be present at the birth.”

3. “You should bring someone who only will tend to any specific needs of your child.”

4. “Bring some toys to keep your child occupied.”

Correct Answer: 3 Rationale 1: A sibling should have his own support person whose primary responsibility is to take care of the child’s needs so that the child will have support if anxiety develops over the birth process, and the mother can concentrate on the labor and birth.

Rationale 2: Children are allowed to be present at births.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: A sibling should have his own support person whose primary responsibility is to take care of the child’s needs so that the child will have support if anxiety develops over the birth process, and the mother can concentrate on the labor and birth.

Rationale 4: Preparing the child on what to expect is beneficial. Toys will not sustain a 5-year-old’s attention for an extended time period.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Describe the most appropriate nursing care for couples during preconception counseling to help ensure their best possible health state.

Question 5 Type: MCSA The nurse is presenting a prenatal class for couples beginning prenatal care. What information is most important for the nurse to include?

1. You can have a certified nurse–midwife or a physician for your provider.

2. You can give birth in either of two different types of rooms, each with different equipment.

3. The birthing unit was remodeled and redecorated last year.

4. Some of the providers recommend circumcision for baby boys.

Correct Answer: 1 Rationale 1: This statement is the most important. The nurse should inform patients what their options are, including the types of providers available.

Rationale 2: This statement is too vague to facilitate decision making by the couple.

Rationale 3: This information does not help patients understand their options or make decisions.

Rationale 4: Because not all patients will be having boys, this statement is only helpful to those patients who give birth to males and see a provider who recommends circumcision. This statement is too narrowly focused to be helpful to all patients.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Assist expectant parents in making the best decisions possible in issues related to pregnancy, labor, and birth.

Question 6 Type: MCSA While teaching a preconception class, the nurse should include which of the following recommendations concerning intake of vitamins during pregnancy?

1. Take supplemental folic acid daily to reduce the risk of trisomy 21 (Down syndrome).

2. The pregnant woman should consult the recommended dietary allowance (RDA) guidelines regarding vitamins.

3. Take Vitamin C daily to reduce the risk of neural tube defects.

4. The pregnant woman should consume the greatest amount of vitamins possible.

Correct Answer: 2 Rationale 1: Folic acid supplementation prior to conception is recommended for decreasing the risk of neural tube defects.

Rationale 2: Intake of vitamins in greater than the recommended dietary allowance (RDA) can cause severe fetal problems and should be avoided.

Rationale 3: Folic acid is linked to decreased risk for neural tube defects.

Rationale 4: Intake of vitamins in greater than the recommended dietary allowance (RDA) can cause severe fetal problems and should be avoided.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Assist expectant parents in making the best decisions possible in issues related to pregnancy, labor, and birth.

Question 7 Type: MCSA An expectant couple desires to determine compatibility with a care provider. They ask the nurse for assistance.

Which of the following questions should the nurse encourage the couple to ask first?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “Can my children attend the birth?”

2. “If I have a cesarean birth, can my husband attend?”

3. “What is your philosophy of birth?”

4. “What percentage of your patients have episiotomies?”

Correct Answer: 3 Rationale 1: Children’s attendance is a complement to the provider’s philosophy.

Rationale 2: A husband’s presence for a cesarean birth is a complement to the provider’s philosophy.

Rationale 3: A thorough understanding of the provider’s philosophy is essential to determining compatibility.

Rationale 4: Episiotomy percentages are a complement to the provider’s philosophy.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Assist expectant parents in making the best decisions possible in issues related to pregnancy, labor, and birth.

Question 8 Type: MCSA The prenatal clinic nurse has presented information on prenatal class options to a couple pregnant for the first time.

Which statement made by the couple indicates that additional information is necessary? “Prenatal classes: 1. “Eliminate the risk of needing a vacuum extraction or cesarean birth.”

2. “Help parents cope with the discomforts and unknowns of childbirth.”

3. “Facilitate better communication between both partners.”

4. “Encourage participants to write a list of their requests for labor and birth.”

Correct Answer: 1 Rationale 1: This is false reassurance. There is no guarantee that an operative birth can be avoided, even if a couple attends prenatal classes.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: This is one of the main goals of prenatal classes: learning skills to help get through the discomforts of childbirth. Participants also learn how the birthing process progresses. This does not imply that students of prenatal classes don’t get epidurals. But participants will learn new skills that will facilitate the birthing process.

Rationale 3: A secondary goal of prenatal classes is to facilitate communication between the pregnant woman and her partner. The primary goals are to inform participants of the birth process and teach them skills to cope with labor and birth.

Rationale 4: One of the strategies used in prenatal classes is to have participants write a birth plan that lists their requests for how they want their birthing experience to be. But putting their desires down in writing is less important than learning about the birth process and learning skills to cope with labor and delivery.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Explain the basic goals of childbirth education in providing care to expectant couples and their families.

Question 9 Type: MCSA A 38-year-old woman with no prior pregnancies calls the clinic to inquire about preconception counseling. Which element of early prenatal education should the nurse expect to facilitate?

1. Availability of prenatal and genetic testing 2. Birth choices 3. Infertility counseling 4. Nutrition classes Correct Answer: 1 Rationale 1: Prenatal and genetic testing is incorporated among early prenatal classes, which often include prepregnant women. Due to maternal age, this woman is at increased risk for having a child with a chromosomal abnormality.

Rationale 2: Birth classes are incorporated into later classes; specifically, the second and third trimester.

Rationale 3: Infertility counseling is not incorporated within preconception counseling.

Rationale 4: Nutrition classes are incorporated among early prenatal education; however, due the woman's age, availability of prenatal and genetic testing is a higher priority.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Explain the goals and content of the various types of antepartum education programs when providing nursing care for expectant couples and their families.

Question 10 Type: MCSA The patient who experienced an emergency cesarean birth with her first child expresses anxiety about her upcoming birth. How can the nurse teaching the patient’s prenatal classes help decrease her anxiety?

1. Encourage muscle tightening with each contraction.

2. Explain that patterned breathing increases anxiety and should be avoided.

3. Instruct the patient to hire a therapeutic massage therapist for labor.

4. Practice progressive relaxation and encourage her to use the technique in labor.

Correct Answer: 4 Rationale 1: Relaxation, not muscle tightening, should be encouraged. Some relaxation techniques teach patients to tighten and then release muscles to learn the difference between tension and relaxation, but the key is to be as relaxed as possible during contractions.

Rationale 2: Patterned breathing techniques decrease, not increase, anxiety. Practice of patterned breathing prior to the onset of labor facilitates their use during labor.

Rationale 3: Although some patients would enjoy a massage therapist during their labor, not all patients enjoy massage, and not all patients have the resources to hire this type of professional for their labor.

Rationale 4: Progressive relaxation (and all relaxation techniques), when practiced prior to labor, is a valuable tool to facilitate relaxation and therefore decrease anxiety during labor.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe interventions that can be implemented by the childbirth educator to decrease pregnant women’s anxiety.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 11 Type: MCSA Regardless of the method of childbirth preparation, most childbirth classes: 1. Present ways of alleviating fear.

2. Teach imagery for relaxation.

3. Use patterned, paced breathing techniques.

4. Present the benefits of epidural anesthesia.

Correct Answer: 1 Rationale 1: The overall goal of prenatal classes is to decrease fear through increasing knowledge and teaching participants skills to help cope with labor. These skills include various relaxation methods and breathing techniques.

Rationale 2: Not all classes teach imagery.

Rationale 3: Not all classes use patterned, paced breathing.

Rationale 4: Many couples will be able to avoid an epidural by using the techniques they learned in classes.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe interventions that can be implemented by the childbirth educator to decrease pregnant women’s anxiety.

Question 12 Type: MCSA The nurse assesses her patient to have mild anxiety concerning the birth process. The patient states that she is not interested in Lamaze classes because she is single and does not want to have natural childbirth. The nurse’s best response would be: 1. “Lamaze classes promise painless childbirth. If you learn their methods, your pain is minimal.”

2. “Lamaze classes can teach you relaxation methods and also the benefits and risks of pain-relief methods. This assists you in making the best decision for you.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “You are very nervous. I think these classes would be best for you.”

4. “Lamaze classes are geared toward couples. You might want to find a different class.”

Correct Answer: 2 Rationale 1: This choice is inappropriate because even with Lamaze, there could be some pain.

Rationale 2: Lamaze teaches relaxation methods by utilizing patterned breathing. Those who are able to use the method require little if any anesthesia during delivery. The other choices are inappropriate.

Rationale 3: Telling a patient that she is nervous is not a reason to take the class. It would be better to encourage the patient to take the class so she will be knowledgeable on the birth experience and it could reduce any anxiety she may have about the experience.

Rationale 4: Lamaze classes are geared toward teaching about the breathing and relaxation during childbirth and often have single parents or non-couple participants.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe interventions that can be implemented by the childbirth educator to decrease pregnant women’s anxiety.

Question 13 Type: MCSA A 29-year-old woman who is pregnant with her first child asks the nurse which childbirth preparation class is most highly recommended for couples. Which nursing response is best?

1. "For couples, the International Childbirth Education Association (ICEA) recommends the Bradley method, which is a partner-coached childbirth."

2. "Lamaze would be the ideal choice of preparation for you and your husband."

3. "Ideally, you can learn about each method, and then choose the one that's best for you.”

4. "Any of the methods will work well, as long as you and your husband do not deviate from the instructions related to that specific method."

Correct Answer: 3

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: The International Childbirth Education Association (ICEA) does not advocate a particular method of childbirth preparation but rather promotes a philosophy of “freedom of choice based on knowledge of alternatives."

Rationale 2: Education regarding the various childbirth preparation classes should be provided, and the woman should choose the option she deems best.

Rationale 3: Education regarding the various childbirth preparation classes should be provided, and the woman should choose the option she deems best.

Rationale 4: International Childbirth Education Association (ICEA) educators often teach a combination of techniques designed to meet individual needs and assist the partner in supporting the woman during labor and birth.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Compare methods of childbirth preparation and the nursing interventions for each.

Question 14 Type: MCSA The nurse is presenting a prenatal education class about the use of Lamaze during childbirth. Which concept should the nurse include in his teaching?

1. Dissociative relaxation 2. Partner-coached childbirth 3. The extended McRoberts position 4. Touch relaxation Correct Answer: 1 Rationale 1: Dissociative relaxation, which is specific to Lamaze, promotes relaxation of uninvolved muscles while the uterus contracts, creating an active relaxation pattern.

Rationale 2: Partner-coached childbirth is an element of the Bradley method.

Rationale 3: The extended McRoberts position is a body-conditioning exercise that helps enable the woman to stretch her hamstring muscles.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Touch relaxation is a two-person relaxation technique in which the woman learns to release tension in the body areas that her partner touches.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare methods of childbirth preparation and the nursing interventions for each.

Question 15 Type: MCSA The nurse is planning a “train the trainer” class for labor and delivery nurses learning to teach prenatal classes.

Which statement indicates that teaching has been effective?

1. “Women like to be in a semi-sitting position when giving birth.”

2. “Teaching alternatives available at our hospital facilitates decision making.”

3. “I will explain that bright lights in the room are best for moms and babies.”

4. “Patients should be taught not to make noise during labor or birth.”

Correct Answer: 2 Rationale 1: No one position for birth is favored by all women. Prenatal classes should teach about alternatives and help strengthen the mind–body connection of patients.

Rationale 2: This is a true statement. To be respectful and facilitate autonomy, prenatal classes should teach about alternatives and help strengthen the mind–body connection of patients.

Rationale 3: Subdued lighting and soft music are options that are easy to implement and help personalize a family’s birth experience.

Rationale 4: Vocalization during labor and birth should be encouraged, if that is what the patient wants to do. It is not appropriate to expect all laboring patients to want the same things or to behave in the same ways.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO07 - Examine ways in which the nurse conveys respect for patient individuality in preparing for childbirth.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 09 Question 1 Type: MCSA The nurse is auscultating fetal heart tones in a patient who is 37 weeks' gestation. While in a supine position, the patient states, “I’m getting lightheaded and dizzy, and I feel clammy.” Which of the following nursing actions is most appropriate?

1. Place a wedge beneath the patient's right hip.

2. Prepare for administration of packed red blood cells (PRBCs).

3. Help the patient turn onto her right side.

4. Administer supplemental oxygen.

Correct Answer: 1 Rationale 1: The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which compression of the vena cava by the uterus reduces right atrial blood flow. Signs and symptoms include decreased blood pressure, dizziness, pallor, and clamminess. Appropriate interventions include having the woman lie on her left side, or placing a pillow or wedge under her right hip as she lies in a supine position.

Rationale 2: The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which compression of the vena cava by the uterus reduces right atrial blood flow. Repositioning the patient onto her left side or placing a pillow or wedge under her right hip are appropriate interventions.

Rationale 3: The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which compression of the vena cava by the uterus reduces right atrial blood flow. Positioning the patient on her right side would likely exacerbate the reduction in right atrial blood flow.

Rationale 4: The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which compression of the vena cava by the uterus reduces right atrial blood flow. Priority interventions include repositioning the patient onto her left side, or placing a pillow or wedge under her right hip.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Identify the anatomic and physiologic changes that occur during pregnancy in providing nursing care to expectant women.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 2 Type: MCSA The patient with a normal pre-pregnancy weight asks why she has been told to gain 25–35 pounds during her pregnancy, but her underweight friend was told to gain more weight. The nurse should tell the patient that recommended weight gain during pregnancy should be: 1. 25–35 pounds, regardless of a patient’s pre-pregnancy weight.

2. More than 25–35 pounds for an overweight patient.

3. More than 25–35 pounds for an underweight woman.

4. The same for a normal-weight woman as for an overweight woman.

Correct Answer: 3 Rationale 1: Pre-pregnancy weight determines the recommended weight gain during pregnancy. Women of normal weight should gain 25–35 pounds during pregnancy for optimal fetal outcome.

Rationale 2: Overweight women should gain 15–25 pounds during pregnancy.

Rationale 3: Underweight women are encouraged to gain 28-40 pounds during pregnancy.

Rationale 4: Overweight women should gain 15–25 pounds during pregnancy.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Identify the anatomic and physiologic changes that occur during pregnancy in providing nursing care to expectant women.

Question 3 Type: MCSA The nurse is reviewing the assessment findings of a patient who is 35 weeks' gestation. Which of the following data suggests the need for further investigation?

1. Melasma gravidarum 2. Pseudoanemia 3. Funic souffle Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Glycosuria Correct Answer: 4 Rationale 1: Facial chloasma or melasma gravidarum (also known as the “mask of pregnancy”) is a harmless darkening of the skin over the cheeks, nose, and forehead that sometimes accompanies pregnancy.

Rationale 2: Physiologic anemia of pregnancy or pseudoanemia is common during pregnancy and is an expected finding.

Rationale 3: Funic souffle is a normal assessment finding associated with the pulsing of blood through the umbilical cord.

Rationale 4: Glycosuria (glucose in the urine) during pregnancy may be normal or may indicate gestational diabetes, so it always warrants further testing.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Identify the anatomic and physiologic changes that occur during pregnancy in providing nursing care to expectant women.

Question 4 Type: MCSA The patient in the prenatal clinic tells the nurse that she is sure that she is pregnant because she has not had a menstrual cycle for three months, and her breasts are getting bigger. What response by the nurse is best?

1. “Lack of menses and breast enlargement are presumptive signs of pregnancy.”

2. “The changes you are describing are definitely indicators that you are pregnant.”

3. “Lack of menses can be caused by many things. We need to do a pregnancy test.”

4. “Breast and menstrual changes are positive signs of pregnancy. Congratulations.”

Correct Answer: 3 Rationale 1: Although this is true, amenorrhea and breast enlargement also can be caused by weight gain and other conditions. A pregnancy test is needed to determine whether the patient is pregnant.

Rationale 2: This statement is false because amenorrhea and breast enlargement are presumptive signs of pregnancy because they can be caused by other conditions.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This is a true statement and addresses that these changes could be caused by things other than pregnancy.

Rationale 4: This statement is false because amenorrhea and breast enlargement are presumptive signs. It is too early to determine if congratulations are in order.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Assess the subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy in patients.

Question 5 Type: MCSA The nurse has completed a presentation for newly-pregnant women about the changes of pregnancy. Which participant's statement reflects accurate comprehension of the information?

1. "A positive Goodell's sign is a probable change of pregnancy."

2. "Three positive pregnancy tests in a one week period is considered to be a positive change of pregnancy."

3. “Uterine souffle is a positive change of pregnancy.”

4. “Changes in the pelvic organs are presumptive signs of pregnancy.”

Correct Answer: 1 Rationale 1: A positive Goodell's sign can be objectively identified but may also be caused by conditions other than pregnancy; therefore, it is considered to be a probable change of pregnancy.

Rationale 2: Because other conditions may cause elevated hCG, pregnancy tests are considered probable changes of pregnancy.

Rationale 3: Because uterine souffle can be objectively identified but may be caused by conditions other than pregnancy, it is considered to be a probable change of pregnancy.

Rationale 4: Changes in the pelvic organs can be objectively identified; however, because some pelvic organ changes may be associated with conditions other than pregnancy, they are considered to be probable changes of pregnancy.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Assess the subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy in patients.

Question 6 Type: MCSA A patient who is experiencing her first pregnancy has just completed the initial prenatal examination with a certified nurse–midwife. Which statement indicates that the patient has a correct understanding of her condition?

1. “Because we heard the baby’s heartbeat, I am undoubtedly pregnant.”

2. “Since I haven’t felt the baby move yet, we don’t know if I’m pregnant.”

3. “My last period was two months ago, which means I’m two months along.”

4. “The increased size of my uterus means that I am finally pregnant.”

Correct Answer: 1 Rationale 1: Hearing the fetal heart rate is a positive or diagnostic change of pregnancy.

Rationale 2: Fetal movement is a presumptive or subjective change of pregnancy. Absence or presence of the sensation of fetal movement is not a conclusive indicator of pregnancy status.

Rationale 3: Amenorrhea is a presumptive or subjective change and does not conclusively verify pregnancy status.

Rationale 4: Increased uterine size is a probable or objective change and does not conclusively verify pregnancy status.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Assess the subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy in patients.

Question 7 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The adolescent patient reports to the clinic nurse that her period is late but that her home pregnancy test is negative. Which response is most appropriate?

1. “This means you are not pregnant.”

2. “You might be pregnant, but it might be too early for your home test to be accurate.”

3. “We don’t trust home tests. Come to the clinic for a blood test.”

4. “Most people don’t use the tests correctly. Did you read the instructions?”

Correct Answer: 2 Rationale 1: Although this might be true, this is not the best response because the pregnancy may not yet be detectable through use of a urine pregnancy test.

Rationale 2: This is an accurate and appropriate response. Most home pregnancy tests have low false positive rates, but the false negative rate is slightly higher. Repeating the test in one week is recommended.

Rationale 3: This statement is not therapeutically worded. Additionally, this statement is not true because home pregnancy tests are quite simple to use and quite accurate. A clinic pregnancy test is usually a urine test. Blood tests are more invasive and more expensive.

Rationale 4: This response does not address the issues presented in the patient’s statement.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Contrast the various types of pregnancy tests.

Question 8 Type: MCSA A 28-year-old patient who is pregnant with her first child reports increased dental caries (cavities) since becoming pregnant. How should the nurse explain the likely cause for this change?

1. “When a woman is pregnant, her teeth lose calcium and she is more susceptible to getting cavities.”

2. “It may be necessary to pay extra attention to dental care while you’re pregnant, especially if you’re vomiting frequently.”

3. “Each woman experiences changes that affect her teeth while she’s pregnant.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “During pregnancy, tooth enamel softens and the woman is more susceptible to getting cavities.”

Correct Answer: 2 Rationale 1: No demonstrable changes occur in the teeth of pregnant women.

The dental caries that sometimes accompany pregnancy are probably caused by inadequate oral hygiene and dental care, especially if the woman has problems with bleeding gums or nausea and vomiting.

Rationale 2: The dental caries that sometimes accompany pregnancy are probably caused by inadequate oral hygiene and dental care, especially if the woman has problems with bleeding gums or nausea and vomiting.

Rationale 3: No demonstrable changes occur in the teeth of pregnant women.

Rationale 4: The dental caries that sometimes accompany pregnancy are probably caused by inadequate oral hygiene and dental care, especially if the woman has problems with bleeding gums or nausea and vomiting.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Identify the anatomic and physiologic changes that occur during pregnancy in providing nursing care to expectant women.

Question 9 Type: MCSA A patient at 30 weeks’ gestation is tearful at the time of her follow-up visit. She tells the prenatal clinic nurse she is excited to finally become a mother and that she has been thinking about what kind of parent she will be.

However, she is upset because her mother has told her that she doesn’t want to be a grandmother because she doesn’t feel old enough. Meanwhile, the patient’s husband has said that the pregnancy doesn’t feel real to him yet and that he will become excited when the baby is actually here. What is the most likely explanation for what is happening within this family?

1. Her husband will not attach with this child and will not be a good father.

2. Her mother is rejecting the role of grandparent and will not help out.

3. The patient is not progressing through the developmental tasks of pregnancy.

4. Each family member is adjusting to the role change at his own pace.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 4 Rationale 1: The husband’s statement is quite common. Partners often feel that a pregnancy isn’t real to them because they are not experiencing any of the physical changes associated with pregnancy.

Rationale 2: Adaptation to the role of grandparent is another life task that takes time. Younger grandparents often have busy and full lives and view grandparenthood as a time for elderly people who are retired and slowed down.

The family will form a view of grandparenthood within this family, in a way that works for them.

Rationale 3: This is a false statement. The patient is at the stage of seeking acceptance of this child by others, which first will be her partner and other family members.

Rationale 4: This is a true statement. When the other family members are at different stages of adjustment to the pregnancy, conflict can ensue.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy when providing nursing care.

Question 10 Type: MCSA The partner of a pregnant patient at 16 weeks’ gestation accompanies her to the clinic. The partner tells you that the baby just doesn’t seem real to him, and he’s having a hard time relating to his partner’s fatigue and food aversions. Which of the following statements would be best for the nurse to make?

1. “If you would concentrate harder, you’d be aware of the reality of this pregnancy.”

2. “My husband had no problem with this. What was your childhood like?”

3. “You might need professional psychological counseling. Ask your physician.”

4. “Many men feel this way. Feeling the baby move will help make it real.”

Correct Answer: 4 Rationale 1: Ambivalence is common among partners, especially prior to either seeing the baby on ultrasound or feeling the baby kick and move.

Rationale 2: The ambivalence and disbelief occur across all socioeconomic groups, in both partners who were fathered well and those who grew up without a father.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This reaction is not indicative of psychological pathology.

Rationale 4: Kicking and ultrasound visualization are concrete evidence of the baby’s existence and often are turning points in acceptance for partners.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy when providing nursing care.

Question 11 Type: MCSA A 20-year-old patient who is at 10 weeks’ gestation is preparing for her first prenatal visit. She confides, “This pregnancy was unplanned. I’m not sure if I want to be pregnant or not. I haven’t even told my boyfriend I’m pregnant. And I haven’t decided if I’m going to continue the pregnancy.” Which of the following statements should the nurse make next?

1. “It’s really unusual for a pregnant woman to feel this way early in the pregnancy.”

2. “These thoughts are because your mother died when you were four years old.”

3. “You should go to a pregnancy support group to be a good mother.”

4. “It’s common to feel ambiguous about pregnancy in the first trimester.”

Correct Answer: 4 Rationale 1: Fathers might not be told immediately about the diagnosis of pregnancy.

Rationale 2: Loss of the patient’s own mother at a young age would not affect the occurrence of ambivalence in the first trimester.

Rationale 3: No psychopathology is present, so a support group is not indicated.

Rationale 4: Ambivalence toward the pregnancy is very common in the first trimester.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy when providing nursing care.

Question 12 Type: MCSA A 25-year-old woman is in the second trimester of her pregnancy. During the interview, you ask her partner what changes they have noticed during the pregnancy. Which of the following answers would indicate a typical response to pregnancy?

1. “She has been more tense and anxious than usual, and she is not sleeping well.”

2. “She daydreams about what kind of parent she is going to be.”

3. “I haven’t noticed anything. I just found out she was pregnant.”

4. “She has been having dreams at night about misplacing the baby.”

Correct Answer: 2 Rationale 1: During the third trimester, the woman typically experiences more anxiety and tension, as well as increased discomfort and insomnia.

Rationale 2: The second trimester usually brings increased introspection and consideration of how she will parent.

Rationale 3: In the first trimester, pregnant women usually tell their partners of the pregnancy, explore their relationship with their mother, and think about their own role as a mother.

Rationale 4: The needs of the newborn typically are not considered until the third trimester, at which time dreams of misplacing the baby or being unable to get to the baby also may be common.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy when providing nursing care.

Question 13 Type: MCSA A patient who is at 14 weeks’ gestation is in the clinic for a regular prenatal visit. The patient is accompanied by her mother. The patient’s mother states that she is very uncertain about how to be a good grandmother to this baby, Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

due to working full time and being so busy. The patient’s mother notes that her own grandmother was retired and was always available when needed by a grandchild. The best response to this concern would be: 1. “Don’t worry. You’ll be a wonderful grandmother. It will all work out fine.”

2. “Grandmothers are supposed to be available. You should retire from your job.”

3. “As long as there is another grandmother available, you don’t have to worry.”

4. “How do you envision your role as grandmother?”

Correct Answer: 4 Rationale 1: Casual and/or false reassurance is not appropriate. Effective therapeutic communication requires supportive, nonjudgmental exploration of the patient’s concerns.

Rationale 2: Assignment of guilt is not appropriate. Effective therapeutic communication requires supportive, nonjudgmental exploration of the patient’s concerns Rationale 3: Minimizing a patient’s concern is not appropriate. Effective therapeutic communication requires supportive, nonjudgmental exploration of the patient’s concerns.

Rationale 4: Supportive, nonjudgmental exploration of the patient’s concerns is one component of therapeutic communication and is appropriate.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy when providing nursing care.

Question 14 Type: MCSA The labor and delivery nurse is talking with a patient who is expected to deliver her baby within the next several hours. The patient and her husband are Lebanese immigrants.

During conversation, the nurse asks the couple if they have chosen a name for their baby. The patient's husband explains that their Muslim beliefs require that they choose the baby's name after the delivery, as it is God's will whether or not the baby will be born. Which nursing response is appropriate?

1. "Thank you for explaining that to me. By sharing your cultural beliefs with me, you're helping me to provide you with the best possible care."

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. "In the United States, you can feel free to choose your baby's name prior to the delivery."

3. "We have a very low rate of complications at this facility."

4. "Are you afraid your baby will not live?"

Correct Answer: 1 Rationale 1: The identification of cultural values is useful in planning and providing culturally sensitive care.

Rationale 2: It is neither realistic nor appropriate to assume that people of another culture will automatically abandon their ways and adopt the practices of a dominant culture.

Rationale 3: The patient's husband is describing the application of a culturally-based belief, not a concern about complications.

Rationale 4: The patient's husband is describing the application of a culturally-based belief, not a fear-based concern.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Discuss cultural factors that may influence a family’s response to pregnancy in the provision of nursing care.

Question 15 Type: MCSA The nurse is presenting an in-service to nursing staff regarding the provision of culturally competent patient care.

Which statement should the nurse include in the presentation?

1. "Many immigrants to a new country will adopt the beliefs and practices of the dominant culture."

2. "Developed countries are becoming increasingly more ethnically diverse."

3. "The rituals and customs of a group reflect the values of the dominant culture."

4. "Identification of cultural values is a task that is unrelated to providing culturally sensitive care."

Correct Answer: 2 Rationale 1: It is not realistic or appropriate to assume that people of another culture will automatically abandon their ways and adopt the practices of the dominant culture.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: In many developed countries such as the United States, Canada, England, Germany and so forth, populations are becoming more and more ethnically diverse as the number of immigrants continues to grow.

Rationale 3: The rituals and customs of a group are a reflection of the group’s values.

Rationale 4: The identification of cultural values is useful in planning and providing culturally sensitive care.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Discuss cultural factors that may influence a family’s response to pregnancy in the provision of nursing care.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 10 Question 1 Type: MCSA The pregnant patient has completed the prenatal questionnaire and asks the nurse why this form had to be completed. The best response by the nurse is: 1. “Some people have things that have happened in the past that could impact their current pregnancy.”

2. “The doctor wants all of the pregnant patients to complete the form so that our records are complete.”

3. “We occasionally identify a health problem that puts the current pregnancy at higher risk.”

4. “This form is designed to predict who will develop problems with their pregnancy or delivery.”

Correct Answer: 3 Rationale 1: Although this is true, this statement is too vague to be the best response. It is best to explain specifically that the impact on the current pregnancy might put the pregnancy at higher risk.

Rationale 2: The purpose of the form is to identify which patients have risk factors; the fact that records are complete is less important than identifying at risk pregnancies.

Rationale 3: This is the reason for risk assessment during pregnancy, whether it is a patient-completed questionnaire or a nurse assessment form.

Rationale 4: The form will identify those patients who have risk factors based on their medical history; prediction implies seeing into the future without a basis for the concern.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Use information provided on a prenatal history to identify risk factors for the mother and/or fetus.

Question 2 Type: MCSA The pregnant patient's prenatal record indicates that she is a gravida 4 para 2022. The nurse understands that this indicates the patient had four pregnancies and: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Has four living children.

2. Delivered two infants preterm.

3. Is pro-abortion.

4. Delivered two term infants.

Correct Answer: 4 Rationale 1: In the four digit number, the fourth number indicates the number of living children, which is 2.

Rationale 2: In the four digit number, the second digit indicates the number of preterm births, so the patient has had no preterm births.

Rationale 3: In the four digit number, the third digit indicates the number of abortions the patient has experienced.

Because abortion may be spontaneous or therapeutic, this number does not does not necessarily reflect a woman's stance on surgical abortion.

Rationale 4: In the four digit number, the first digit indicates the number of term infants born, which is two.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Define common obstetric terminology found in the history of maternity patients.

Question 3 Type: MCSA A multigravida gave birth to an 18-week fetus last week. She is in the clinic for follow-up and notices that her chart states she has had one abortion. The patient is upset over the use of this word. How can the nurse best explain this terminology to the patient?

1. “Abortion is the medical term for all pregnancies that end before 28 weeks.”

2. “Abortion is the word we use when someone has miscarried.”

3. “Abortion is how we label pregnancies that end in the second trimester.”

4. “Abortion is what we call all babies who are stillborn.”

Correct Answer: 1

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Abortions are fetal losses prior to the onset of the third trimester and include elective induced (medical or surgical) abortions, ectopic pregnancies, and spontaneous abortions or miscarriages.

Rationale 2: Abortions are fetal losses prior to the onset of the third trimester and include elective induced (medical or surgical) abortions, ectopic pregnancies, and spontaneous abortions or miscarriages.

Rationale 3: Abortions are fetal losses prior to the onset of the third trimester and include elective induced (medical or surgical) abortions, ectopic pregnancies, and spontaneous abortions or miscarriages.

Rationale 4: Third-trimester losses are considered fetal death in utero, and the term abortion is not used.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Define common obstetric terminology found in the history of maternity patients.

Question 4 Type: MCSA Which of the following patients would be considered a multipara?

1. A patient at 34 weeks’ gestation who previously had one spontaneous abortion 2. A patient at 13 weeks’ gestation who previously delivered two term infants 3. A patient at 28 weeks’ gestation with no previous pregnancies 4. A patient at 32 weeks’ gestation who previously delivered one term infant Correct Answer: 2 Rationale 1: A woman who has had no births at more than 20 weeks' gestation is considered a nullipara.

Rationale 2: A woman who has had two or more births at more than 20 weeks’ gestation is considered a multipara.

Rationale 3: A woman who has had no births at more than 20 weeks' gestation is considered a nullipara.

Rationale 4: A woman who has had one birth at more than 20 weeks’ gestation, regardless of whether the infant was born alive or dead, is considered a primipara.

Global Rationale: Cognitive Level: Analyzing Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Define common obstetric terminology found in the history of maternity patients.

Question 5 Type: MCSA The patient has delivered her first child at 39 weeks. The nurse would explain this to the patient as what type of delivery?

1. Preterm 2. Post-term 3. Term 4. Near term Correct Answer: 3 Rationale 1: Preterm deliveries are those that occur prior to 37 completed weeks’ gestation.

Rationale 2: Post-term applies to birth that occur after 42 weeks' gestation.

Rationale 3: Term births are those that occur from between gestation weeks 38 and 42.

Rationale 4: Near term is not terminology used to describe birth.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Define common obstetric terminology found in the history of maternity patients.

Question 6 Type: MCSA The prenatal clinic nurse is designing a new prenatal intake information form for pregnant patients. Which question is best to include on this form?

1. Where was the father of the baby born?

2. Do genetic diseases run in the family of the baby’s father?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. What is the name of the baby’s father?

4. Are you married to the father of the baby?

Correct Answer: 2 Rationale 1: This is not important information for pregnancy.

Rationale 2: This question has the highest priority because it gets at the physiologic issue of inheritable genetic diseases that might directly impact the baby.

Rationale 3: Although it is helpful for the nurse to know the name of the father’s baby to include him in the prenatal care, this is psychosocial information and much less important than possible genetic diseases that the baby might have inherited.

Rationale 4: Although the marital status of the patient might have cultural significance, this is psychosocial information and much less important than possible genetic diseases that the baby might have inherited.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Identify factors related to the father’s health that are generally recorded on the prenatal record in assessing risk factors for the mother and/or fetus.

Question 7 Type: MCSA The nurse is assessing a primiparous patient. The patient indicates that her religion is Judaism. This information is important for the nurse to assess because: 1. Religious and cultural background can impact what a patient eats during pregnancy.

2. It provides a baseline from which to ask questions about the patient’s religious and cultural background.

3. Knowing what the patient’s beliefs and behaviors regarding pregnancy are is important.

4. Patients sometimes encounter problems in their pregnancies based on what religion they practice.

Correct Answer: 2 Rationale 1: Although this is true, much more than diet is impacted by religious and cultural background; values, beliefs, expectations for the birth, and acceptance or refusal of medical treatment are also influenced by religious or cultural background.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: This is the best explanation because not all people interpret or live out their religious or cultural backgrounds the same way. It is imperative to avoid stereotyping patients. Thus, the nurse should use the information on the patient’s background as an educated starting point from which to base further questions about how this specific patient enacts her religious or cultural background.

Rationale 3: Not all people interpret or live out their religious or cultural backgrounds the same way. It is imperative to avoid stereotyping patients based on what their background is. The nurse must use the information on the patient’s background as an educated starting point from which to base further questions about how this specific patient enacts her religious or cultural background.

Rationale 4: How a patient enacts her religion occasionally will cause problems with pregnancy. But the most important reason for asking a patient for her religious or cultural background is to have a starting point from which to base further questions on the specifics of how this patient is impacted by or enacts her cultural or religious background as a unique individual.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Evaluate those areas of the initial assessment that reflect the psychosocial and cultural factors related to a woman’s pregnancy.

Question 8 Type: MCSA The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings?

1. Document the findings on the prenatal chart.

2. Have the physician see the patient today.

3. Instruct the patient to avoid direct sunlight.

4. Analyze previous thyroid hormone lab results.

Correct Answer: 2 Rationale 1: These abnormalities must be reported to the physician immediately.

Rationale 2: Mottling of the skin is indicative of poor oxygenation and a circulation problem. Skin and nail bed pallor can indicate either hypoxia or anemia. These abnormalities must be reported to the physician immediately.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Spider nevi are common in pregnancy due to the increased vascular volume and high estrogen levels.

Nasal passages can be inflamed during pregnancy from edema, caused by increased estrogen levels.

Rationale 4: The thyroid gland increases in size during pregnancy due to hyperplasia.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Predict the normal physiologic changes a nurse would expect to find when performing a physical assessment of a pregnant woman.

Question 9 Type: MCSA A 25-year-old primigravida is 20 weeks pregnant. At the clinic, her nurse begins a prenatal assessment and obtains the following vital signs. Which finding would require the nurse to contact the physician?

1. Pulse 88/min 2. Respirations 30/min 3. Temperature 37.4°C (99.3°F) 4. Blood pressure 134/82 Correct Answer: 2 Rationale 1: A slight increase in pulse is an expected finding during pregnancy due to the increased oxygen consumption to support fetal metabolism.

Rationale 2: Tachypnea is not a normal finding and requires medical care.

Rationale 3: Temperature is an expected finding during pregnancy due to the increased oxygen consumption to support fetal metabolism.

Rationale 4: The blood pressure is within normal limits.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO05 - Predict the normal physiologic changes a nurse would expect to find when performing a physical assessment of a pregnant woman.

Question 10 Type: MCSA The nurse is seeing prenatal patients in the clinic. Which patient is exhibiting expected findings?

1. Primip at 12 weeks with fetal heart tones heard by Doppler fetoscope 2. Multip at 22 weeks who reports no fetal movement felt yet 3. Primip at 26 weeks with fundal height of 30 cm 4. Multip at 12 weeks reports bright red vaginal bleeding.

Correct Answer: 1 Rationale 1: This is an expected finding because fetal heart tones should be heard by 12 weeks using an ultrasonic Doppler fetoscope.

Rationale 2: This is an abnormal finding. Fetal movement should be felt by 20 weeks.

Rationale 3: This is an abnormal finding. Beginning in the second trimester, the fundal height should correlate with weeks of gestation; thus, at 26 weeks’ gestation, the fundal height should be about 26 cm.

Rationale 4: This is an abnormal finding. Bright red bleeding during pregnancy is never expected.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Predict the normal physiologic changes a nurse would expect to find when performing a physical assessment of a pregnant woman.

Question 11 Type: MCSA The nurse receives a phone call from a patient who thinks she is pregnant. The patient reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What is the patient’s estimated date of delivery (EDD)?

1. November 13 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. January 17 3. January 10 4. December 3 Correct Answer: 2 Rationale 1: Naegele’s rule is to add 7 days to the last menstrual period and subtract 3 months. The LMP is April 10; therefore, January 17 is the EDD. Rationale 2: Naegele’s rule is to add 7 days to the last menstrual period and subtract 3 months. The LMP is April 10; therefore, January 17 is the EDD. Rationale 3: Naegele’s rule is to add 7 days to the last menstrual period and subtract 3 months. The LMP is April 10; therefore, January 17 is the EDD. Rationale 4: Naegele’s rule is to add 7 days to the last menstrual period and subtract 3 months. The LMP is April 10; therefore, January 17 is the EDD. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Calculate the estimated date of birth using the common methods.

Question 12 Type: MCSA The nurse explains to a pregnant woman that her antepartum assessment will include assessment of clinical pelvimetry. Which patient response reflects understanding of the reason for this test?

1. “It will help understand how big a baby I can have.”

2. “It will be used to find out whether my baby has a chromosomal abnormality."

3. “It will help tell whether my pelvis is big enough to deliver my baby vaginally."

4. “It will be used to screen for gestational diabetes.”

Correct Answer: 3 Rationale 1: Clinical pelvimetry is performed to estimate the adequacy of pelvic size for the purpose of vaginal delivery; delivery of larger infants may be accommodated via Cesarean section.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Clinical pelvimetry involves estimating the adequacy of pelvic size for facilitating vaginal birth.

Rationale 3: Clinical pelvimetry is performed to estimate the ease or difficulty associated with vaginal delivery of an infant.

Rationale 4: Screening for maternal gestational diabetes requires some form of glucose screening.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Describe the essential measurements that can be determined by clinical pelvimetry.

Question 13 Type: MCSA The nurse is assisting a physician during a prenatal examination. The physician seeks to estimate the adequacy of the patient’s pelvis for birth. The nurse understands that the physician will need to perform which measurement vaginally?

1. True conjugate 2. Diagonal conjugate 3. Transverse outlet diameter 4. Obstetrical conjugate Correct Answer: 2 Rationale 1: The true conjugate is a measurement of the pelvic inlet and cannot be directly measured.

Rationale 2: The diagonal conjugate is measured from the lower edge of the symphysis to the sacral promontory.

Rationale 3: The transverse outlet diameter is measured externally.

Rationale 4: The obstetrical is a measurement of the pelvic inlet and cannot be directly measured.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO07 - Describe the essential measurements that can be determined by clinical pelvimetry.

Question 14 Type: MCSA The nurse is working with a prenatal patient. Which statement indicates that additional teaching is necessary?

1. “I will have Rh testing, even though this is my first pregnancy.”

2. My vagina will be cultured at 36 weeks for group B strep.”

3. “Because I am married, I won’t have the STI screening.”

4. “My blood will be checked for hemoglobin level.”

Correct Answer: 3 Rationale 1: This is a true statement. All patients are screened for blood type, Rh factor, and Rh antibodies, regardless of how many previous pregnancies (if any) they have had.

Rationale 2: This is a true statement. Women are tested for group B strep to prevent neonatal infection.

Rationale 3: All women should be screened for syphilis, gonorrhea, and hepatitis B. Rationale 4: This is a true statement. All women will have their hemoglobin assessed.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Describe the major screening tests used during the prenatal period in the assessment of the prenatal patient.

Question 15 Type: MCSA Which phone call should the prenatal clinic nurse return first?

1. Primip at 32 weeks, reports headache and blurred vision 2. Multip at 18 weeks, reports no fetal movement this pregnancy 3. Primip at 16 weeks, reports increased urinary frequency Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Multip at 40 weeks, reports sudden gush of fluid and contractions Correct Answer: 1 Rationale 1: Headache and blurred vision are signs of pre-eclampsia, which is potentially life-threatening for both mother and fetus. This patient has top priority.

Rationale 2: Fetal movement should be felt by 19–20 weeks. Multips sometimes feel fetal movement prior to 19 weeks, but the lack of fetal movement prior to 20 weeks is considered normal. This patient is a lower priority.

Rationale 3: Increased urinary frequency is common during pregnancy as the increased size of the uterus puts pressure on the urinary bladder. Urinary frequency is expected. If the patient were reporting dysuria or hematuria, a UTI would be suspected, but this patient is only reporting increased urinary frequency. This patient is a lower priority.

Rationale 4: A term patient who is experiencing contractions and a sudden gush of fluid is in labor. Although laboring patients should be in contact with their provider for advice on when to go to the hospital, labor at term is an expected finding. This patient is a lower priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO09 - Assess the prenatal patient for the danger signs of pregnancy.

Question 16 Type: MCSA The nurse is completing an assessment for a prenatal visit. Which statement indicates that further teaching is necessary?

1. “Because I’m in my third trimester, I should return to the clinic in a month.”

2. “Now that I’ve felt fetal movement, I should feel movement regularly.”

3. “Before I take any over-the-counter medications, I should contact my doctor.”

4. “Alcohol is possibly harmful to my baby, even at the end of my pregnancy.”

Correct Answer: 1 Rationale 1: This statement is incorrect because prenatal visits during the third trimester are every two weeks from 26 to 36 weeks, and every week from 36 weeks to delivery.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: This is a true statement. Once fetal movement is perceived, it should be felt regularly. Initially, this might not be every day, but in the third trimester, fetal movement should be noticeable several times per day.

Rationale 3: This is a true statement. Regardless of the gestational age, over-the-counter medications can have deleterious effects on mom or baby; thus, it is important for a pregnant woman to consult her provider prior to taking any over-the-counter medications throughout the pregnancy.

Rationale 4: This is a true statement. Alcohol should be avoided throughout pregnancy and lactation.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO10 - Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal patient.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 11 Question 1 Type: MCSA The nurse is preparing a class for expectant fathers. Which information should the nurse include?

1. Siblings adjust readily to the new baby.

2. Sexual activity is safe for normal pregnancy.

3. The expectant mother decides the feeding method.

4. Fathers are expected to be involved in labor and birth.

Correct Answer: 2 Rationale 1: Siblings often have difficulty adapting to the arrival of a new baby. Regression is often seen in siblings’ behaviors.

Rationale 2: During a normal pregnancy, sexual activity is safe for both mother and baby.

Rationale 3: Often, the father wants input into the feeding method.

Rationale 4: In some cultures, labor and birth are only for women, and it is inappropriate for fathers to be involved with the labor and birth.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Describe the most appropriate nursing care to help maintain the well-being of the expectant father and siblings during a family’s pregnancy.

Question 2 Type: MCSA The nurse is caring for a pregnant patient. The patient’s husband has come to the prenatal visit. Which question is best for the nurse to use to assess the adaptation to pregnancy by the father-to-be?

1. “What kind of work do you do?”

2. “What furniture have you gotten for the baby?”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “How moody has your wife been lately?”

4. “How are you feeling about becoming a father?”

Correct Answer: 4 Rationale 1: What kind of work the husband does is not an indicator of his adaptation.

Rationale 2: What furniture has been obtained is not an indicator of his adaptation.

Rationale 3: The husband’s perception of his wife’s moodiness is not an indicator of his adaptation.

Rationale 4: The adaptation of a husband to pregnancy includes his feelings about impending fatherhood.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe the most appropriate nursing care to help maintain the well-being of the expectant father and siblings during a family’s pregnancy.

Question 3 Type: MCSA The nurse is caring for a patient in the prenatal clinic. The patient recently arrived in the United States as a refugee from a country in Africa. This is the first patient from this cultural background with whom the nurse has worked. Which intervention is most appropriate in the care of this patient?

1. Ask the patient about her expectations during the labor and birth.

2. Determine if the patient has been tested for tuberculosis.

3. Help the patient into the paper dressing gown prior to her exam.

4. Look for written handouts on prenatal care in the patient’s language.

Correct Answer: Rationale 1: Women new to the U.S. will have little or no experience with the U.S. health care system. Culture heavily influences a patient’s behaviors and attitudes during pregnancy, labor, and birth, so determining what the patient wants during her labor and birth will facilitate both a better experience for the family and a calmer situation for the health care team.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Although tuberculosis is pandemic in refugee camps, and testing for tuberculosis in new arrivals to the U.S. is important, this question is about prenatal care. Testing for tuberculosis is not related to prenatal care.

Rationale 3: The patient is probably unfamiliar with paper dressing gowns and will need some instruction (often through demonstration). But this is not the highest priority. It is more important to find out what the patient expects to happen during her labor and birth.

Rationale 4: Providing written handouts in the patient’s primary language is important. But a higher priority for prenatal care would be to assess what the patient’s expectations for labor and birth are.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Examine the significance of cultural considerations in managing nursing care during pregnancy.

Question 4 Type: MCSA A Hispanic American patient who is 26 weeks pregnant asks if her curandero, or folk healer, may accompany her to all future prenatal appointments. Which response by the nurse reflects respect for the patient's cultural beliefs?

1. "Yes, we will work as a team as much as possible in taking care of you."

2. "National law prohibits the inclusion of anyone who is unlicensed to practice health care from giving healthrelated advice."

3. "Because of the risks to your baby, we do not recommend that patients use alternative healthcare methods."

4. "We prefer that only the father of the baby and your relatives accompany you to your prenatal visits."

Correct Answer: 1 Rationale 1: During pregnancy and birth, cultural and spiritual practices, including alternative healers and caregivers, should be incorporated into prenatal care as much as possible.

Rationale 2: While certain disciplines require licensure and certification, numerous complementary and alternative healers provide health-related advice.

Rationale 3: Cultural competence includes incorporating the patient's cultural and spiritual beliefs into her care, while evaluating the potential negative health consequences of her healthcare beliefs.

Rationale 4: The patient is free to choose who accompanies her during prenatal visits.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Examine the significance of cultural considerations in managing nursing care during pregnancy.

Question 5 Type: MCSA A Chinese woman who is 16 weeks pregnant reports to the nurse that ginseng and bamboo leaves help to reduce her anxiety. How should the nurse respond to this patient?

1. Advise the patient to avoid the use of all herbs.

2. Assess the amount and frequency with which the patient is using the remedy.

3. Tell the patient that her remedies have no scientific foundation.

4. Assess where the patient obtains her remedy, and investigate the source.

Correct Answer: 2 Rationale 1: Because some herbs have negative effects on pregnancy, using a reliable reference to determine the actions of the herbs can educate both the nurse and the patient.

Rationale 2: Use of herbs is a common alternative healthcare practice for many women. Pregnant women are often taught “secret family recipes” for avoiding or minimizing the discomforts of pregnancy. It is appropriate to assess the amount and frequency of the patient’s use of the herbs.

Rationale 3: Some remedies do have scientific foundation, so it is not appropriate to instruct the patient that none do.

Rationale 4: It is outside the nurse’s scope to assess the source of the herbs.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Examine the significance of cultural considerations in managing nursing care during pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 6 Type: MCSA The nurse is teaching an early pregnancy class for patients in the first trimester of pregnancy. Which statement requires immediate intervention by the nurse?

1. “When my nausea is bad, I will drink some ginger tea.”

2. “The fatigue I am experiencing will improve in the second trimester.”

3. “It is normal for my vaginal discharge to get green-colored.”

4. “I will urinate less often during the middle of my pregnancy.”

Correct Answer: 3 Rationale 1: Ginger helps nausea, and is safe for use during pregnancy.

Rationale 2: First-trimester fatigue is common; fatigue usually improves during the second trimester.

Rationale 3: Leukorrhea is an increase in white vaginal discharge and is an expected finding during pregnancy.

Green discharge is not a normal finding and indicates a bacterial infection. The infection can be a sexually transmitted infection or bacterial vaginosis. Further assessment is required for a patient with green vaginal discharge.

Rationale 4: As the uterus rises in the pelvis during the second trimester, urinary frequency decreases. Urinary frequency increases again during the end of the third trimester as the fetal head descends into the pelvis.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Explain the causes of the common discomforts of pregnancy.

Question 7 Type: MCSA A patient who is at 10 weeks' gestation tells her nurse, "I'm making too much saliva, and I spit on people every time I talk! What's wrong with me?" How should the nurse respond?

1. "Let's schedule you for a doctor's appointment, because excessive salivation can signal a complication of pregnancy."

2. "That's called ptyalism, and it's usually caused by increased salt intake during the second trimester."

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. "You should avoid astringent mouthwashes and chewing gum."

4. "Excess salivation commonly occurs during the first trimester, although the cause is unknown."

Correct Answer: 4 Rationale 1: Excess salivation, also called ptyalism, is a normal occurrence in women during the first trimester.

Rationale 2: Ptyalism, which is excess production of saliva, usually occurs during the first trimester and the cause is unknown.

Rationale 3: Astringent mouthwashes, chewing gum, and sucking hard candy may help relieve the bitter taste that often accompanies ptyalism.

Rationale 4: Ptyalism, which is excess production of saliva, commonly occurs during the first trimester and the cause is unknown.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Explain the causes of the common discomforts of pregnancy.

Question 8 Type: MCSA Upon arriving at the prenatal clinic in the morning, the nurse receives messages from four patients. Which patient complaint should be addressed first?

1. Primip at 9 weeks' gestation with increased fatigue and nocturia 2. Multip at 30 weeks' gestation with vaginal bleeding after performing yoga 3. Primip at 24 weeks' gestation with ankle edema 4. Multip at 35 weeks' gestation with new onset of hemorrhoids Correct Answer: 2 Rationale 1: Fatigue and increased urination at night is a common pregnancy-related discomfort during the first trimester.

Rationale 2: Vaginal bleeding after yoga is a warning sign that should be immediately reported to the primary care provider; this patient is the highest priority for care.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Particularly during the second and third trimester, ankle edema is a common pregnancy-related discomfort.

Rationale 4: Hemorrhoids are a common pregnancy-related discomfort, especially during the second and third trimester.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Summarize appropriate measures and interventions to alleviate the common discomforts of pregnancy.

Question 9 Type: MCSA A 32-year-old primipara who is 8 weeks' gestation asks you if she should expect any respiratory changes as her pregnancy progresses. What should the nurse tell her?

1. "By the third trimester, you will no longer feel as though you’re short of breath.”

2. "If you develop shortness of breath, it should improve in the last few weeks of your pregnancy, as lightening occurs."

3. "Shortness of breath is an abnormal finding during any stage of pregnancy, and it's considered a serious complication."

4. "You may experience shortness of breath due to stretching of the round ligament."

Correct Answer: 2 Rationale 1: Shortness of breath occurs as the uterus rises into the abdomen and causes pressure on the diaphragm. This problem worsens in the last trimester.

Rationale 2: The primigravida experiences considerable relief from shortness of breath in the last few weeks of pregnancy, when lightening occurs and the fetus and uterus move down in the pelvis.

Rationale 3: Because of decreased vital capacity from pressure of the enlarging uterus on the diaphragm, shortness of breath is a common problem of pregnancy.

Rationale 4: Round ligament stretching causes a “grabbing” sensation in the lower abdomen and inguinal area.

Global Rationale: Cognitive Level: Analyzing Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Summarize appropriate measures and interventions to alleviate the common discomforts of pregnancy.

Question 10 Type: MCSA The patient in her first trimester of pregnancy is experiencing nausea. To promote self-care, the nurse should help the pregnant patient understand that the nausea might be relieved by: 1. Eating spicy foods.

2. Not eating until two hours after rising.

3. Eating small, frequent meals.

4. Avoiding carbonated beverages.

Correct Answer: 3 Rationale 1: The nausea of pregnancy can be exacerbated by ketosis, fatigue, and certain foods, such as those containing caffeine or spices.

Rationale 2: Eating dry carbohydrates prior to rising each day can help to prevent or decrease the severity of the nausea.

Rationale 3: Avoiding severe hunger by eating small, frequent meals throughout the day can help to prevent or decrease the severity of the nausea.

Rationale 4: Carbonated beverages might be helpful in decreasing nausea.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Summarize appropriate measures and interventions to alleviate the common discomforts of pregnancy.

Question 11 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

A patient in her third trimester of pregnancy reports frequent leg cramps. What strategy would be most appropriate for the nurse to suggest?

1. Point the toes of the affected leg.

2. Increase intake of protein-rich foods.

3. Limit activity for several days.

4. Flex the foot to stretch the calf.

Correct Answer: 4 Rationale 1: Pointing the toes will exacerbate leg cramps.

Rationale 2: Protein intake does not affect leg cramps.

Rationale 3: Limiting activity is not appropriate.

Rationale 4: Leg cramps are a common problem in pregnancy, resulting from an imbalance in the calcium– phosphorus ratio; pressure on nerves or decreased circulation in the legs from the enlarged uterus; or fatigue.

Dorsiflexing the foot will stretch the calf muscles and will help relieve the cramps.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Summarize appropriate measures and interventions to alleviate the common discomforts of pregnancy.

Question 12 Type: MCSA The prenatal patient in her third trimester tells the clinic nurse that she works eight hours a day as a cashier and stands when at work. What response by the nurse is best?

1. “No problem. Your baby will be fine.”

2. “Do you get regular breaks for eating?”

3. “Your risk of preterm labor is higher.”

4. “Standing might increase ankle swelling.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: Standing more than five hours a day increases the risk of preterm labor. To be therapeutic in communication, avoid false reassurance.

Rationale 2: Although breaks for eating, drinking, and toileting are important for pregnant employees, it is more important to tell the patient about the increased risk of preterm labor.

Rationale 3: Pregnant women who stand for more than five a day have an increased risk of preterm labor.

Because preterm labor can put the infant’s life at risk, this statement would be the highest priority.

Rationale 4: Although this is true, it is less important than teaching the patient about the risks of preterm labor when standing more than five hours a day.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe self-care measures that a pregnant woman and her family can take to maintain and promote her well-being during pregnancy.

Question 13 Type: MCSA The pregnant patient has asked the nurse what kinds of medications cause birth defects. Which statement would best answer this question?

1. “Birth defects are very rare. Don’t worry; your doctor will watch for problems.”

2. “To be safe, don’t take any medication without talking to your doctor.”

3. “Too much vitamin C is one of the most common issues but is avoidable.”

4. “Almost all medications will cause birth defects in the first trimester.”

Correct Answer: 2 Rationale 1: The nurse should avoid a “don’t worry” answer to ensure therapeutic communication, but it is appropriate to instruct the patient to talk to the doctor about medications.

Rationale 2: Teratogens are substances that can cause birth defects. Alcohol is one example, as are warfarin (Coumadin) and isotretinoin (Roaccutane). The greatest risk is during the first trimester, but not all medications are teratogenic. Those medications with clear evidence of teratogenicity are classified in pregnancy category X and should be avoided when conception is being attempted and during the first trimester.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Vitamin C can cause rebound scurvy but is not teratogenic.

Rationale 4: Not all medications are teratogenic.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Describe self-care measures that a pregnant woman and her family can take to maintain and promote her well-being during pregnancy.

Question 14 Type: MCSA A pregnant patient who swims 3–5 times per week asks the nurse if she should stop this activity. What is the appropriate nursing response?

1. “You should decrease the number of times you swim per week.”

2. “You should continue your exercise program because it would be beneficial.”

3. “You should discontinue your exercise program immediately.”

4. “You should increase the number of times you swim per week.”

Correct Answer: 2 Rationale 1: Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.

Rationale 2: Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.

Rationale 3: Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.

Rationale 4: Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Describe self-care measures that a pregnant woman and her family can take to maintain and promote her well-being during pregnancy.

Question 15 Type: MCSA The pregnant patient is in her 21st week of pregnancy and is planning a vacation with her family. She asks the nurse which method of travel would be recommended for her to use. How should the nurse respond? “The safest method of travel is to: 1. “Take an automobile.”

2. “Fly on an airplane.”

3. “Travel by train.”

4. “Not travel this late in pregnancy.”

Correct Answer: 3 Rationale 1: Automobile travel does not allow for frequent enough movement.

Rationale 2: Airplane travel does not allow for frequent enough movement.

Rationale 3: In the latter half of pregnancy, frequent movement is recommended for pregnant women, both to increase comfort and to decrease venous pooling, which can lead to thrombophlebitis. The train allows the most movement for the traveling pregnant woman.

Rationale 4: It is not necessary to cease travel altogether.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe self-care measures that a pregnant woman and her family can take to maintain and promote her well-being during pregnancy.

Question 16 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is explaining the importance of fetal activity assessment to the patient. What should the nurse do to best reinforce the significance of fetal kick counting to the patient?

1. Perform daily phone calls to the patient at work or home.

2. Review the patient’s written record of fetal movement at each visit.

3. Ask the patient to remember to count the fetal movements.

4. Explain the rationale for counting fetal movement to the patient.

Correct Answer: 2 Rationale 1: Daily phone calls would take emphasis away from the importance of the patient’s counting of fetal movement.

Rationale 2: Patients should be instructed to begin counting fetal movement between 24 and 28 weeks. A fetus that has been active and has a sudden decrease in movements could be conserving energy due to hypoxia.

Movements are counted in a specified time period, such as for one hour after each meal, or beginning with arising in the morning.

Rationale 3: Writing down the count is more accurate than the patient’s simply remembering. When the nurse examines the written record the patient has kept, it reinforces the importance of the record and improves the likelihood of continued record keeping.

Rationale 4: Knowing the reasons for the counting will increase understanding of the process but will not reinforce its significance of the task.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe self-care measures that a pregnant woman and her family can take to maintain and promote her well-being during pregnancy.

Question 17 Type: MCSA A 23-year-old patient is 10 weeks' gestation with her first pregnancy. She expresses worry over feeling no sexual desire for her husband and asks if this is normal. How should the nurse respond?

1. "That sounds normal. In many cases, sexual desire decreases in the first trimester, but it increases again during the second trimester."

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. "That's unusual. Usually, there are minimal changes in sexual desire throughout a healthy pregnancy."

3. "That sounds normal. During the first trimester, sexual desire often decreases; however, by the third trimester, sexual desire is usually greater than before pregnancy."

4. "That's unusual. Throughout a healthy pregnancy, sexual desire usually increases with each trimester."

Correct Answer: 1 Rationale 1: During the first trimester, factors such as fatigue, nausea, vomiting, and breast tenderness may decrease desire for sexual activity. During the second trimester, as these discomforts lessen and pelvic vascular congestion increases, the woman may experience greater sexual satisfaction than before pregnancy.

Rationale 2: While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester.

Rationale 3: While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester.

Rationale 4: While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Examine the concerns that the expectant couple may have about sexual activity.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 12 Question 1 Type: MCSA The prenatal clinic nurse is caring for a 15-year-old primiparous patient at 8 weeks’ gestation. The patient is 64 inches tall and weighs 115 pounds. The patient asks the nurse why she is supposed to gain so much weight. What is the best response by the nurse?

1. “Gaining 25–35 pounds is recommended for healthy fetal growth.”

2. “It’s what your certified nurse–midwife recommended for you.”

3. “Inadequate weight gain delays lactation after delivery.”

4. “Weight gain is important to assure that you get enough vitamins.”

Correct Answer: 3 Rationale 1: For an appropriate weight woman, 25–35 pounds of weight gain is recommended for optimal fetal growth and development.

Rationale 2: Although this statement might be true, the patient has asked a “why” question that should be directly answered.

Rationale 3: Inadequate weight gain can lead to decreased fetal growth and development.

Rationale 4: Vitamin intake is related to the types of food consumed, not to caloric intake. Because this patient is 15, her diet is probably not optimal, and her intake of empty calories or junk food might make up the majority of her calorie intake.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Describe the recommended levels of weight gain during pregnancy when providing nursing caring for pregnant women.

Question 2 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is preparing an antenatal nutrition class for pregnant women. Which material should be included in the teaching?

1. Dietary protein can only be obtained through consuming dairy, meat, and eggs.

2. During pregnancy, consumption of oily fish should be avoided.

3. Iron absorption is generally higher for vegetable products than for animal products.

4. Nutritional iodine requirements generally can be met through intake of iodized salt.

Correct Answer: 4 Rationale 1: Excluding dairy, meat, and eggs, adequate dietary protein can be obtained by consuming a varied diet with adequate caloric intake and plant-based proteins.

Rationale 2: Oily fish provide the best source of docosahexaenoic acid (DHA), which may reduce the risk of preterm birth, preeclampsia, low birth weight, and enhance fetal and infant brain development.

Rationale 3: Iron absorption is generally higher for animal products than for vegetable products.

Rationale 4: Intake of iodized salt generally provides the recommended intake of iodine.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Explain the significance of specific nutrients in the diet of the pregnant woman.

Question 3 Type: MCSA The nurse is presenting a preconception counseling class. The nurse instructs the participants that niacin intake should increase during pregnancy to promote metabolic coenzyme activity. The nurse would know that teaching has been effective if a patient suggests which of the following foods as a source of niacin?

1. Fish 2. Apples 3. Broccoli 4. Milk Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: Dietary sources of niacin include meats, fish, and enriched grains.

Rationale 2: Apples will provide sources of other vitamins; however, they do not contain significant niacin.

Rationale 3: Broccoli will provide sources of other vitamins; however, it does not contain significant niacin.

Rationale 4: Milk will provide sources of other vitamins; however, it does not contain significant niacin.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Explain the significance of specific nutrients in the diet of the pregnant woman.

Question 4 Type: MCSA The nurse evaluates the diet of a pregnant patient and finds that it is low in zinc. The nurse knows that zinc intake should increase during pregnancy to promote protein metabolism. Which of the following foods should the nurse suggest in order to increase intake of zinc?

1. Shellfish 2. Bananas 3. Yogurt 4. Cabbage Correct Answer: 1 Rationale 1: Zinc is found in greatest concentration in meats and meat by-products. Enriched grains also tend to be high in zinc.

Rationale 2: Bananas are high in other nutrients but do not have significant levels of zinc.

Rationale 3: Yogurt is high in other nutrients but does not have significant levels of zinc.

Rationale 4: Cabbage is high in other nutrients but does not have significant levels of zinc.

Global Rationale:

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Explain the significance of specific nutrients in the diet of the pregnant woman.

Question 5 Type: MCSA The nurse is providing nutritional counseling for a postpartum patient with a hemoglobin of 8.0. Which statement indicates that additional teaching is necessary?

1. “My iron is low, but it will increase as I take iron supplements.”

2. “I need to increase food sources that contain iron.”

3. “If I drink lots of milk, I will increase my iron level faster.”

4. “I might feel less energetic and tire more easily while my iron is low.”

Correct Answer: 3 Rationale 1: Iron supplements are indicated with anemia. This patient’s hemoglobin level is 8.0; lower than 10 is considered anemia during pregnancy. Taking iron will increase hemoglobin.

Rationale 2: Anemia requires additional iron. Many foods, such as red meat, will provide iron. Increasing ironrich foods will improve anemia.

Rationale 3: Milk does not contain iron; it contains calcium. Increased calcium intake will not increase hemoglobin levels. Further, iron should not be taken with milk, as the iron will not be absorbed.

Rationale 4: Hemoglobin carries oxygen; when the hemoglobin level is low, the muscles are not adequately oxygenated, especially during activity, and fatigue results.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Compare nutritional needs during pregnancy, the postpartum period, and lactation with non-pregnant requirements.

Question 6 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The breastfeeding mother is concerned that her milk production has decreased. The nurse knows that further patient teaching is needed based on which statement?

1. “I am drinking a minimum of 8–10 glasses of liquid a day.”

2. “I have started cutting back on my protein intake.”

3. “At least three times a day, I am drinking a glass of milk.”

4. “I try to take a nap in the morning and afternoon when the baby is sleeping.”

Correct Answer: 2 Rationale 1: The breastfeeding mother must consume a minimum of 8–10 glasses of liquid per day.

Rationale 2: The decreased intake of protein will decrease milk production.

Rationale 3: The breastfeeding mother must increase her protein and calcium intake.

Rationale 4: It has also been found that adequate rest is necessary for the body to maintain its production of milk.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Compare nutritional needs during pregnancy, the postpartum period, and lactation with non-pregnant requirements.

Question 7 Type: MCSA The nurse is conducting a postpartum home visit. The patient has been home for a week and is formula feeding her infant. Which statement by the patient indicates that she understands the teaching?

1. "I have increased my caloric intake by 600 calories per day."

2. "My dietician has set my weight loss goal at 1 to 2 pounds per week."

3. "Instead of making another doctor's appointment, I started a diet that my best friend recommended."

4. "My daily regimen includes taking extra vitamin A, vitamin C, and thiamine in order to meet my body's increased need for nutrients after pregnancy."

Correct Answer: 2 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: If the mother has a good understanding of nutritional principles, it is sufficient to advise her to reduce her daily caloric intake by about 300 kcal and to return to pre-pregnancy levels for other nutrients.

Rationale 2: Weight loss goals of 1 to 2 lb. (0.45 to 0.9 kg)/week are usually suggested for mothers who formula feed.

Rationale 3: The woman should diet only under the guidance of her primary healthcare provider.

Rationale 4: After birth, the formula-feeding mother’s dietary requirements return to pre-pregnancy levels.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Compare nutritional needs during pregnancy, the postpartum period, and lactation with non-pregnant requirements.

Question 8 Type: MCSA The nurse is planning an educational session for pregnant vegans. What information should the nurse include?

1. Eating beans and rice provides complete protein needs.

2. Soy is not a good source of protein for vegans.

3. Rice contains a high level of vitamin B12.

4. Vegan diets are high in iron.

Correct Answer: 1 Rationale 1: Neither rice nor beans and other legumes contain complete protein requirements on their own.

However, consuming both in a meal or in a day provides for complete protein needs.

Rationale 2: Soy is a very good source of protein and calcium and is safe during pregnancy.

Rationale 3: Rice contains very low amounts of vitamin B12. Four servings of vitamin B12 per day are recommended during pregnancy.

Rationale 4: Vegan diets are low in iron, and pregnant vegans often experience anemia.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy.

Question 9 Type: MCSA A pregnant patient who is a lacto-ovo vegetarian asks the nurse to help her plan a diet that includes adequate protein intake. What instruction should the nurse give?

1. “Because you don't eat meat, eggs, or dairy products, it's important to eat adequate plant-based proteins.”

2. “To improve protein absorption, avoid simultaneous intake of animal protein and plant protein.”

3. “Following a lacto-ovo vegetarian diet will require you to take a daily supplement of vitamin B12.”

4. “In addition to eggs and dairy products, beans, peanut butter, and soy milk can be effective sources of plantbased proteins.”

Correct Answer: 4 Rationale 1: While lacto-ovo vegetarians do not eat meat, they do eat eggs, milk, and dairy products.

Rationale 2: Plant protein quality can be improved if it is consumed with certain animal proteins.

Rationale 3: Vegan diets, in which no animal products are consumed, often require daily supplementation of vitamin B12.

Rationale 4: A diet that includes plant proteins such as beans and rice, peanut butter on whole-grain bread, and whole-grain cereal with soymilk, helps ensure the expectant mother obtains all the essential amino acids.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy.

Question 10 Type: MCSA Which patient statement on cultural or religious influences on nutrition requires intervention?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “My grandmother makes sure I eat a serving of greens each day.”

2. “I avoid milk and meat at meals because I am Jewish.”

3. “My auntie sent me clay from the south to eat every day.”

4. “Because I am Muslim, I do not ever eat any pork products.”

Correct Answer: 3 Rationale 1: Greens, such as collard greens and spinach, have high amounts of folic acid and are healthy foods to eat during pregnancy. Women from the southern United States often eat greens.

Rationale 2: A kosher diet involves avoiding pork and shellfish and not eating dairy and meat at the same meal.

Rationale 3: Eating clay is pica. The clay, being a type of soil, can be contaminated with hazardous substances and should be avoided. Some African Americans, especially those from the south, practice clay-eating pica.

Rationale 4: Dietary restrictions in the Muslim tradition include avoidance of pork. Because other meats are eaten, the patient is not at risk for protein or iron deficiency.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing care management of pregnant women.

Question 11 Type: MCSA The nurse is working with a pregnant 14-year-old. The patient confides that she's concerned she may be struggling with bulimia nervosa. Which nursing observation best supports the patient's statement?

1. The patient is of normal weight for her height and reports binge eating followed by purging.

2. Despite being extremely underweight, the patient describes herself as being fat.

3. The patient reports dietary cravings for soil and clay.

4. In terms of food variety and quantity, the patient's diet is extremely restrictive.

Correct Answer: 1

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Bulimia is characterized by binge eating and purging, and individuals with bulimia nervosa often maintain normal or near-normal weight for their height.

Rationale 2: Anorexia nervosa is an eating disorder characterized by an extreme fear of weight gain and fat, and it incorporates a self-perception of being overweight even when the individual is extremely underweight.

Rationale 3: Dietary cravings for and consumption of nonnutritive substances is consistent with pica.

Rationale 4: The dietary intake of individuals with anorexia nervosa is very restrictive in both variety and quantity.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing care management of pregnant women.

Question 12 Type: MCSA When preparing nutritional instruction, which of the following pregnant patients would the nurse consider highest priority?

1. 40-year-old gravida 2 2. 22-year-old primigravida 3. 35-year-old gravida 4 4. 15-year-old nulligravida Correct Answer: 4 Rationale 1: The 40-year-old has completed her growth cycle, and her body can focus on diverting the nutritional needs to the fetus.

Rationale 2: The 22-year-old has completed her growth cycle, and her body can focus on diverting the nutritional needs to the fetus.

Rationale 3: The 35-year-old has completed her growth cycle, and her body can focus on diverting the nutritional needs to the fetus.

Rationale 4: Adolescent patients typically are still in their own growth cycle. Suddenly, they have to supply nutrition for themselves and the fetus. This places them at greatest risk for malnutrition.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare recommendations for weight gain and nutrient intakes in the pregnant adolescent with those for the mature pregnant adult.

Question 13 Type: MCSA Which statement is best to include when teaching a pregnant adolescent about nutritional needs of pregnancy?

1. “It is important eat iron-rich foods like meat every day.”

2. “Calcium and milk aren’t needed until the third trimester.”

3. “Folic acid intake is the key to having a healthy baby.”

4. “You just need to pay attention to what you eat now.”

Correct Answer: 1 Rationale 1: Adolescents often have an iron intake that is inadequate for pregnancy. Giving specific examples are most helpful when giving nutritional information.

Rationale 2: Calcium is needed throughout pregnancy and should be consumed daily.

Rationale 3: Although folic acid is important during pregnancy to prevent neural tube defects, and for lactation, there is not one single nutritional element responsible for having a healthy baby.

Rationale 4: This response is too vague to be helpful. Adolescents will need specific information to improve nutrition during pregnancy.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent.

Question 14 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The school nurse is planning a class about nutrition for pregnant teens. The nurse knows that several of the pregnant teenage patients have been diagnosed with iron-deficiency anemia. Which should the nurse encourage the teens to consume more of in order to increase iron absorption?

1. Gatorade 2. Orange juice 3. Milk 4. Green tea Correct Answer: 2 Rationale 1: Gatorade does not contain vitamin C. Rationale 2: Vitamin C is found in citrus fruits and juices and is known to enhance the absorption of iron from meat and non-meat sources.

Rationale 3: Milk does not contain vitamin C. Rationale 4: Green tea does not contain vitamin C. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent.

Question 15 Type: MCSA The nurse is working with a pregnant teen. In order to accurately assess the teen’s nutritional intake, the nurse should: 1. Assess laboratory values.

2. Ask her to complete a 24-hour dietary recall.

3. Observe for clinical signs of malnutrition.

4. Ask about her cooking facilities.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 2 Rationale 1: Laboratory values only provide information about the nutritional status of the patient.

Rationale 2: A 24-hour recall is the only method listed that assesses the patient’s food intake.

Rationale 3: Clinical signs of malnutrition only provide information about the nutritional status of the patient.

Rationale 4: Cooking facilities might not be related to food intake.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent.

Question 16 Type: MCSA The nurse is leading a session on nutrition for newly delivered women. Which statement indicates that teaching has been effective?

1. “Because I am breastfeeding, I need a low calcium intake.”

2. “Breastfeeding requires that I eat lots of protein daily.

3. “Since I am bottle-feeding, I don’t have to eat vegetables.”

4. “Bottle-feeding moms like me require a high sodium intake.”

Correct Answer: 2 Rationale 1: Breastfeeding requires an increase of 1,000 mg per day of calcium—the same amount of calcium that is recommended during pregnancy.

Rationale 2: Breastfeeding patients should consume 65 g of protein daily during the first six months of breastfeeding and 62 g daily during the second six months. Protein is a major ingredient in breast milk.

Rationale 3: Although vitamin intake is not directly related to bottle-feeding, good nutritional habits are important to form while bottle-feeding, because in the future, the baby will be eating what the mother eats.

Rationale 4: Sodium intake is not increased during bottle-feeding.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Compare nutritional counseling issues for breastfeeding and formula-feeding mothers.

Question 17 Type: MCSA The nurse is preparing a prenatal class about infant feeding methods. The maternal nutritional requirements for breastfeeding and formula-feeding will be discussed. What statement should the nurse include?

1. “Breastfeeding requires a continued high intake of protein and calcium.”

2. “Formula-feeding mothers should protect their health with a lot of calcium.”

3. “Producing breast milk requires calories, but any source of food is fine.”

4. “Formula-feeding mothers need a high protein intake to avoid fatigue.”

Correct Answer: 1 Rationale 1: Lactation requires calories, along with increased protein and calcium intake.

Rationale 2: Formula-feeding mothers do not need additional nutrients.

Rationale 3: Although any food source would provide the additional calories, these needs are best met by using increased protein intake as the source for the required additional calories to support milk production.

Rationale 4: Formula-feeding moms do not need additional nutrients.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Compare nutritional counseling issues for breastfeeding and formula-feeding mothers.

Question 18 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is observing the meal selections of a group of pregnant and postpartal patients. One meal consists of a cup of skim milk, soy burger on a bun, baked beans, 8 ounces of water, four carrot sticks, and a mixed fresh fruit cup. For which patient is this meal the best choice?

1. 27-year-old primip, 8 weeks’ gestation, Hgb 11.0 2. 30-year-old multip two days postpartum, bottle-feeding 3. 15-year-old primip, one day postpartum, breastfeeding 4. 20-year-old multip, 32 weeks’ gestation, reports fatigue.

Correct Answer: 3 Rationale 1: This patient needs a high-iron diet. The meal described is high in calcium and protein, but low in iron.

Rationale 2: The meal described is high in calcium and protein. This meal would be more than adequate for a bottle-feeding patient, but it is better suited to a breastfeeding patient.

Rationale 3: This is the best patient for this meal. Because the patient is an adolescent, she needs a high-protein diet, and because she is breastfeeding, she needs a high-calcium diet. The meal described is high in calcium and protein: milk, soy, and beans all are sources of protein, while milk and soy are good sources of calcium.

Rationale 4: The high protein and calcium of the described meal are good during pregnancy, but the report of fatigue could indicate a low hemoglobin level that requires additional assessment prior to recommending a specific diet.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO09 - Apply the nursing process to support an optimal diet for the pregnant or postpartum woman.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 13 Question 1 Type: MCSA The nurse is giving a community presentation about adolescent pregnancy. Which presentation statement most accurately reflects a challenge of pregnancy associated with early adolescence?

1. “Pregnancy is less likely to be related to an intimate relationship.”

2. “Girls in this stage have developed value systems that are separate and distinct from those of their parents.”

3. “Most often, when a girl in early adolescence enters the healthcare system, she will be accompanied by the father of the baby.”

4. "Self-consciousness about body changes related to pregnancy usually isn't an issue for early adolescents."

Correct Answer: 1 Rationale 1: For early adolescents, pregnancy is probably not the result of an intimate relationship.

Rationale 2: The early adolescent's value system still closely reflects that of parents, so she turns to her parents for a decision or approval of a decision.

Rationale 3: During early adolescence, a pregnant girl generally enters the healthcare system with an adult, most likely her mother; parents are still seen as locus of control.

Rationale 4: Along with self-consciousness about normal physiologic changes, for early adolescents, selfconsciousness and low self-esteem are likely to intensify with rapid breast enlargement and abdominal enlargement of pregnancy.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Compare the three stages of adolescence: early adolescence, middle adolescence, and late adolescence.

Question 2 Type: MCSA The school sexual health clinic nurse has female adolescent students waiting to be seen. Which student should be seen first?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. 14-year-old whose 17-year-old sister is pregnant 2. 15-year-old who reports using condoms regularly 3. 16-year-old who had Chlamydia treated two weeks ago 4. 17-year-old with a history of child abuse Correct Answer: 3 Rationale 1: Although this student is at risk for becoming pregnant because her sister is experiencing an adolescent pregnancy, it is not known whether this patient is sexually active. This student is not the top priority.

Rationale 2: Condom use will decrease the risk of becoming pregnant. This patient is a low priority.

Rationale 3: This patient is the top priority. Having had Chlamydia, a sexually transmitted infection, indicates that the patient is sexually active and not using a barrier method of birth control. This patient is at risk for pregnancy and another STI. Rationale 4: Although adolescents with a history of abuse are more likely to become pregnant than are their peers who have not experienced abuse, too little information is given about this patient to determine risk for pregnancy.

This patient is not the top priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Describe the major factors that contribute to adolescent pregnancy.

Question 3 Type: MCSA While developing a conference for adolescents, the nurse prepares a handout describing socioeconomic and cultural factors that contribute to adolescent pregnancy. Which information should the nurse include in the handout?

1. All cultures share an aversion to early pregnancy.

2. The younger the teen when she first gets pregnant, the less likely she is to have another pregnancy in her teens.

3. Poverty is a major risk factor for teen pregnancy.

4. A child born to a teenage mother is at a lower risk for teen pregnancy.

Correct Answer: 3 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Early pregnancy is desirable in some cultures, such as where Islam is the predominant religion, where large families are desired, where social change is slow in coming, and where most childbearing occurs within marriage.

Rationale 2: The younger the teen when she first gets pregnant, the more likely she is to have another pregnancy in her teens.

Rationale 3: Poverty is a major risk factor for teen pregnancy, as 85% of births to unmarried teens occur among those adolescents from poor to low-income families.

Rationale 4: Daughters and sisters of a woman who had a baby in her early teens tend to have intercourse earlier and are at higher risk for teen pregnancy themselves.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Describe the major factors that contribute to adolescent pregnancy.

Question 4 Type: MCSA The nurse is working with a group of pregnant teens. Which statement indicates that teaching has been successful?

1. “Pregnant teens are more likely to quit school prior to graduation.”

2. “Because I am young, I have a low risk for pre-eclampsia.”

3. “My baby could come late because I am a teenager.”

4. “I am more likely to use birth control after I have this baby.”

Correct Answer: 1 Rationale 1: Patients who give birth the first time as adolescents are more likely to have lower educational levels, including a higher rate of dropping out of high school and not attending college or vocational training.

Rationale 2: Pre-eclampsia is more likely to occur in teen mothers than in mothers older than age 19.

Rationale 3: Postdates are not a risk for adolescent pregnancy; preterm birth and small-for-gestational-age infants are risks for pregnant teens.

Rationale 4: Patients who give birth the first time as adolescents are more likely to have their next child during adolescence as well. Birth control use is not higher among teen parents.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Identify the physical, psychologic, and sociologic risks faced by a pregnant adolescent.

Question 5 Type: MCSA A 20-weeks’-gestation adolescent patient states that it is important not to have a baby that weighs too much. She states this has been her rationale for limiting calories. Her weight has decreased from 110 pounds to 106 pounds.

What would be the best nursing response?

1. “You are causing harm to your baby.”

2. “It’s okay to want a small baby when you’re a teen.”

3. “You shouldn’t be worrying about your figure.”

4. “Your baby needs adequate nutrition to develop.”

Correct Answer: 4 Rationale 1: The first role of the nurse is to explain why food is important to the growing fetus, specifying how each food group will help the fetus develop. Next, the nurse must assist the pregnant adolescent to plan foods that she likes to eat from each food group.

Rationale 2: Anticipatory guidance in the body changes of pregnancy will assist the adolescent’s adjustment to them. Although many teens are anxious, this teen is expressing a direct nutritional deficit.

Rationale 3: Pregnant adolescents are just adapting to a new body image created by the changes of puberty when the pregnancy produces rapid and substantial body changes. The desire to maintain a socially desirable figure can lead to nutritional deficits.

Rationale 4: Teens might not understand the physiology behind the profound body changes of pregnancy.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO03 - Identify the physical, psychologic, and sociologic risks faced by a pregnant adolescent.

Question 6 Type: MCSA Which of the following statements, if made by the pregnant adolescent, indicates that she understands her increased risk of physiologic complications during pregnancy?

1. “It’s no big deal that I started prenatal care in my seventh month.”

2. “My anemia and eating mostly fast food are not important.”

3. “I need to take good care of myself so my baby doesn’t come early.”

4. “Smoking and using crack cocaine won’t harm my baby.”

Correct Answer: 3 Rationale 1: Early and regular prenatal care is the best intervention to prevent complications or to detect them early, to minimize the harm to both the teen and her fetus.

Rationale 2: Pregnant adolescents are at great risk for complications such as anemia.

Rationale 3: Early and regular prenatal care is the best intervention to prevent complications or to detect them early, to minimize the harm to both the teen and her fetus.

Rationale 4: Pregnant adolescents are at great risk for complications such as pregnancy-induced hypertension, anemia, preterm birth, low-birth-weight infants, fetal harm from cigarette smoking, alcohol consumption, or the use of street drugs.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify the physical, psychologic, and sociologic risks faced by a pregnant adolescent.

Question 7 Type: MCSA The nurse is working with male teens whose partners are pregnant. What situation requires that the nurse intervene? The father-to-be states that: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. He is the only other person who will be present, although his girlfriend wants her mother to be with her during the birth.

2. He is not convinced that he is the father of the baby and doesn’t want his name on the birth certificate.

3. The pregnancy doesn’t seem real to him, and he’s not sure what he should do to plan for the future.

4. Because his father was not involved in his life, he wants to be actively involved in the life of his child.

Correct Answer: 1 Rationale 1: It is common for pregnant adolescents to want their mothers to accompany them for the labor and birth. Overriding his girlfriend’s expressed desire could be an indication that their relationship is abusive. Because studies indicate 16–37% of pregnant teens experience abuse from their partners, this statement requires follow-up by the nurse to assess for abuse.

Rationale 2: Many young fathers are not sure if they are the father of the baby and do not want to be listed on the birth certificate if they are not sure. Often these young men will request paternity testing to either verify or discount their parentage.

Rationale 3: An early pregnancy is often an abstract concept to fathers. It is normal for a teen to be unsure about the future.

Rationale 4: This might be the case when a young father was raised without his own father, or a lack of involvement with the child might be seen as the norm and desired.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Delineate the characteristics of the fathers of children born to adolescent mothers.

Question 8 Type: MCSA The nurse seeks to involve the adolescent father in the prenatal care of his girlfriend. The rationale for this nursing strategy includes: 1. Increasing the self-care behaviors of the pregnant teen.

2. Avoiding conflict between the adolescent father and pregnant teen.

3. Improving the long-term outcome of the relationship.

4. Avoiding legal action by the adolescent father’s family.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: Involving the partner of a pregnant adolescent helps the mother-to-be feel more confident in her decision making and improves her self-confidence and self-esteem, which in turn will improve positive self-care behaviors.

Rationale 2: If the patient desires the participation of her partner, the nurse should provide education and support appropriate to the age, knowledge, and developmental level of the adolescent father.

Rationale 3: Involving the patient’s partner in prenatal care will not decrease the likelihood that this relationship will be short-term.

Rationale 4: The nurse first must explore what the relationship is between the pregnant teen and the father.

Relationships between adolescents tend to be short-lived, and pregnancy is an added stressor for the couple.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Delineate the characteristics of the fathers of children born to adolescent mothers.

Question 9 Type: MCSA Which statement by a parent of a pregnant, unmarried 15-year-old is expected?

1. “We’re very happy for her. It will be easier to focus on education with a new baby.”

2. “I’m not going to get involved. She understands how her health insurance works.”

3. “Her father told her to stop dating that boy. Now look at the trouble she’s gotten into.”

4. “An abortion is the best choice for her. She can deal with our Catholic priest later.”

Correct Answer: 3 Rationale 1: Most parents accept the pregnancy but are not excited when their 15-year-old is pregnant. And education is harder when child care is involved. Teens that give birth are less likely to complete their education.

Rationale 2: The parent of a pregnant teen is usually the support person and helps the teen understand how to access prenatal care. It is unlikely that a 15-year-old would understand health insurance.

Rationale 3: This statement indicates anger and dismay, which are expected when a parent finds out about a teen daughter’s pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: This statement indicates that the parent is not going to discuss the pregnancy with the teen but might be forcing the teen into abortion. Because religious tradition impacts views on abortion, and Catholicism disapproves of abortion, the teen might not accept abortion as an option.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Discuss the possible reactions of the adolescent’s family and social support group to the adolescent’s pregnancy.

Question 10 Type: MCSA Which of the following statements from the mother of a pregnant 13-year-old would be an expected response?

1. “We had such high hopes for you.”

2. “But she was always an easygoing child.”

3. “I told you that boy was up to no good.”

4. “This is just one of those things that happen.”

Correct Answer: 1 Rationale 1: When an adolescent pregnancy is first revealed to the teen’s mother, the result is often anger, shame, or disappointment. The degree of negative response will be determined by the age of the teen, the family expectations for the teen, and the presence or absence of other teen pregnancies in the family or support network.

In early adolescents, the teen’s mother frequently accompanies her daughter to prenatal examinations. The role of the nurse is to facilitate communication between mother and daughter and provide education for both.

Rationale 2: When an adolescent pregnancy is first revealed to the teen’s mother, the result is often anger, shame, or disappointment.

Rationale 3: When an adolescent pregnancy is first revealed to the teen’s mother, the result is often anger, shame, or disappointment.

Rationale 4: When an adolescent pregnancy is first revealed to the teen’s mother, the result is often anger, shame, or disappointment.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Discuss the possible reactions of the adolescent’s family and social support group to the adolescent’s pregnancy.

Question 11 Type: MCSA Which approach to planning educational activities is best suited to a group of pregnant adolescents?

1. Primarily using audio-based presentations during teaching 2. Avoiding the inclusion of handouts with bulleted items and white space as part of the teaching 3. Combining teaching for adolescent mothers of all ages as one group 4. Respecting confidentiality and building trust by avoiding the topics of drug and alcohol abuse Correct Answer: 1 Rationale 1: Many teens prefer teaching aids that are visual and that they can handle, such as realistic fetal models.

Rationale 2: Some pregnant teens have low reading levels and tend to prefer handouts and posters that have visual interest, short sentences, bulleted items, and white space.

Rationale 3: Teaching adolescents in groups according to their ages may be more effective for learning because younger adolescent mothers' parenting skills and emotional needs may differ from those of older adolescent mothers.

Rationale 4: The nurse should review the risks associated with the use of tobacco, caffeine, drugs, and alcohol, as well as discussing the fetal effects of these substances.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Formulate a plan of care to meet the needs of a pregnant adolescent.

Question 12 Type: MCSA The nurse is working in a teen pregnancy clinic. In order to give the pregnant adolescent a role in her prenatal care, the nurse should allow the teen to: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Choose the type of prenatal vitamin she takes.

2. Measure and record her weight at each visit.

3. Choose the schedule of her prenatal visits.

4. Decide if she wants her labor to be induced.

Correct Answer: 2 Rationale 1: Prenatal vitamins are prescribed by the certified nurse–midwife or the physician. Many formulations exist, and some might not be indicated for this patient due to her nutritional practices and lab results. In addition, if the patient is a member of a health maintenance organization, only certain medications (including prenatal vitamins) are accepted for coverage.

Rationale 2: Having the patient weigh herself and record her weight provides her with information that indicates she is growing a healthy fetus.

Rationale 3: Prenatal visit schedules are set to detect developing complications of pregnancy.

Rationale 4: Induction of labor is a medical decision and should not be taken lightly.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Formulate a plan of care to meet the needs of a pregnant adolescent.

Question 13 Type: MCSA A 16-year-old is making her first prenatal visit to the clinic in her fourth month of pregnancy. The nurse’s first responsibility would be to: 1. Contact the social worker.

2. Develop a trusting relationship.

3. Schedule the patient for prenatal classes.

4. Teach the patient about proper nutrition.

Correct Answer: 2

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: A social worker might be able to provide assistance with financial program eligibility, support groups, or obtaining baby items such as furniture and car seats.

Rationale 2: The most important goal for the nurse caring for a pregnant adolescent is to be open-minded and nonjudgmental in order to foster trust between the adolescent and the nurse. Through a trusting relationship, the nurse can provide counseling and education to the mother-to-be, both about her body and the fetus.

Rationale 3: Prenatal classes specifically designed for teen moms and attended by only teen moms facilitate both learning and support for the teens.

Rationale 4: Although nutrition is an important physiologic need, without a trusting relationship, little teaching will occur because the teen will often “tune out” adults that she does not trust.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Formulate a plan of care to meet the needs of a pregnant adolescent.

Question 14 Type: MCSA The nurse has been asked by a community organization to give a presentation on prevention of teen pregnancy.

Which statement indicates appropriate steps toward reduction of the local teen pregnancy rate?

1. Abstinence-only education will be offered in the school and clinics.

2. Classes on how to parent will be mandatory in high school.

3. Plans are made to create a low-cost reproductive health clinic.

4. Parents will be encouraged to avoid discussing sexual activity.

Correct Answer: 3 Rationale 1: Abstinence first with information on contraception is most effective in reducing teen pregnancy rates.

Rationale 2: Parenting classes for teens who are neither pregnant nor parents do not address reducing teen pregnancy.

Rationale 3: Confidential, low cost contraceptive education and services are most likely to increase contraceptive use by teens that are sexually active and therefore decrease teen pregnancy rates.

Rationale 4: Parents are the biggest influence on teens’ decisions to begin or avoid sexual activity. Parents should be encouraged to talk openly and frankly with their teens about their views on sex, contraception, and abstinence.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Describe successful community approaches to prevention of adolescent pregnancy.

Question 15 Type: MCSA The nurse is planning a community adolescent pregnancy prevention program aimed toward parents. Which of the following recommendations should be included in the program include in order to be effective?

1. Instead of bringing up the topic of sex, parents should allow their children to reach a point where the child initiates the discussion.

2. Parents should encourage steady dating.

3. Rather than embarrassing an adolescent by addressing specific topics related to sex, parents should speak in broad, general terms.

4. Parents should not allow their son to develop an intense relationship with a girl who is much younger.

Correct Answer: 4 Rationale 1: Parents need to talk with their children about sex early and often and be specific in the discussions.

Rationale 2: Parents need to clearly discourage early dating as well as frequent and steady dating.

Rationale 3: Parents should be specific in their discussions about sex.

Rationale 4: Parents should take a strong stand against allowing a daughter to date a much older boy; nor should they allow a son to develop an intense relationship with a much younger girl.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Describe successful community approaches to prevention of adolescent pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 14 Question 1 Type: MCSA The nurse is responding to phone calls. Which call should the nurse return first?

1. 37 weeks’ gestation, reports no fetal movement for 24 hours 2. 29 weeks’ gestation, reports increased fetal movement.

3. 32 weeks’ gestation, reports decreased fetal movement for 2 days 4. 35 weeks’ gestation, reports decreased fetal movement for 4 hours Correct Answer: 1 Rationale 1: A lack of fetal movement in a fetus in the third trimester can indicate fetal hypoxia or fetal death.

This patient is the highest priority.

Rationale 2: Increased fetal movement is not indicative of a problem.

Rationale 3: Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, this patient is not the highest priority.

Rationale 4: Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, four hours is a very short amount of time to assess decreased fetal movement.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity as a means of establishing fetal well-being.

Question 2 Type: MCSA A woman at 28 weeks’ gestation is asked to keep a fetal activity diary and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for over 30 minutes. The most appropriate initial comment by the nurse would be:

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “You need to come to the clinic right away for further evaluation.”

2. “Have you been smoking?”

3. “When did you eat last?”

4. “Your baby might be asleep.”

Correct Answer: 4 Rationale 1: The mother would need to come to the clinic only if there had been no fetal activity for several hours.

Rationale 2: Smoking typically will stimulate the infant.

Rationale 3: After meals, an infant typically is active and moving.

Rationale 4: Lack of fetal activity for 30 minutes typically is insignificant and means only that the infant is sleeping. If the mother truly is concerned, in 30 minutes, she could eat a complex-carbohydrate snack. This would stimulate the infant, and the mother should have fetal activity. But at present, this is an indicator the infant is sleeping.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity as a means of establishing fetal well-being.

Question 3 Type: MCSA The nurse is preparing a patient in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching had been effective?

1. “If the ultrasound is normal, it means my baby has no abnormalities.”

2. “The nuchal translucency measurement will diagnose Down syndrome.”

3. “I might be able to see who the baby looks like with the ultrasound.”

4. “Measuring the length of my cervix will determine if I will deliver early.”

Correct Answer: 3 Rationale 1: Not all fetal anomalies are detectable by ultrasound.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Nuchal translucency measurements are screening, not diagnostic, for trisomies 13, 18, and 21.

Rationale 3: Ultrasounds provide a very clear photo-like image of the fetus, often providing parents the opportunity to identify a familial characteristic such as nose shape.

Rationale 4: Transvaginal ultrasound is used to measure the cervical length as a screening for risk of preterm labor. However, a normal-length cervix does not preclude preterm birth.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Describe the methods, clinical applications, and results of ultrasound in the nursing care management of the pregnant woman.

Question 4 Type: MCSA A woman is at 32 weeks’ gestation. Her fundal height measurement at this clinic appointment is 26 centimeters.

After reviewing her ultrasound results, the healthcare provider asks the nurse to schedule the patient for a series of sonograms to be done every two weeks. The nurse should make sure that the patient understands that the main purpose for this is to: 1. Assess for congenital anomalies.

2. Evaluate fetal growth.

3. Determine fetal presentation.

4. Rule out a suspected hydatidiform mole.

Correct Answer: 2 Rationale 1: Assessment of anomalies would require only one ultrasound.

Rationale 2: A person who is at 32 weeks’ gestation should measure 32 cm of fundal height. When a discrepancy between fundal height and measurement exists, the purpose of serial ultrasounds is to monitor fetal growth.

Rationale 3: Fetal presentation would require only one ultrasound.

Rationale 4: Ruling out a hydatidiform mole would require only one ultrasound.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Describe the methods, clinical applications, and results of ultrasound in the nursing care management of the pregnant woman.

Question 5 Type: MCSA In assisting with an abdominal ultrasound procedure for determination of fetal age, the nurse: 1. Asks the woman to sign an operative consent form prior to the procedure.

2. Has the woman empty her bladder before the test begins.

3. Assists the woman into a supine position on the examining table.

4. Instructs the woman to eat a fat-free meal two hours before the scheduled test time.

Correct Answer: 3 Rationale 1: Abdominal ultrasounds are not invasive procedures and do not require a consent form.

Rationale 2: The recommendation is that the patient should have a full bladder to help elevate the uterus out of the pelvic cavity for better visualization.

Rationale 3: Patients are placed in a supine position on the table.

Rationale 4: Dietary intake is not relevant to the ultrasound.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Describe the methods, clinical applications, and results of ultrasound in the nursing care management of the pregnant woman.

Question 6 Type: MCSA The prenatal clinic nurse is responding to a patient who has had an assessment for fetal well-being. Which statement indicates that the patient understands the test result?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby.”

2. “The reactive nonstress test means that my baby is not growing because of a lack of oxygen.”

3. “Because my contraction stress test was positive, we know that my baby will tolerate labor well.”

4. “My biophysical profile score of 6 points indicates everything being normal and healthy for my baby.”

Correct Answer: 1 Rationale 1: The Doppler velocimetry test looks at blood flow through the umbilical artery. A normal result indicates there is no vasospasm decreasing blood flow to the placenta; therefore, the baby is getting an adequate blood supply.

Rationale 2: The nonstress test utilizes external fetal monitoring to assess the fetal heart rate in relationship to fetal movement. When accelerations in the fetal heart rate are associated with fetal movement (a reactive result), the fetus is well oxygenated, and the placenta is functioning well.

Rationale 3: A contraction stress test creates mild contractions. The presence of decelerations is termed a positive result and indicates a lack of adequate placental functioning.

Rationale 4: The biophysical profile score should be 8 (with adequate amniotic fluid) or 10. A score of 6 is abnormal and indicates that further assessment is needed.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Describe the use, procedure, information obtained, and nursing considerations to evaluate fetal well-being when using Doppler blood flow studies/umbilical velocimetry, nonstress test, contraction stress test, and biophysical profile test.

Question 7 Type: MCSA At 32 weeks’ gestation, a woman is scheduled for a second nonstress test (following the one she had at 28 weeks’ gestation). Which response by the patient would indicate an adequate understanding of this procedure?

1. “I can’t get up and walk around during the test.”

2. “I’ll have an IV started before the test.”

3. “I must avoid drinks containing caffeine for 24 hours before the test.”

4. “I need to have a full bladder for this test.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: The purpose of the nonstress test is to determine the results of movement on fetal heart rate. The patient will have to lie still on her side during the procedure.

Rationale 2: There is no IV needed to administer medications.

Rationale 3: Caffeine might cause the infant to be more active and cause the test to go more quickly.

Rationale 4: Patients usually are asked to have their bladders full only for ultrasounds.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Describe the use, procedure, information obtained, and nursing considerations to evaluate fetal well-being when using Doppler blood flow studies/umbilical velocimetry, nonstress test, contraction stress test, and biophysical profile test.

Question 8 Type: MCSA During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test and last 20 seconds each. The nurse realizes these results will be interpreted as: 1. A negative test.

2. A reactive test.

3. A non-reactive test.

4. An equivocal test Correct Answer: 3 Rationale 1: Nonstress tests are scored as either reactive or non-reactive.

Rationale 2: A reactive stress test has the expected results of an increase in heart rate of 15 beats per minute for 15 seconds or more.

Rationale 3: In a non-reactive stress test, the reactivity criteria are not met. Since this patient experienced a deceleration during the test, this is considered non-reactive.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Nonstress tests are scored as either reactive or non-reactive.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Describe the use, procedure, information obtained, and nursing considerations to evaluate fetal well-being when using Doppler blood flow studies/umbilical velocimetry, nonstress test, contraction stress test, and biophysical profile test.

Question 9 Type: MCSA A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation?

1. The fetal heart rate decelerates when three contractions occur within a 10-minute period.

2. The fetal heart rate accelerates when contractions last up to 60 seconds.

3. There are more than five fetal movements in a 10-minute period.

4. There are more than three uterine contractions in a 6-minute period.

Correct Answer: 4 Rationale 1: Decelerations are considered a positive contraction stress test.

Rationale 2: The acceleration of the heart rate is considered a negative contraction stress test.

Rationale 3: The fetal movement is considered a negative contraction stress test.

Rationale 4: Hyperstimulation is characterized by contractions closer than or equal to every 6 minutes or lasting longer than 90 seconds.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Describe the use, procedure, information obtained, and nursing considerations to evaluate fetal well-being when using Doppler blood flow studies/umbilical velocimetry, nonstress test, contraction stress test, and biophysical profile test.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 10 Type: MCSA Of all the patients who have been scheduled to have a biophysical profile, for which patient should the nurse clarify the physician’s order?

1. A gravida with intrauterine growth restriction 2. A gravida with mild hypertension of pregnancy 3. A gravida who is post-term 4. A gravida who complains of decreased fetal movement for 2 days Correct Answer: 2 Rationale 1: The infant who has intrauterine growth problems might be compromised due to placental insufficiency.

Rationale 2: The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypertension will need to be monitored more closely throughout the pregnancy but is not a candidate at present for a biophysical profile.

Rationale 3: The infant who is post-term might be compromised due to placental insufficiency.

Rationale 4: The gravida who is experiencing decreased fetal movement for 2 days needs assessment of the placenta and the fetus.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Describe the use, procedure, information obtained, and nursing considerations to evaluate fetal well-being when using Doppler blood flow studies/umbilical velocimetry, nonstress test, contraction stress test, and biophysical profile test.

Question 11 Type: MCSA The nurse is reviewing nursing documentation related to the care of a patient who had an amniocentesis. Which nursing notes reflect appropriate patient care?

1. An Rh-positive patient received RhoGAM after the amniocentesis.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. The patient was monitored for 30 minutes after completion of the test.

3. Prior to discharge, the patient demonstrated vaginal spotting.

4. The patient reported that she takes insulin before each meal and at bedtime.

Correct Answer: 2 Rationale 1: Only Rh-negative patients receive RhoGAM after amniocentesis. The Rh-positive patient should not ever receive RhoGAM. Rationale 2: Twenty to thirty minutes of fetal monitoring is performed to assess for fetal well-being and to rule out injury of the fetus or placenta during the exam.

Rationale 3: Vaginal spotting after the amniocentesis is not an expected finding. A patient experiencing vaginal bleeding of any amount after amniocentesis requires additional assessment and should not be sent home.

Rationale 4: Whether or not a patient takes insulin has nothing to do with amniocentesis. This answer does not relate to the question asked.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Explain the use of amniocentesis as a diagnostic tool.

Question 12 Type: MCSA Each of the following pregnant women is scheduled for a 14-week antepartum visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which patient?

1. 28-year-old with history of rheumatic heart disease 2. 18-year-old with exposure to HIV 3. 20-year-old with a history of preterm labor 4. 35-year-old with a child with spina bifida Correct Answer: 4 Rationale 1: The patient with rheumatic heart disease would need to be monitored for pregnancy and the stressors it places on the patient.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: The patient with HIV exposure needs HIV testing and protection education.

Rationale 3: The patient with a history of preterm labor needs education on prevention and signs and symptoms of preterm labor.

Rationale 4: Alpha-fetoprotein (AFP) is elevated in multigestational pregnancies and in pregnancies with neural tube defects such as spina bifida and Down syndrome. The 35-year-old is considered to be of advanced maternal age and is at risk for having a child with Down syndrome, and with the past history of a child with spina bifida, would be highly encouraged to have the AFP screening.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Explain the use of amniocentesis as a diagnostic tool.

Question 13 Type: MCSA The nurse is creating a patient education brochure describing amniocentesis. Which statement is most important for the nurse to include in the brochure?

1. “Prior to the amniocentesis, you will be asked to sign a consent form.”

2. “After the amniocentesis, your vital signs will be monitored.”

3. “During the amniocentesis, you might experience leaking of fluid.”

4. “Following the amniocentesis, you can return to normal activities.”

Correct Answer: 2 Rationale 1: This is a true statement, but direct patient care, including monitoring for complications, is a higher priority.

Rationale 2: Vital signs are monitored and fetal monitoring is performed after amniocentesis to verify that both mother and fetus are physiologically stable after the test is completed.

Rationale 3: Leaking of fluid is a complication of amniocentesis indicating rupture of membranes.

Rationale 4: Activity should be restricted for 24 hours after the amniocentesis to help prevent complications.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Describe the nurse’s role and responsibilities in assisting during amniocentesis.

Question 14 Type: MCSA A woman who is 12 weeks' gestation asks the nurse if she can undergo chorionic villus sampling (CVS) testing in order to determine whether her baby has a neural tube defect. Which response is best?

1. "Yes, at 12 weeks' gestation, CVS can be used to diagnose a neural tube defect."

2. "No, because CVS testing is not performed until after 20 weeks' gestation."

3. "Yes, at 12 weeks' gestation, CVS is combined with amniocentesis to diagnose neural tube defects."

4. "No, because CVS testing alone at any stage cannot detect neural tube defects."

Correct Answer: 4 Rationale 1: CVS is typically performed between 10 and 13 weeks' gestation; however, CVS does not detect neural tube defects.

Rationale 2: While CVS is typically performed between 10 and 13 weeks' gestation, this test cannot detect neural tube defects.

Rationale 3: CVS is typically performed between 10 and 13 weeks' gestation; however, amniocentesis is not performed until 15 weeks' gestation.

Rationale 4: While CVS is typically performed between 10 and 13 weeks' gestation, this test cannot detect neural tube defects.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Compare the advantages and disadvantages of chorionic villus sampling (CVS) to amniocentesis.

Question 15 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

A woman who is 15 weeks' gestation received normal chorionic villus sampling (CVS) results and abnormal quadruple screen test results. For detection of congenital anomalies, which test should the nurse expect the woman to be offered next?

1. Amniocentesis 2. Ultrasound 3. Contraction Stress Test (CST) 4. Nonstress test (NST) Correct Answer: 1 Rationale 1: Women who have a normal CVS and an abnormal quadruple screen test would be offered amniocentesis to screen for congenital anomalies.

Rationale 2: While ultrasound has many uses, is not useful in the diagnosis of congenital anomalies.

Rationale 3: The contraction stress test is used to assess fetal status.

Rationale 4: The nonstress test is used to assess fetal status.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Compare the advantages and disadvantages of chorionic villus sampling (CVS) to amniocentesis.

Question 16 Type: MCSA Prior to performing amniocentesis, which nursing action is appropriate?

1. Administering Rh immune globulin to a woman who is Rh-negative 2. Prepping the abdominal skin with povidone-iodine (Betadine) 3. Assisting the woman with assuming a right lateral position 4. Providing non-sterile gloves for use by the physician performing the procedure Correct Answer: 2 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Rh immune globulin is administered prophylactically following an amniocentesis to prevent Rh sensitization in an Rh-negative woman.

Rationale 2: Prior to amniocentesis, current guidelines recommend prepping the abdominal skin with povidoneiodine (Betadine).

Rationale 3: The woman should be positioned supine for amniocentesis.

Rationale 4: When performing amniocentesis, sterile gloves are worn by the physician.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Identify nursing interventions that are aimed at ensuring the safety of the mother and fetus during antepartum testing.

Question 17 Type: MCSA The nurse is assisting a nurse-midwife with performing a contraction stress test (CST) on a patient who is 30 weeks' gestation. The monitor reveals a hypersystole pattern. What order should the nurse expect to receive from the physician?

1. Change the patient's position to Trendelenburg.

2. Assist the patient with application of an electric breast pump.

3. Obtain a 15-minute recording of uterine activity.

4. Administer a tocolytic medication.

Correct Answer: 4 Rationale 1: The patient is demonstrating hypersystole pattern of uterine contraction and would most likely receive a tocolytic medication.

Rationale 2: Breast stimulation may be used to produce uterine contractions during CST. Rationale 3: While monitoring is appropriate, a hypersystole pattern of uterine contractions requires pharmacologic treatment with a tocolytic agent.

Rationale 4: During CST, development of a hypersystole pattern requires prompt administration of a tocolytic agent.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Identify nursing interventions that are aimed at ensuring the safety of the mother and fetus during antepartum testing.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 15 Question 1 Type: MCSA The nurse is caring for a pregnant woman who admits to cocaine and ecstasy use on a regular basis. The patient states, “Everybody knows that alcohol is bad during pregnancy, but what’s the big deal about ecstasy?” The best response by the nurse is: “Ecstasy: 1. “Can cause a high fever in you and therefore cause the baby harm.”

2. “Leads to deficiencies of thiamine and folic acid, which help the baby develop.”

3. “Produces babies with small heads and short bodies with brain function alterations.”

4. “Produces intrauterine growth restriction and meconium aspiration.”

Correct Answer: 1 Rationale 1: High body temperature is a side effect of MDMA (ecstasy). Increased body temperature increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major organ damage.

Rationale 2: Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid. Folic acid helps prevent neural tube defects.

Rationale 3: Cocaine causes these fetal effects, not ecstasy.

Rationale 4: Heroin causes these fetal effects, not ecstasy.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

Question 2 Type: MCSA The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which of the following statements made by the patient indicates to the nurse that the patient has understood the teaching?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “I can continue to drink alcohol until I am diagnosed as pregnant.”

2. “I need to stop drinking alcohol completely when I start trying to get pregnant.”

3. “A beer once a week will not damage the fetus.”

4. “I can drink alcohol while breastfeeding since it doesn’t pass into breast milk.”

Correct Answer: 2 Rationale 1: Women should discontinue drinking alcohol when they start to attempt pregnancy.

Rationale 2: Women should discontinue drinking alcohol when they start to attempt pregnancy.

Rationale 3: It is not known how much alcohol will cause fetal damage; therefore, alcohol during pregnancy is contraindicated.

Rationale 4: Alcohol passes readily into breast milk; therefore, it should be avoided, or the milk should be pumped and dumped after alcohol consumption.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

Question 3 Type: MCSA A woman’s history and appearance suggest drug abuse. The nurse’s best approach would be to: 1. Ask the woman directly, “Do you use any street drugs?”

2. Ask the woman if she would like to talk to a counselor.

3. Ask some questions about over-the-counter medications and avoid the mention of illicit drugs.

4. Explain how harmful drugs can be for her baby.

Correct Answer: 1 Rationale 1: The best method of dealing with the patient that the nurse suspects of using drugs is to be direct and ask the question in a direct fashion without prejudice, bias, or negative body language. Lack of judgmental attitudes/body language typically results in honest answers.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: It is the responsibility of the nurse to question the patient.

Rationale 3: It is the responsibility of the nurse not to avoid the issue.

Rationale 4: When talking to patients in a therapeutic manner, it is important not to be threatening or judgmental; an example of the latter behavior would be stating that the drugs will harm the baby.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

Question 4 Type: MCSA A 20-year-old woman is at 28 weeks’ gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for: 1. Erythroblastosis fetalis.

2. Diabetes mellitus.

3. Abruptio placentae.

4. Pregnancy-induced hypertension.

Correct Answer: 4 Rationale 1: Erythroblastosis fetalis is secondary to physiological blood disorders such as Rh incompatibility.

Rationale 2: Diabetes is an endocrine disorder that is unrelated to drug use/abuse.

Rationale 3: Abruptio placentae is seen more commonly with cocaine/crack use.

Rationale 4: Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or pre-eclampsia).

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

Question 5 Type: MCSA The patient with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon.

What anticipatory guidance should the nurse provide this patient?

1. Insulin needs decrease in the first trimester and increase during the third trimester.

2. The risk of ketoacidosis decreases during the length of the pregnancy.

3. Vascular disease that accompanies diabetes slows progression.

4. The baby is likely to have a congenital abnormality because of the diabetes.

Correct Answer: 1 Rationale 1: In addition, insulin requirements drop suddenly after delivery of the placenta.

Rationale 2: The risk of ketoacidosis increases during pregnancy.

Rationale 3: Vascular disease progresses more rapidly during pregnancy, especially if blood sugar control is not good. Problems such as nephropathy and retinopathy can result.

Rationale 4: Infants of diabetic mothers have a 5–10% greater risk of having a congenital abnormality. This risk increases to 20–25% if the HbA1c is over 10%.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

Question 6 Type: MCSA A newly diagnosed type 1, insulin-dependent diabetic with good blood sugar control is at 20 weeks’ gestation.

She asks the nurse how her diabetes will affect her baby. The best explanation would include: 1. “Your baby may be smaller than average at birth.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. “Your baby will probably be larger than average at birth.”

3. “As long as you control your blood sugar, your baby will not be affected at all.”

4. “Your baby might have high blood sugar for several days.”

Correct Answer: 2 Rationale 1: Poorly controlled type 1 diabetics who have developed vascular problems will have infants who are small for gestational age (SGA) due to placental insufficiency.

Rationale 2: The infant of a diabetic mother produces excessive amounts of insulin in response to the high blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because the infant utilizes the glucose in the bloodstream.

Rationale 3: The demands of pregnancy will make it difficult for the best of patients to control blood sugar on a regular basis.

Rationale 4: Within minutes of delivery, the baby of an insulin-dependent diabetic can begin to have low blood sugar.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

Question 7 Type: MCSA A 26-year-old multigravida is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this patient?

1. “Exercise either just before meals or wait until two hours after a meal.”

2. “Carry hard candy (or other simple sugar) when exercising.”

3. “If your blood sugar is 120 mg/dl, eat 20 g of carbohydrate.”

4. “If your blood sugar is more than 120 mg/dl, drink a glass of whole milk.”

Correct Answer: 2 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: It is best to exercise just after the meal in order to utilize the glucose.

Rationale 2: A patient should be encouraged to continue any exercise programs in which she already is involved.

She should keep hard candy (simple sugar) with her at all times, just in case the exercise induces hypoglycemia.

Rationale 3: A finger stick result of 120 mg/dl is considered to be normal.

Rationale 4: Such patients need no additional carbohydrate or protein intake.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

Question 8 Type: MCSA A 31-year-old woman who is at high risk for diabetes is at 18 weeks' gestation. During her first antenatal visit, which is the accurate approach to evaluating the patient for diabetes?

1. Begin serial testing of the patient's serum glucose and HA1c at 24 weeks' gestation.

2. If diabetes is diagnosed, consider this condition to be gestational diabetes mellitus (GDM).

3. Recognize HA1c equal to or greater than 4.5% or a fasting plasma glucose level equal to or greater than 90 mg/dl as being diagnostic of diabetes.

4. Conduct screening for type 2 diabetes mellitus as soon as possible.

Correct Answer: 4 Rationale 1: Women at high risk for type 2 DM should be screened for diabetes as soon as possible.

Rationale 2: Women who are determined to have diabetes at this visit should be diagnosed as having overt diabetes and not GDM. Rationale 3: HA1c equal to or greater than 6.5% would be considered diagnostic as would a fasting plasma glucose level equal to or greater than 126 mg/dl or a 2-hour plasma glucose equal to or greater than 200 mg/dl during an oral glucose tolerance test (OGTT).

Rationale 4: Women at high risk for type 2 DM should be screened for diabetes as soon as possible.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

Question 9 Type: MCSA The pregnant patient at 23 weeks’ gestation has a hemoglobin of 9.5. Which diet choice indicates that teaching has been effective?

1. Tofu with mixed vegetables in curry, milk, whole-wheat bun 2. Roast beef, steamed spinach, tomato soup, orange juice 3. Pork chop, mashed potatoes and gravy, cauliflower, tea 4. Broiled fish, lettuce salad, grapefruit half, carrot sticks Correct Answer: 2 Rationale 1: This diet is high in calcium. The patient has iron-deficiency anemia and requires a high-iron diet.

Rationale 2: This patient is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells.

Rationale 3: This meal has a moderate amount of protein, but no vitamin C. The meal containing beef is better.

Rationale 4: This meal is high in fiber, low in fat, and moderately high in protein, but low in iron. This patient is anemic and needs iron.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Distinguish among the four major types of anemia associated with pregnancy with regard to signs, treatment, and implications for pregnancy.

Question 10 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

A woman at 30 weeks' gestation and a history including sickle cell anemia presents to the clinic complaining of fever, chills, and diarrhea for three days. What are the most serious potential complications faced by this patient?

1. Electrolyte imbalance 2. Sickle cell crisis 3. Fetal neural tube defects 4. Severe lethargy Correct Answer: 2 Rationale 1: While the patient may experience electrolyte imbalance, sickle cell crisis is the most serious potential complication of dehydration and fever.

Rationale 2: Dehydration and fever can trigger sickling and crisis; for this reason, maternal infections are treated promptly.

Rationale 3: Fever, chills, and dehydration in the patient with sickle cell anemia are not associated with an increased incidence of neural tube defects.

Rationale 4: While the patient may develop severe lethargy, her greatest risk concerns development of sickle cell crisis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Distinguish among the four major types of anemia associated with pregnancy with regard to signs, treatment, and implications for pregnancy.

Question 11 Type: MCSA A patient who is at 18 weeks' gestation has been newly diagnosed with megaloblastic anemia. Which statement by the patient indicates that she understands the teaching?

1. “I should include fresh leafy green vegetables, red meat, fish, poultry, and legumes in my diet.”

2. “Whenever possible, I should boil my vegetables in at least 2 quarts of water.”

3. “Megaloblastic anemia is not known to cause any serious risks to my baby.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “My body makes red blood cells that are smaller than they should be."

Correct Answer: 1 Rationale 1: Folic acid, which is used to treat megaloblastic anemia, is readily available in foods such as fresh leafy green vegetables, red meat, fish, poultry, and legumes.

Rationale 2: Folic acid, which is crucial for inclusion in the diet of patients with megaloblastic anemia, is easily destroyed by overcooking or cooking with large quantities of water.

Rationale 3: Maternal folic acid deficiency has been associated with an increased risk of neural tube defects (NTDs) such as spina bifida, meningomyelocele, and anencephaly in the newborn.

Rationale 4: In megaloblastic anemia, red blood cells become enlarged and are fewer in number.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Distinguish among the four major types of anemia associated with pregnancy with regard to signs, treatment, and implications for pregnancy.

Question 12 Type: MCSA The patient at 9 weeks’ gestation has been told that her HIV test was positive. The patient is very upset and tells the nurse, “I didn’t know I had HIV! What will this do to my baby?” The nurse knows teaching has been effective when the patient states: 1. “I cannot take the medications that control HIV during my pregnancy because they will harm the baby.”

2. “My baby will probably be born with anti-HIV antibodies, but that doesn’t mean it is infected.”

3. “The pregnancy will increase the progression of my disease and will reduce my CD4 counts.”

4. “The HIV won’t affect my baby, and I will have a low-risk pregnancy without additional testing.”

Correct Answer: 2 Rationale 1: Most of the medications that control HIV progression are safe to take during pregnancy.

Antiretroviral medications are recommended during pregnancy to prevent perinatal transmission.

Rationale 2: Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV antibodies.

These antibodies clear over time, and an accurate test can be obtained by 15 months of age.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: There is no evidence to indicate that pregnancy increases the progression of HIV/AIDS. Rationale 4: Pregnancy affected by HIV/AIDS is considered complicated, and the fetus is monitored closely.

Fetal assessments include weekly nonstress tests beginning at 32 weeks.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Describe acquired immunodeficiency syndrome (AIDS), including care of the pregnant woman with HIV/AIDS, neonatal implications, and ramifications for the childbearing family.

Question 13 Type: MCSA During her first antepartal visit, a patient who is at 10 weeks' gestation reports that she is HIV-positive. Which statement made by the patient indicates an understanding of the plan of care both during the pregnancy and postpartally?

1. "I'm supposed to take highly active antiretroviral therapy (HAART), but only during the first trimester."

2. "I should not breastfeed my baby."

3. "If I have a cesarean section, there's an increased risk that my HIV will be passed to my baby."

4. "When my baby is 2 months old, he or she will be tested for HIV." Correct Answer: 2 Rationale 1: Longer duration therapy is preferable to shorter duration approaches, and it is best to start prophylaxis after the first trimester and no later than 28 weeks’ gestation in women who do not require immediate therapy for their own health.

Rationale 2: HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth.

Rationale 3: Cesarean section reduces the transmission of HIV from mother to infant.

Rationale 4: Following birth, HIV infection in infants should be diagnosed using HIV virologic assays as soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is positive.

Global Rationale: Cognitive Level: Evaluating Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Describe acquired immunodeficiency syndrome (AIDS), including care of the pregnant woman with HIV/AIDS, neonatal implications, and ramifications for the childbearing family.

Question 14 Type: MCSA A woman is 32 weeks pregnant. She is HIV-positive, but asymptomatic. What would be important in managing her pregnancy and delivery?

1. An amniocentesis at 30 and 36 weeks 2. Weekly nonstress testing beginning at 32 weeks’ gestation 3. Application of a fetal scalp electrode as soon as her membranes rupture in labor 4. Administration of intravenous antibiotics during labor and delivery Correct Answer: 2 Rationale 1: All invasive procedures that would expose the uninfected infant to the HIV virus are avoided.

Rationale 2: Patients who are HIV-positive are considered high-risk pregnancies. Therefore, beginning at about 32 weeks, these patients have weekly nonstress tests to assess for placental function and an ultrasound every 2–3 weeks to assess for intrauterine growth retardation (IUGR).

Rationale 3: All invasive procedures that would expose the uninfected infant to the HIV virus are avoided.

Rationale 4: Antibiotics would be ineffective for either the mother or the infant who was HIV-positive.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Describe acquired immunodeficiency syndrome (AIDS), including care of the pregnant woman with HIV/AIDS, neonatal implications, and ramifications for the childbearing family.

Question 15 Type: MCSA A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the patient needs to be retested for HIV? Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Hemoglobin of 11 g/dL and a rapid weight gain 2. Elevated blood pressure and ankle edema 3. Shortness of breath and frequent urination 4. Unusual fatigue and recurring Candida vaginitis Correct Answer: 4 Rationale 1: The patient would be anemic and anorexic.

Rationale 2: The patient would have a decrease in blood pressure and no ankle edema.

Rationale 3: Shortness of breath and frequent urination do not indicate a need to retest for HIV. Rationale 4: The patient who is HIV-positive would have a suppressed immune system and would experience symptoms of fatigue and opportunistic infections such as Candida vaginitis.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Describe acquired immunodeficiency syndrome (AIDS), including care of the pregnant woman with HIV/AIDS, neonatal implications, and ramifications for the childbearing family.

Question 16 Type: MCSA The nurse is reviewing prenatal charts. A patient at 24 weeks has a history of class II heart disease secondary to rheumatic fever. What would the nurse expect to see in the chart?

1. Dyspnea and chest pain with mild exertion 2. Elective cesarean birth scheduled for 37 weeks 3. Discussed need for labor epidural and vacuum extraction 4. Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally Correct Answer: 3 Rationale 1: Dyspnea and angina with mild exertion are not expected with class II heart disease even during pregnancy, but are symptoms seen in class IV heart disease.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Cesarean birth is only undertaken in cardiac patients for fetal or maternal intrapartal indications, not for cardiac reasons alone.

Rationale 3: Lumbar epidural analgesia decreases the stress response during labor, while vacuum extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the heart during birth.

Rationale 4: 3+ pre-tibial edema is never an expected finding during pregnancy. Pulse over 100 and respiratory rate over 24 are indicators of cardiac decompensation.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Describe the effects of various heart disorders on pregnancy, including their implications for nursing care.

Question 17 Type: MCSA The prenatal clinic nurse has received four phone calls. Which patient should be called first?

1. Primip at 28 weeks with history of asthma reporting difficulty breathing and shortness of breath 2. Multip at 6 weeks with a seizure disorder inquiring what foods are good folic acid sources for her 3. Primip at 35 weeks with a positive HBsAG wondering what treatment her baby will receive after birth 4. Multip at 11 weeks with untreated hyperthyroidism describing the onset of vaginal bleeding Correct Answer: 1 Rationale 1: Asthma exacerbations are most common between 24 and 36 weeks. Asthma attacks can lead to maternal hypoxia, which can lead to fetal hypoxia. This patient is the top priority.

Rationale 2: Women with seizure disorders should be started on folic acid supplements prior to pregnancy, and should continue throughout pregnancy. This patient is not the highest priority.

Rationale 3: A patient with a positive HBsAG is contagious for hepatitis B. The risk of transmission to the fetus at birth is reduced by bathing the neonate as soon as possible after birth and giving the infant immunoprophylaxis and the first HBsAG vaccine dose. The patient seeking information about what will happen after delivery is a low priority when there are pregnant patients currently experiencing physiologic problems.

Rationale 4: Pregnant women with untreated hyperthyroidism have an increased risk of fetal loss. Vaginal bleeding at 11 weeks could indicate that spontaneous abortion is taking place. But the majority of spontaneous Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

abortions prior to 12 weeks’ gestation are complete and without complications. This patient is not experiencing a normal pregnancy, but the health of both mother and fetus are not in immediate danger.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Compare the effects of selected pregestational medical conditions on pregnancy.

Question 18 Type: MCSA The patient was found to have hepatitis B surface antigen (HBsAG) early in her pregnancy. The nurse is explaining to the patient what will happen during labor and birth because the patient is contagious for hepatitis B. Which statement by the patient indicates that additional teaching is needed?

1. “An internal fetal monitor will be applied as soon as possible during labor.”

2. “My baby will get a bath as soon as its temperature is stable.”

3. “Two shots will be given to my baby to prevent transmission of hepatitis B.” 4. “Breastfeeding is a good feeding method for my baby.”

Correct Answer: 1 Rationale 1: An internal fetal monitor will be avoided.

Rationale 2: The presence of hepatitis B surface antigen (HBsAG) indicates that the patient is contagious for and capable of transmitting hepatitis B. Perinatal transmission is most likely to occur at the time of birth; thus, measures are taken to prevent exposing the fetus to the mother’s blood and body fluids and to clean the baby’s skin thoroughly of fluids as soon as possible after birth.

Rationale 3: A newborn of a mother with HBsAG will receive an injection of hepatitis B immune globulin and a hepatitis B vaccine injection.

Rationale 4: Breastfeeding is not contraindicated in a patient with HBsAG. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO07 - Compare the effects of selected pregestational medical conditions on pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 16 Question 1 Type: MCSA The nurse is supervising care in the emergency department. Which situation most requires an intervention?

1. Moderate vaginal bleeding at 36 weeks’ gestation; patient has an IV of lactated Ringer’s solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks’ gestation and abdominal cramping; ultrasound scheduled in one hour 3. Bright red bleeding with clots at 32 weeks’ gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks’ gestation with normal vital signs; patient reports an absence of fetal movement Correct Answer: 3 Rationale 1: Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the patient’s vascular volume.

Rationale 2: Bleeding in the first trimester can be indicative of spontaneous abortion beginning or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring and will determine care. Because this patient is very early in the pregnancy and only experiencing spotting, it is not appropriate to have an IV at this time.

Rationale 3: Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid. This patient has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this situation. Since there is no information given that the patient has an IV started, this patient is the least stable, and therefore the highest priority.

Rationale 4: Watery, dark red bleeding in the third trimester can indicate placental abruption with ruptured membranes. Normal vital signs indicate a normal vascular volume. A lack of fetal movement could indicate fetal hypoxia or fetal demise. The fetus is at greatest risk in this situation; the mother is stable.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 2 Type: MCSA The prenatal clinic nurse is caring for a patient with hyperemesis gravidarum at 14 weeks’ gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?

1. Weigh the patient.

2. Give 1 liter of lactated Ringer’s solution IV. 3. Administer 30 ml Maalox (magnesium hydroxide) orally.

4. Encourage clear liquids orally.

Correct Answer: 2 Rationale 1: Weighing the patient provides information on weight gain or loss, but it is not the top priority in a patient with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The patient needs IV fluids.

Rationale 2: The vital signs indicate hypovolemia. Giving this patient a liter of lactated Ringer’s solution intravenously will re-establish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.

Rationale 3: The vital signs indicate hypovolemia. There is no indication that the patient has dyspepsia. The patient needs IV fluids.

Rationale 4: The patient needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a patient with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Discuss the medical therapy and nursing care for a woman with hyperemesis gravidarum.

Question 3 Type: MCSA A 28-year-old woman who is at 16 weeks’ gestation has just undergone screening for ABO incompatibility. She asks the nurse why her blood contains anti-A antibodies. What is the nurse’s best response?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “Anti-A antibodies occur naturally, as a result of exposure to foods and different infections.”

2. “It’s most likely that you contracted anti-A antibodies through sexual activity.”

3. “Anti-A antibodies are inherited; usually, they are genetically passed down from father to daughter.”

4. “You may have contracted anti-A antibodies as a result of a viral infection.”

Correct Answer: 1 Rationale 1: Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram negative bacteria.

Rationale 2: Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram negative bacteria.

Rationale 3: Women develop anti-A and anti-B antibodies naturally as a result of exposure to the A and B antigens through the foods they eat and through exposure to infection by gram negative bacteria.

Rationale 4: Women develop anti-A and anti-B antibodies as a result of exposure to the A and B antigens through infection by gram negative bacteria, as well as through exposure to the foods they eat.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

Question 4 Type: MCSA While preparing a class on maternal-fetal ABO incompatibility for antepartum patients, the nurse is creating a brochure. Which statement should be included in the brochure information?

1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus.

2. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother’s blood type.

3. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus.

4. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction between the antigen sites on the maternal RBCs. Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected.

Rationale 2: Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother’s blood type.

Rationale 3: In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected.

Rationale 4: The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal RBCs. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

Question 5 Type: MCSA A patient who is at 32 weeks’ gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing?

1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM) to the patient 2. Notify the patient’s primary care provider and document the potential need for treatment of fetal hemolytic anemia in the patient’s baby after delivery.

3. Obtain an antibody screen (indirect Coombs’ test) to determine whether the patient has developed isoimmunity.

4. Note the potential for ABO incompatibility and plan to carefully assess the patient’s neonate for the development of hyperbilirubinemia.

Correct Answer: 4 Rationale 1: RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood.

Rationale 2: Unlike Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: An antibody screen (indirect Coombs’ test) is done to determine whether an Rh-negative woman is sensitized (has developed isoimmunity) to the Rh antigen.

Rationale 4: Unlike Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment, however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert caregivers to the need for carefully assessing the newborn for the development of hyperbilirubinemia.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

Question 6 Type: MCSA The nurse identifies the following assessment findings on a patient with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet. On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the pre-eclampsia?

1. Blood pressure 158/104 2. Urinary output 20 mL/hour 3. Reflexes 21 4. Platelet count 150,000 Correct Answer: 2 Rationale 1: The blood pressure has not had a significant rise.

Rationale 2: The decrease in urine output is an indication of decrease in GFR, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change.

Rationale 3: The reflexes are normal at 21.

Rationale 4: The platelet count is normal, though it is at the lower end.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Describe the development and course of hypertensive disorders associated with pregnancy.

Question 7 Type: MCSA The community nurse is working with a patient at 32 weeks’ gestation who has been diagnosed with preeclampsia. Which statement indicates that additional information is needed?

1. “I should call the doctor if I develop a headache or blurred vision.”

2. “Lying on my left side as much as possible is good for the baby.”

3. “My urine may become darker and smaller in amount each day.”

4. “Pain in the top of my abdomen is a sign my condition is worsening.”

Correct Answer: 3 Rationale 1: Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the physician.

Rationale 2: Left lateral position maximizes uterine and renal blood flow and therefore is the optimal position for a patient with pre-eclampsia.

Rationale 3: Oliguria is a complication of pre-eclampsia caused by renal involvement and is a sign that the condition is worsening. Oliguria should be reported to the physician.

Rationale 4: Epigastric pain is an indication of liver enlargement, a symptom of worsening pre-eclampsia, and should be reported to the physician.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of the pregnant woman with a hypertensive disorder.

Question 8 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is assessing a newly admitted patient who is 32 weeks’ gestation. The patient’s chief complaints are sudden onset of intense nausea and a frontal headache for the past two days. The patient’s initial blood pressure is 158/98 and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing?

1. Placing a wedge under the patient’s left hip so that she is in a right lateral tilt position 2. Administration of diuretics and facilitating a dietary regimen of strict sodium restriction 3. Conducting a urine dipstick test to assess for proteinuria 4. Ordering a low-protein diet plan for the patient Correct Answer: 3 Rationale 1: This patient’s signs and symptoms are consistent with pre-eclampsia. Appropriate interventions include instituting bed rest with the patient positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion.

Rationale 2: This patient’s signs and symptoms are consistent with pre-eclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating pre-eclampsia.

Rationale 3: This patient’s signs and symptoms are consistent with pre-eclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria.

Rationale 4: This patient’s signs and symptoms are consistent with pre-eclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/ day) to replace protein lost in the urine.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Describe the development and course of hypertensive disorders associated with pregnancy.

Question 9 Type: MCSA The nurse receives the following report on a patient who delivered 36 hours ago: para 1, rubella immune, Anegative, antibody screen negative, newborn B-positive, Coombs’ negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse?

1. Ask if she is breast- or bottle-feeding.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Administer rubella vaccine.

3. Determine if RhoGAM has been given.

4. Discuss the discharge education with the patient.

Correct Answer: 3 Rationale 1: This is important but is not the top priority.

Rationale 2: The patient is rubella-immune and does not need the rubella vaccine.

Rationale 3: The patient is A-negative and the newborn B-positive. The patient needs RhoGAM prior to discharge. Without RhoGAM, the patient will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy.

Rationale 4: Discharge education is always important, but in this case it is not the most important action.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Relate the cause, fetal/neonatal risks, prevention, and clinical therapy to the nursing care of the woman at risk for Rh alloimmunization.

Question 10 Type: MCSA The patient with blood type A, Rh-negative delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?

1. “I need to get RhoGAM so I don’t have problems with my next pregnancy.”

2. “Because my baby is Rh-positive, I don’t need RhoGAM.” 3. “If my baby had the same blood type I do, it might cause complications.”

4. “Before my next pregnancy, I will need to have a RhoGAM shot.”

Correct Answer: 1 Rationale 1: Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization.

Rationale 3: It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization.

Rationale 4: Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM). The injection must be given with 72 hours after delivery to prevent alloimmunization.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Relate the cause, fetal/neonatal risks, prevention, and clinical therapy to the nursing care of the woman at risk for Rh alloimmunization.

Question 11 Type: MCSA Which maternal–child patient should the nurse see first?

1. Blood type O, Rh-negative 2. Indirect Coombs’ test negative 3. Direct Coombs’ test positive 4. Blood type B, Rh-positive Correct Answer: 3 Rationale 1: This patient is Rh-negative, but there is no indication that the alloimmunization has occurred.

Rationale 2: An indirect Coombs’ test looks for Rh antibodies in the maternal serum; a negative result indicates the patient has not been alloimmunized.

Rationale 3: A direct Coombs’ test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and the baby is making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia.

Rationale 4: This patient’s blood type creates no problems.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Relate the cause, fetal/neonatal risks, prevention, and clinical therapy to the nursing care of the woman at risk for Rh alloimmunization.

Question 12 Type: MCSA Which situation in the high-risk antepartal unit requires immediate intervention?

1. A third-trimester patient pregnant with twins who required an appendectomy yesterday is positioned in a supine position.

2. Oxygen is being administered at 2 L via nasal cannula to a patient in her third trimester who underwent an urolithotomy today.

3. Fetal monitoring is being performed on a patient in her third trimester who is scheduled for a cholecystectomy tomorrow.

4. The patient in her third trimester who returned from bowel resection surgery has a nasogastric tube attached to intermittent suction.

Correct Answer: 1 Rationale 1: A patient undergoing surgery in the third trimester should be positioned in a left lateral position or with a hip wedge placed. Being supine will cause vena cava syndrome and hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger uterus and heavier uterine contents, makes vena cava syndrome more problematic.

Rationale 2: Oxygen is required during and after surgery during pregnancy to maintain adequate fetal oxygenation.

Rationale 3: Fetal monitoring prior to, during, and after surgery on pregnant patients is important to assess the fetal condition.

Rationale 4: Due to the decreased peristalsis of pregnancy, pregnant patients who undergo abdominal surgery are at risk for vomiting. An NG tube is placed to prevent vomiting.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Summarize the risks and implications of surgical procedures performed during pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 13 Type: MCSA The nurse is caring for a patient at 35 weeks’ gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern?

1. “Blood pressure 110/68, pulse 90.”

2. "Entrance wound present below the umbilicus.”

3. “Patient is positioned in a left lateral tilt.”

4. “Clear fluid is leaking from the vagina.”

Correct Answer: 2 Rationale 1: These are normal vital signs, indicating a hemodynamically stable patient.

Rationale 2: Penetrating abdominal trauma has a 59–80% fetal injury rate. This fetus is at great risk for injury.

Rationale 3: Positioning the patient in a lateral tilt position prevents vena cava syndrome.

Rationale 4: Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes.

Although this is not a normal finding at 35 weeks, this fetus is near term and would likely survive birth at this time.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO08 - Discuss the implications of trauma caused by an accident or battering for the pregnant woman and her fetus.

Question 14 Type: MCSA The nurse is admitting a patient at 28 weeks’ gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask?

1. “What did you do to make your spouse so angry?”

2. “How many times has this happened in the past?”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “Do you have a safe place that you can go?”

4. “Will you be pressing charges against your spouse?”

Correct Answer: 3 Rationale 1: This statement is blaming and must be avoided to establish a trusting, therapeutic relationship with an abused patient.

Rationale 2: Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority.

Rationale 3: This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of a repeated attack and further injury to both mother and fetus.

Rationale 4: Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more importance.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Discuss the implications of trauma caused by an accident or battering for the pregnant woman and her fetus.

Question 15 Type: MCSA Which statement indicates that teaching has been effective?

1. “Because I have toxoplasmosis, my baby might be born with an abnormally long body.”

2. “The rubella infection I experienced in my second trimester may lead me to become deaf.”

3. “My baby may develop a serious blood infection because I have group B strep in my vagina.”

4. “My 8-year-old’s parvovirus infection won’t affect my baby because I am four months along.”

Correct Answer: 3 Rationale 1: Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma, convulsions, or retinochoroiditis.

Rationale 2: Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are given during labor.

Rationale 4: Parvovirus effects on the fetus are most severe when the maternal infection occurs prior to the 20th week.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO09 - Contrast the effects of various infections on the pregnant woman and her unborn child.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 17 Question 1 Type: MCMA The nurse is caring for laboring patients. Which women are experiencing problems related to a critical factor of labor?

Standard Text: Select all that apply.

1. Primip at 7 cm, fetus in military attitude 2. Multip at 3 cm, fetus in longitudinal lie 3. Primip at 4 cm, fetus with macrocephaly due to hydrocephalus 4. Multip at 6 cm, fetus at −2 station, mild contractions 5. Primip at 5 cm, fetal presenting part is right shoulder Correct Answer: 1,3,4,5 Rationale 1: Attitude refers to the relationship of the fetal parts to one another. Military attitude is an unflexed neck; normal fetal attitude is flexion of the neck. Military attitude creates a larger diameter of the head fitting through the pelvis. This patient is experiencing a problem between the maternal pelvis and the presenting part.

Rationale 2: Lie refers to the relationship between the cephalocaudal axis of the mother to the cephalocaudal axis of the fetal body; longitudinal lie is normal.

Rationale 3: Hydrocephalus can lead to macrocephaly, or an abnormally large head. Macrocephalic babies might not fit through the bony pelvis and could require birth by cesarean. This patient is experiencing a problem between the maternal pelvis and the presenting part.

Rationale 4: Station refers to how low in the pelvis the baby’s presenting part is; −2 station is high in the pelvis.

Contractions should be strong to cause fetal descent and cervical dilation. Mild contractions will not move the baby down or open the cervix. This patient is experiencing a problem between the maternal pelvis and the presenting part.

Rationale 5: The presenting part is the fetal part coming through the cervix. The occiput or back of the baby’s head is the most common and most effective presenting part. A shoulder presentation cannot deliver vaginally and will require a cesarean birth. This patient is experiencing a problem between the maternal pelvis and the presenting part.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe the five critical factors that influence labor in the assessment of an expectant woman and fetus’s progress in labor and birth.

Question 2 Type: MCSA The charge nurse has received a shift change report. Which patient requires immediate intervention?

1. Multip at 6 cm undergoing induction of labor, strong contractions every three minutes 2. Primip at 4 cm whose fetus is in a longitudinal lie with an cephalic presentation 3. Multip at 10 cm and fetus at +2 station experiencing a strong expulsion urge 4. Primip at 3 cm screaming in fear because her mother died during childbirth Correct Answer: 4 Rationale 1: Strong contractions every three minutes are an adequate labor pattern during induction of labor. This patient is experiencing no complications.

Rationale 2: Longitudinal lie with cephalic presentation is a head-down position. This is expected.

Rationale 3: 10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected.

Rationale 4: This patient is most likely fearful that she will die during labor if her mother died during childbirth.

It is very rare to die during childbirth in developing countries. The extreme fear this patient is experiencing could stimulate the fight-or-flight mechanism and hormone cascade, which can significantly slow the progress of her labor; screaming and muscle tension increase the body’s oxygen consumption, and in extreme cases can lead to fetal hypoxia. This patient requires education and a great deal of support and is therefore the top priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Summarize the implications of abnormalities present in each of the five critical factors on the outcome of labor and the health of the expectant woman and the fetus.

Question 3 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in three hours of contractions occurring every five minutes. The best response by the nurse is: 1. “Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress.”

2. “When your perineal body thins out, your cervix will begin to dilate much faster than it is now.”

3. “What did you expect? You’ve only had contractions for a few hours. Labor takes time.”

4. “The hormones that cause labor to begin are just getting to be at levels that will change your cervix.”

Correct Answer: 1 Rationale 1: Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much less time than for subsequent labor and births.

Rationale 2: The perineal body thinning primarily occurs during the second stage of labor; it is not expected now.

Rationale 3: This reply is not therapeutic. Although it is true that this patient has only been in early labor for a short time, and it is true that labor for a primip averages 12–24 hours, the nurse must always be therapeutic in all communication.

Rationale 4: The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Examine an expectant woman’s and fetus’s response to labor based on the physiological processes that occur during labor.

Question 4 Type: MCSA The primiparous patient at 40 weeks’ gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?

1. “Unless you have pain with urination, we don’t need to worry about it.”

2. “These symptoms usually mean the baby’s head has descended further.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “Come in for an appointment today and we’ll check everything out.”

4. “This might indicate that the baby is no longer in a head down position.”

Correct Answer: 2 Rationale 1: Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection.

Rationale 2: This is the best response because it most directly addresses what the patient has reported. Increased pelvic pressure and urinary frequency are premonitory signs of labor.

Rationale 3: There is no need for an additional appointment, as increased pelvic pressure and urinary frequency are premonitory signs of labor.

Rationale 4: The patient is experiencing premonitory signs of labor; the fetus changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Assess for the premonitory signs of labor when caring for an expectant woman.

Question 5 Type: MCSA The primiparous patient at 39 weeks’ gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make?

1. “You shouldn’t work so much at this point in pregnancy.”

2. “What you are describing is not commonly experienced in the last weeks.”

3. “Your body may be telling you it is going into labor soon.”

4. “If the bladder pressure continues, come in to the clinic tomorrow.”

Correct Answer: 3 Rationale 1: There is no indication that the patient should decrease her work schedule.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Lightening is a common and expected finding.

Rationale 3: One of the premonitory signs of labor includes lightening: The baby drops lower into the pelvis, which creates increased pelvic and bladder pressure but less pressure on the diaphragm, which makes breathing easier.

Rationale 4: Lightening does not indicate pathology, and therefore there is no need to come to the clinic if the symptoms continue.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Assess for the premonitory signs of labor when caring for an expectant woman.

Question 6 Type: MCSA A 25-year-old woman is 38 weeks’ gestation with her first pregnancy. For the third time in one week, she presents to the hospital with complaints that are determined to be suggestive of false labor. Prior to discharge, the patient states, “I’m so embarrassed for thinking I was in labor. I feel like a fool.” What is the nurse’s best response?

1. “We’ll discuss the differences between true labor and false labor so this doesn’t happen again.”

2. “It’s impossible to distinguish between false labor and true labor.”

3. “Don’t feel bad. Everyone makes mistakes sometimes.”

4. “It’s very difficult to tell the difference between true and false labor. Please know we’re here to take care of you whenever you need us.”

Correct Answer: 4 Rationale 1: Rather than reinforcing the woman’s incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman’s embarrassment.

Rationale 2: While it may be difficult to subjectively distinguish between false labor and true labor, vaginal examination can be performed to determine if cervical dilatation is occurring.

Rationale 3: Instead of reinforcing the woman’s perception of having made an error, the nurse should reassure her that her embarrassment is unwarranted.

Rationale 4: Rather than reinforcing the woman’s incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman’s embarrassment.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Differentiate between false and true labor in an expectant woman.

Question 7 Type: MCMA The nurse is teaching a prenatal class about false labor. The nurse should teach patients that false labor most likely will include which of the following?

Standard Text: Select all that apply.

1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Increased thin vaginal secretions Correct Answer: 1,4 Rationale 1: True labor contractions intensify while walking.

Rationale 2: True labor results in increased intensity and frequency of contractions.

Rationale 3: True labor results in progressive dilation.

Rationale 4: True labor results in pain beginning low in the abdomen and radiating upward or into the back.

Rationale 5: True labor results in an increase in vaginal secretions.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Differentiate between false and true labor in an expectant woman.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 8 Type: MCSA The nurse is caring for a laboring patient. A cervical exam indicates 8 cm dilation. The patient is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important?

1. Leave the patient alone so she can rest.

2. Ask the family to take a coffee and snack break.

3. Encourage the patient to have an epidural for pain.

4. Reassure the patient that she will not be left alone.

Correct Answer: 4 Rationale 1: The patient is in the transitional phase of the first stage of labor and will not want to be alone.

Rationale 2: The patient is in the transitional phase of the first stage of labor. The family members might want to take a break, but the patient will not want to be alone.

Rationale 3: The patient is in the transitional phase of the first stage of labor. There is no indication that the patient wants pain relief.

Rationale 4: Because the patient is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the patient and reassuring her that she will not be alone are the highest priorities at this time.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Describe the physiologic changes occurring in an expectant woman during each stage of labor in the nursing care management of the expectant woman.

Question 9 Type: MCSA During the fourth stage of labor, your patient’s assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse should be to: 1. Turn the patient onto her left side.

2. Place the bed in Trendelenburg position.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. Massage the fundus.

4. Continue to monitor.

Correct Answer: 4 Rationale 1: A left lateral position is not necessary with a BP of 110/60 and a pulse of 90.

Rationale 2: Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.

Rationale 3: The uterus should be midline and firm; massage is not necessary.

Rationale 4: The patient’s assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Describe the physiologic changes occurring in an expectant woman during each stage of labor in the nursing care management of the expectant woman.

Question 10 Type: MCSA A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are two minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure. How should the nurse interpret this complaint?

1. The patient’s complaint is congruent with her current stage of labor.

2. The patient’s complaint may indicate the need for delivery via cesarean section.

3. Based upon the patient’s complaint, she is experiencing the active phase of labor.

4. The patient’s complaint is consistent with placental separation, which is normal for her current stage of labor.

Correct Answer: 1 Rationale 1: The objective findings and patient’s complaint are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: The objective findings and patient’s complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).

Rationale 3: The objective findings and patient’s complaint are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).

Rationale 4: Placental separation occurs after the infant is born.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Describe the physiologic changes occurring in an expectant woman during each stage of labor in the nursing care management of the expectant woman.

Question 11 Type: MCSA The labor and delivery nurse is reviewing charts. Of which patient should the nurse inform the supervisor?

1. Multip at 5 cm requesting labor epidural analgesia 2. Primip whose cervix remains at 6 cm for four hours 3. Multip who has developed nausea and vomiting 4. Primip requesting her partner to stay with her Correct Answer: 2 Rationale 1: Contacting the supervisor is required when an abnormal situation is present. A multip requesting an epidural at 5 cm is not abnormal.

Rationale 2: Average cervical change among primips in the active phase of the first stage of labor is 1.2 cm/hour; thus, this patient’s lack of cervical change is unexpected and should be reported to the supervisor.

Rationale 3: Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation is present.

Rationale 4: Patients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Predict an expectant mother’s progression through the various stages of labor based on assessment data.

Question 12 Type: MCSA Which patient requires immediate intervention by the labor and delivery nurse?

1. Multip at 8 cm, systolic blood pressure has increased 35 mm Hg 2. Primip that delivered one hour ago with WBC of 50,000 3. Multip at 5 cm with a respiratory rate of 22 between contractions 4. Primip in active labor with urine output of 100 ml/hour Correct Answer: 2 Rationale 1: The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor.

Rationale 2: A white count of 25,000–30,000 is normal at the end of labor and during the early postpartum period.

This white count is abnormally high and requires further assessment and provider notification.

Rationale 3: The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This patient requires no further intervention.

Rationale 4: This is a normal urine output and requires no further intervention.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Explain the maternal systemic responses to labor in the nursing care of an expectant woman.

Question 13 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor?

1. Increased pulse 2. Elevated blood pressure 3. Muscle tension 4. Increased respirations Correct Answer: 3 Rationale 1: Increased pulse is a manifestation of pain, but it does not impede labor.

Rationale 2: Elevated blood pressure is a manifestation of pain, but it does not impede labor.

Rationale 3: Muscle tension can impede labor progress by increased oxygen and calorie consumption and by creating a mechanical obstruction that the uterine contractions must overcome to achieve labor progress.

Rationale 4: Increased respiration is a manifestation of pain, but it does not impede labor.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Explain the maternal systemic response to labor in the nursing care of an expectant woman.

Question 14 Type: MCSA A healthy 18-year-old patient who is 40 weeks’ gestation presents at the clinic complaining of vaginal expulsion of stringy mucus followed by blood-tinged secretions. She denies any discomfort or any other changes. Based upon the patient’s complaints, what is most likely to occur within the next 24 to 48 hours?

1. Onset of labor 2. Spontaneous abortion 3. Cesarean section 4. Chorioamnionitis Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: Softening and effacement of the cervix is accompanied by expulsion of the mucous plug and a small amount of blood loss from the exposed cervical capillaries. The resulting pink-tinged secretions are called bloody show. Bloody show is considered a sign that labor will begin within 24 to 48 hours.

Rationale 2: The patient is most likely demonstrating expulsion of the mucous plug and bloody show, which is considered a sign that labor will begin within 24 to 48 hours.

Rationale 3: The patient is describing pregnancy-related changes associated with imminent onset of labor. Based upon her report, there is no indication that cesarean section will be necessary.

Rationale 4: Chorioamnionitis is associated with premature rupture of amniotic membranes (PROM). Based upon the patient’s report, she is demonstrating mucus plug expulsion and bloody show.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Assess for the premonitory signs of labor when caring for an expectant woman.

Question 15 Type: MCSA While caring for a labor patient, the nurse determines during a vaginal exam that the baby’s head has internally rotated. This information is given to the family. The labor support person asks the nurse, “What other position changes will the baby undertake during labor and birth?” How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation?

1. Flexion, extension, restitution, external rotation, and expulsion 2. Expulsion, external rotation, and restitution 3. Restitution, flexion, external rotation, and expulsion 4. Extension, restitution, external rotation, and expulsion Correct Answer: 4 Rationale 1: The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

Rationale 2: The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

Rationale 4: The fetus changes position in the following order: descent, engagement, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO09 - Examine fetal responses to labor.

Question 16 Type: MCSA A patient in active labor is demonstrating intense contractions and demonstrates cervical dilatation of 3 cm without rupture of amniotic membranes. The attending physician requests an amnihook. What procedure does the nurse anticipate that the physician will perform?

1. Cesarean section 2. Placental separation 3. Cervical dilatation 4. Artificial rupture of membranes (AROM) Correct Answer: 4 Rationale 1: Based upon the scenario, there is no indication for cesarean section. Rather, this patient likely requires artificial rupture of amniotic membranes (AROM), which is performed using an amnihook.

Rationale 2: Placental separation usually occurs naturally, about 5 minutes after the birth of the newborn. Based upon the scenario, this patient requires artificial rupture of amniotic membranes (AROM).

Rationale 3: Based upon this scenario, the patient is demonstrating cervical dilatation consistent with the first stage of labor without rupture of amniotic membranes (ROM). She likely requires artificial rupture of membranes (AROM), which is performed using an amnihook.

Rationale 4: Based upon this scenario, the patient likely requires artificial rupture of membranes (AROM), which is performed using an amnihook.

Global Rationale:

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Predict an expectant mother’s progression through the various stages of labor based on assessment data.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 18 Question 1 Type: MCSA The nurse is admitting a patient to the labor and delivery unit. Which aspect of the patient’s history requires notifying the physician?

1. Blood pressure 120/88 2. Father is a carrier of sickle-cell trait 3. Dark red vaginal bleeding 4. History of domestic abuse Correct Answer: 3 Rationale 1: Blood pressure 120/88. Although the diastolic reading is slightly elevated, this is not the top priority.

Rationale 2: The infant also might have sickle trait, but sickle trait is not life-threatening at this time.

Rationale 3: Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and fetus.

Rationale 4: This patient is at risk for harm after delivery but is not in a life-threatening situation at this time.

This is not the highest priority for the patient.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe a maternal assessment of the laboring woman that includes the patient history, high-risk screening, and physical and psychosociocultural factors.

Question 2 Type: MCSA The nurse is preparing to assess a laboring primiparous patient who has just arrived in the labor and birth unit.

Which statement indicates that additional education is needed?

1. “You are going to do a vaginal exam to see how far dilated my cervix is.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. “The reason for a pelvic exam is to determine how low in the pelvis my baby is.”

3. “When you check my cervix, you will find out how thinned out it is.”

4. “After you assess my pelvis, you will be able to tell when I will deliver.”

Correct Answer: 4 Rationale 1: Cervical dilation is one aspect of the pelvic exam assessment.

Rationale 2: Determining the station of the presenting part is one aspect of the pelvic exam assessment.

Rationale 3: Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam assessment.

Rationale 4: An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about the contractions. The nurse will not have enough information following the cervical exam to estimate time of birth.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Evaluate the progress of labor by assessing the laboring woman’s contractions, cervical dilatation, and effacement.

Question 3 Type: MCSA The nurse is working with a pregnant adolescent. The patient asks the nurse how the baby’s condition is determined during labor. Which statement indicates the patient education was successful? “During labor, the nurse will: 1. “Check your cervix by doing a pelvic exam every two hours.”

2. “Assess the baby’s heart rate with an electronic fetal monitor.”

3. “Look at the color and amount of bloody show that you have.”

4. “Verify that your contractions are strong but not too close together.”

Correct Answer: 2 Rationale 1: Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal status. The patient has asked specifically about assessing fetal status in labor.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: This option best answers the question the patient has asked.

Rationale 3: Although bloody show is monitored, doing so does not assess fetal status. The patient has asked specifically about assessing fetal status in labor.

Rationale 4: Although contraction strength is palpated abdominally, the patient has asked about assessing fetal status in labor.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Describe an intrapartum fetal assessment to determine fetal position and presentation, fetal heart rate, and fetal status.

Question 4 Type: MCSA The nurse is preparing to assess the fetus of a laboring patient. Which assessment should the nurse perform first?

1. Perform Leopold’s maneuver to determine fetal position.

2. Count the fetal heart rate for 30 seconds and multiply by two.

3. Dry the maternal abdomen before using the Doppler.

4. Place the patient into a left lateral position.

Correct Answer: 1 Rationale 1: This is the first step so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided.

Rationale 2: Although this is how to auscultate the fetal heart rate, it is better to perform Leopold’s maneuver to determine fetal position so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided.

Rationale 3: Prior to using the Doppler device, a water-based gel is applied to the skin.

Rationale 4: The fetal heart tone assessment should be performed while the patient is either supine with a lateral tilt or while in left lateral position. Leopold’s maneuver is performed first to determine where to listen for fetal heart tones.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Describe the steps and frequency for performing auscultation of fetal heart rate.

Question 5 Type: MCSA The student nurse is to perform Leopold’s maneuver on a laboring patient. Which assessment requires intervention by the staff nurse?

1. The patient is assisted into supine position, and the position of the fetus is assessed.

2. The upper portion of the uterus is palpated, and then the middle section.

3. After determining where the back is located, the cervix is assessed.

4. Following voiding, the patient’s abdomen is palpated from top to bottom.

Correct Answer: 3 Rationale 1: Determination of fetal position and station is the point of Leopold’s maneuver. The patient is supine to facilitate uterine palpation.

Rationale 2: This is correct order of the first and second Leopold’s maneuver.

Rationale 3: The cervical exam is not a part of Leopold’s maneuvers abdominal palpation is the only technique used for Leopold’s maneuver.

Rationale 4: The patient is instructed to void prior to beginning Leopold’s maneuver to facilitate comfort; Leopold’s maneuver is essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Delineate the procedure for performing Leopold’s maneuver and the information that can be obtained.

Question 6 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is explaining to a student nurse how to determine fetal presentation and position by performing Leopold’s maneuver. The nurse should explain that the second maneuver in this procedure is used to determine: 1. Whether the fetal head or buttocks occupies the uterine fundus.

2. The location of the fetal back.

3. Whether the pelvic inlet contains the head or buttocks.

4. The descent of the presenting part into the pelvis.

Correct Answer: 2 Rationale 1: The first maneuver determines what part of the fetus is in the fundus.

Rationale 2: The second Leopold’s maneuver determines the location of the fetal back.

Rationale 3: The third maneuver determines which fetal part is in the pelvic inlet.

Rationale 4: The fourth maneuver determines the flexion of the fetal neck and descent into the pelvis.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Delineate the procedure for performing Leopold’s maneuver and the information that can be obtained.

Question 7 Type: MCSA The charge nurse is looking at the charts of laboring patients. Which patient most requires further intervention?

1. Multip at 7 cm, fetal heart tones auscultated every 90 minutes 2. Primip at 10 cm and pushing, external fetal monitor applied 3. Multip with meconium-stained fluid, internal fetal scalp electrode in use 4. Primip in preterm labor, external monitor in place Correct Answer: 1

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is too infrequently.

Rationale 2: External monitoring can be used instead of auscultation of the fetal heart tones during labor.

Rationale 3: Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present.

Rationale 4: External monitoring during preterm labor will assess both contractions and fetal status.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Describe the indications, methods, and steps for performing and recording electronic fetal monitoring.

Question 8 Type: MCSA While orienting a new nurse to the obstetrics unit, the R.N. preceptor is describing how to determine the baseline (BL) fetal heart rate (FHR). Which statement should the R.N. preceptor include in order to accurately describe the BL FHR? 1. “The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute is the baseline rate.”

2. “The baseline FHR should include periodic or episodic changes in FHR.” 3. “Normal baseline FHR ranges from 100 to 180 beats per minute.”

4. “The baseline FHR excludes periods of marked variability.”

Correct Answer: 4 Rationale 1: The baseline rate is the mean FHR during a 10-minute period rounded to increments of 5 beats per minute (bpm).

Rationale 2: The baseline FHR excludes periodic or episodic changes and periods of marked variability.

Rationale 3: Normal FHR (baseline rate) ranges from 110 to 160 beats per minute.

Rationale 4: The baseline FHR excludes periodic or episodic changes and periods of marked variability.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Distinguish between baseline and periodic changes in fetal heart rate monitoring, and the appearance and significance of each.

Question 9 Type: MCSA Which of the following, if seen on an electronic fetal monitoring strip, would the nurse explain to a laboring patient as a change in the baseline fetal heart rate?

1. Acceleration 2. Late deceleration 3. Sinusoidal pattern 4. Tachycardia Correct Answer: 4 Rationale 1: Accelerations are periodic changes of the fetal heart rate.

Rationale 2: Late decelerations are periodic changes of the fetal heart rate.

Rationale 3: A sinusoidal pattern is a periodic change of the fetal heart rate.

Rationale 4: Bradycardia and tachycardia are changes in the fetal heart rate baseline.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO07 - Distinguish between baseline and periodic changes in fetal heart rate monitoring, and the appearance and significance of each.

Question 10 Type: MCSA The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Assist the patient to change from Fowler’s to left lateral position.

2. Apply oxygen to the patient at 2 liters per nasal cannula.

3. Notify the operating room of the need for a cesarean birth.

4. Determine the color of the leaking amniotic fluid.

Correct Answer: 1 Rationale 1: The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the patient might get the fetus off the cord and eliminate the variable decelerations.

Rationale 2: Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable.

Rationale 3: There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable decelerations.

Rationale 4: The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is meconium-stained or bloody.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Evaluate fetal heart rate tracings using a systematic approach.

Question 11 Type: MCSA The primigravida in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability.

Which statement indicates that the patient understands the nurse’s teaching? “The most important part of fetal heart monitoring is the: 1. “Absence of variable decelerations.”

2. “Presence of variability.”

3. “Fetal heart rate baseline.”

4. “Depth of decelerations.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 2 Rationale 1: Variable decelerations indicate cord compression.

Rationale 2: Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system.

Rationale 3: The fetal heart rate baseline does not indicate central nervous system function.

Rationale 4: The depth of decelerations does not indicate central nervous system function.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Evaluate fetal heart rate tracings using a systematic approach.

Question 12 Type: MCSA A woman is in labor. The fetus is in vertex position. When the patient’s membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately: 1. Change the patient’s position in bed.

2. Notify the physician that birth is imminent.

3. Administer oxygen at 2 liters per minute.

4. Begin continuous fetal heart rate monitoring.

Correct Answer: 4 Rationale 1: Changing the patient’s position is not indicated.

Rationale 2: Meconium-stained amniotic fluid does not indicate that birth is imminent.

Rationale 3: Oxygen administration is not indicated.

Rationale 4: Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO08 - Evaluate fetal heart rate tracings using a systematic approach.

Question 13 Type: MCSA The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations.

Which nursing intervention should be implemented first?

1. Alert the physician/CNM of the fetal status.

2. Administer oxygen to the patient at 4 liters per minute via nasal cannula.

3. Decrease the rate of infusion of intravenous fluids.

4. Facilitate a maternal left lateral position.

Correct Answer: 4 Rationale 1: While the attending physician or CNM should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct patient care. Initially, the mother should be placed in the left lateral position.

Rationale 2: Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 liters per minute via facemask.

Rationale 3: Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids.

Rationale 4: In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO09 - Compare nonreassuring fetal heart rate patterns to appropriate nursing responses.

Question 14 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The laboring primiparous patient with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? “The monitor: 1. “Is necessary so we can see how your labor is progressing.”

2. “Will prevent complications from the meconium in your fluid.”

3. “Helps us to see how the baby is tolerating labor.”

4. “Can be removed, and oxygen can be given instead.”

Correct Answer: 3 Rationale 1: The fetal monitor does not help visualize labor progress. Labor progress is assessed through the pelvic exam, checking to see if the cervix is dilating and the fetus descending into the pelvis.

Rationale 2: The fetal monitor will provide information on how the baby is tolerating labor, but it does not prevent complications such as meconium aspiration syndrome.

Rationale 3: This is the reason fetal monitoring is used.

Rationale 4: Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Fetal monitoring provides information on the status of the fetus, and it is a necessary assessment when the amniotic fluid is meconium-stained.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO10 - Explain the family’s responses to electronic fetal monitoring in nursing care management.

Question 15 Type: MCSA The clinical coordinator is observing a nursing student as he provides care to a patient who is in early labor.

Which of the student’s actions should be addressed for correction during the student’s daily clinical evaluation?

1. Application of a fetal heart monitor followed by an explanation of the reason for its use 2. Upon entering the patient’s room, speaking with the patient prior to looking at the fetal heart monitor 3. Using layman’s terms to provide the patient with an explanation of the rationale for electronic fetal monitoring Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Incorporating cues that arise from intuition or from observations of the patient and family as opposed to focusing on the fetal heart monitor Correct Answer: 1 Rationale 1: Before using the electronic fetal monitor, the nurse needs to fully explain to the patient the reason for its use and the information that it can provide.

Rationale 2: The nurse can acknowledge the patient’s need to be the central focus by always speaking to and looking at the woman when entering the room, before looking at the monitor.

Rationale 3: The technical language of electronic fetal monitoring and other procedures may act as a barrier, isolating the patient and emphasizing her experience.

Rationale 4: To prevent dehumanization of the nurse-patient relationship, the nurse should incorporate cues that may arise from intuition or from observations of or interactions with the patient and family, as opposed to focusing only upon objective monitor-based data.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO10 - Explain the family’s responses to electronic fetal monitoring in nursing care management.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 19 Question 1 Type: MCSA The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching has been effective? “When a patient arrives in labor: 1. “A urine specimen is obtained by catheter to check for protein and ketones.”

2. “She will be positioned supine to facilitate a normal blood pressure.”

3. “Her prenatal record is reviewed for indications of domestic abuse.”

4. “A vaginal exam is performed if delivery appears to be imminent.”

Correct Answer: 4 Rationale 1: A midstream clean-catch specimen is obtained to assess for proteinuria and ketonuria.

Rationale 2: Supine position predisposes the patient to supine hypotension syndrome; side-lying is preferred.

Rationale 3: Domestic abuse is not the sole reason the prenatal record is examined; any complications of pregnancy are noted.

Rationale 4: Unless delivery seems imminent because the patient is bearing down or contractions are very close and strong, the vaginal exam is performed after the vital signs are obtained.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO01 - Identify admission data for a woman admitted to the birthing area.

Question 2 Type: MCMA The patient presents to labor and delivery stating that her water broke two hours ago. Indicators of normal labor include: Standard Text: Select all that apply.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Fetal heart rate of 130 with average variability.

2. Blood pressure of 130/80.

3. Maternal pulse of 160.

4. Protein of +1 in urine.

5. Odorless, clear fluid on underwear.

Correct Answer: 1,2,5 Rationale 1: FHR 120–160 with variability is a normal indication.

Rationale 2: Maternal vital sign of blood pressure below 140/70 is a normal indication.

Rationale 3: A pulse of 60–100 is a normal indication.

Rationale 4: Proteinuria of +1 or more could be a sign of pre-eclampsia.

Rationale 5: Fluid clear and without odor is a normal indication.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Identify admission data for a woman admitted to the birthing area.

Question 3 Type: MCSA The laboring patient and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first?

1. The sterile vaginal exam 2. Welcoming the couple 3. Auscultation of the fetal heart rate 4. Checking for ruptured membranes Correct Answer: 2

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: The sterile vaginal exam should be performed after rapport has been established and maternal vital signs have been assessed.

Rationale 2: Establishing rapport will decrease anxiety of the couple and facilitate a more pleasant birth experience.

Rationale 3: Welcoming the couple is more important upon arrival.

Rationale 4: Although assessing for intact or ruptured membranes is a part of the admission assessment, welcoming the couple is more important upon arrival.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Describe the nursing care of a woman and her partner/family upon admission to the birthing area.

Question 4 Type: MCSA An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to: 1. Insist that he leave the room for at least the next hour.

2. Tell him he is not being as effective as he was and that he needs to let someone else take over.

3. Offer to remain with his partner while he takes a break.

4. Suggest that the patient’s mother might be of more help.

Correct Answer: 3 Rationale 1: Insisting that the father leave does not reassure him about the care the woman will receive in his absence.

Rationale 2: Telling him that he is ineffective does not reassure him about the care the woman will receive in his absence.

Rationale 3: Support persons frequently are reluctant to leave the laboring woman to take care of their own needs.

Offering to stay with the woman so that he can take a break reassures the support person that the woman will be well cared for in his absence.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Suggesting that the patient’s mother take his place does not reassure him about the care the woman will receive in his absence.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Describe the nursing care of a woman and her partner/family upon admission to the birthing area.

Question 5 Type: MCSA The laboring patient has been found to be having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a −2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority?

1. Encourage the husband to remain in the room.

2. Keep the patient on bed rest at this time.

3. Apply an internal fetal scalp electrode.

4. Obtain a clean-catch urine specimen.

Correct Answer: 2 Rationale 1: It is unknown from the given information whether it is culturally appropriate for the patient’s husband to remain in the room for the labor and birth.

Rationale 2: Because the membranes are ruptured and the head is high in the pelvis at a −2 station, the patient should be maintained on bed rest to prevent cord prolapse.

Rationale 3: An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This patient has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present.

Rationale 4: A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid contamination might falsely increase the protein present. Preventing cord prolapse, which is life-threatening to the fetus, is a higher priority.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Use assessment data to determine the nursing interventions to meet the psychologic, social, physiologic, and spiritual needs of the woman and her partner/family during each stage of labor.

Question 6 Type: MCSA A healthy woman who is scheduled for elective cesarean birth is being admitted to the hospital. Her surgery is scheduled to begin in 4 hours. The woman asks for a sip of coffee with creamer. How should the nurse respond?

1. “Since you’re having surgery today, you’re not allowed to have anything to eat or drink.”

2. “You can drink black coffee.”

3. “You may have coffee with creamer.”

4. “You’re only allowed to drink water right now.”

Correct Answer: 2 Rationale 1: Avoiding both liquids and solids during labor, which was once standard practice, is no longer so because evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth.

Rationale 2: Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration.

Rationale 3: Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration. While black coffee is considered a clear liquid, adding creamer would be contraindicated.

Rationale 4: Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration. Black coffee is considered to be a clear liquid.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Compare methods of promoting comfort during the first and second stages of labor.

Question 7 Type: MCMA Breathing techniques used in labor provide which of the following?

Standard Text: Select all that apply.

1. A form of anesthesia 2. A source of relaxation 3. An increased ability to cope with contractions 4. A source of distraction Correct Answer: 2,3,4 Rationale 1: Breathing techniques do not provide a form of anesthesia.

Rationale 2: When used correctly, breathing techniques can increase the woman’s pain threshold and permit relaxation.

Rationale 3: When used correctly, breathing techniques can enhance the ability to cope with contractions.

Rationale 4: When used correctly, breathing techniques can provide a sense of control and allow the uterus to function more effectively.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Compare methods of promoting comfort during the first and second stages of labor.

Question 8 Type: MCSA Five minutes after delivery, the neonate’s body is pink with blue extremities. The heart rate is 150. The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Stimulation and resuscitative efforts 2. Oxygen via face mask and endotracheal suctioning 3. Rescue breathing and stimulation 4. Nasopharyngeal suctioning and blow-by oxygen Correct Answer: 4 Rationale 1: The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called “blow-by” oxygen).

Rationale 2: The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called “blow-by” oxygen).

Rationale 3: The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called “blow-by” oxygen).

Rationale 4: The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called “blow-by” oxygen).

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

Question 9 Type: MCSA The neonatal nurse specialist is presenting a class to nursing students. When describing a proper method for preventing heat loss in the neonate, which statement should the neonatal nurse specialist include in his presentation?

1. “If the newborn is under a radiant-heated unit, he or she is dried, placed on a dry blanket, and left uncovered under the radiant heat.”

2. “After delivery, the newborn is immediately placed in skin-to-skin contact with the mother.”

3. “If a radiant-heated unit is used to keep the neonate warm, he or she is dried, wrapped in a dry blanket, and placed under the radiant heat.”

4. “Immediately after delivery, the newborn is wrapped in a blanket and placed on the mother’s chest.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: If the newborn is under a radiant-heated unit, he or she is dried, placed on a dry blanket, and left uncovered under the radiant heat. Because radiant heat warms the outer surface of objects, a newborn wrapped in blankets will receive no benefit from radiant heat.

Rationale 2: After delivery, the newborn is dried immediately and wet blankets are removed. Warmed blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The newborn may also be placed under a radiant-heated unit.

Rationale 3: If the newborn is under a radiant-heated unit, he or she is dried, placed on a dry blanket, and left uncovered under the radiant heat. Because radiant heat warms the outer surface of objects, a newborn wrapped in blankets will receive no benefit from radiant heat.

Rationale 4: After delivery, the newborn is dried immediately and wet blankets are removed. Warmed blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The newborn may also be placed under a radiant-heated unit.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

Question 10 Type: MCSA One minute after delivery, the neonate’s heart rate is 120 beats per minute. She demonstrates a vigorous cry and is actively moving. The infant resists the nurse’s attempts to straighten her arm. When the nurse flicks the soles of her feet, the infant grimaces. Her body is pink and her extremities are blue. What APGAR score should the nurse assign to this infant?

1. 9 2. 8 3. 7 4. 6 Correct Answer: 2

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant’s APGAR score is 8.

Rationale 2: Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant’s APGAR score is 8.

Rationale 3: Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant’s APGAR score is 8.

Rationale 4: Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point and a pink body with blue extremities correlates with 1 point. This infant’s APGAR score is 8.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

Question 11 Type: MCSA Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is: 1. Placing the newborn under the radiant warmer.

2. Placing the newborn on the maternal abdomen.

3. Allowing the mother a chance to rest immediately after delivery.

4. Taking the newborn to the nursery for the initial assessment.

Correct Answer: 2 Rationale 1: Removing the baby from the mother does not promote interaction.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Placing the baby on the maternal abdomen promotes attachment and bonding and gives the mother a chance to interact with her baby immediately.

Rationale 3: Removing the baby from the mother does not promote interaction.

Rationale 4: Removing the baby from the mother does not promote interaction.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

Question 12 Type: MCSA A young adolescent is transferred to the labor and delivery unit from the emergency department. The patient is in active labor but did not know that she was pregnant. The most important nursing action is to: 1. Determine who might be the father of the baby for paternity testing.

2. Ask the patient what kind of birthing experience she would like to have.

3. Assess blood pressure and check for proteinuria.

4. Obtain a Social Services referral to discuss adoption.

Correct Answer: 3 Rationale 1: Paternity testing is a lower priority than the physiologic well-being of the patient and fetus.

Rationale 2: A patient with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.

Rationale 3: Pre-eclampsia is more common among adolescents than in young adults, and it is potentially lifethreatening to both the mother and fetus. This assessment is the highest priority.

Rationale 4: During labor is an inappropriate time to discuss adoption or parenting. Wait until after the birth to have this discussion when dealing with an adolescent who did not know she was pregnant prior to the onset of labor.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Examine the unique needs of the adolescent during birth in the provision of nursing care.

Question 13 Type: MCSA As compared with admission considerations for an adult woman in labor, the nurse’s priority for an adolescent in labor would be: 1. Cultural background.

2. Plans for keeping the infant.

3. Support persons.

4. Developmental level.

Correct Answer: 4 Rationale 1: Cultural background is important to planning anyone’s care.

Rationale 2: Before considering this area, it is important to identify the adolescent’s level of development so that a plan of care is consistent with the adolescent’s abilities.

Rationale 3: Support person(s) are important to planning anyone’s care.

Rationale 4: Knowing the adolescent’s level of development is also important when planning nursing care for the mother who is keeping her infant.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Examine the unique needs of the adolescent during birth in the provision of nursing care.

Question 14 Type: MCSA The nurse encounters a woman giving birth at the local mall. What should the nurse do first?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Apply counterpressure to the perineum.

2. Ask a bystander for a dry piece of clothing.

3. Visualize the perineum.

4. Determine if the membranes have ruptured.

Correct Answer: 3 Rationale 1: This is appropriate if the presenting part is crowning. Counterpressure to the perineum helps prevent perineal lacerations.

Rationale 2: Prior to birth, some dry cloth object should be obtained to dry the infant and prevent neonatal hypothermia.

Rationale 3: Inspecting the perineum is the only method of determining whether the patient is going to give birth imminently. This is the top priority.

Rationale 4: This is less important than knowing whether the baby is coming at this time.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Describe the role and responsibility of the nurse in management of a precipitous labor and birth.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 20 Question 1 Type: MCSA The laboring patient has rated her pain at 9 on a scale of 1–10, and she requests IV pain medication. She has refused epidural anesthesia, but her certified nurse-midwife (CNM) has ordered butorphanol tartrate (Stadol) for administration to the patient. Which action should the nurse complete next?

1. Advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

2. Offer the woman epidural anesthesia once more and describe the effectiveness of this method of labor pain control.

3. Obtain maternal vital signs and assess the fetal heart rate (FHR).

4. Administer oxygen via face mask at 6 to 10 liters per minute.

Correct Answer: 1 Rationale 1: Prior to administration of medication, the nurse must explain the pharmacologic effects of the medication and obtain consent for administration.

Rationale 2: The woman has refused epidural anesthesia but is authorized to receive butorphanol tartrate. The nurse’s next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Rationale 3: Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Rationale 4: Routine oxygen administration is not indicated for administration of butorphanol tartrate to an asymptomatic patient in labor. The nurse’s next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Describe the use, administration, dose, onset of action, adverse effects, and contraindications of systemic drugs that promote pain relief during labor in determining the nursing care management of the woman in labor and her fetus.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 2 Type: MCSA A patient has just been admitted for labor and delivery. She is having mild contractions every 15 minutes lasting 30 seconds. The patient wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the patient understands that: 1. In order to respect her wishes, no medication will be given.

2. Pain relief will allow a more enjoyable birth experience.

3. The use of medications allows the patient to rest and be less fatigued.

4. Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.

Correct Answer: 4 Rationale 1: It is important to respect the patient’s wishes when possible. Once the effects are explained, it is still the patient’s choice whether to receive medication.

Rationale 2: While pain relief can lead to a more enjoyable experience, it might be the view of the nurse but not the mother.

Rationale 3: While pain relief can allow the mother to be less fatigued, it might be the view of the nurse but not the mother.

Rationale 4: The decision not to medicate should be an informed one, and it is possible that the patient does not know about the effects pain and stress can have on the fetus. Once the effects are explained, it is still the patient’s choice whether to receive medication.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Describe the use, administration, dose, onset of action, adverse effects, and contraindications of systemic drugs that promote pain relief during labor in determining the nursing care management of the woman in labor and her fetus.

Question 3 Type: MCSA The nurse has presented a teaching session on pain relief options to a prenatal class. Which patient statement indicates that additional teaching is needed?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “An epidural can be continuous or one dose.”

2. “General anesthesia is usually recommended for a patient who delivers by way of cesarean section.”

3. “Narcotics can be given through a patient’s epidural infusion catheter.”

4. “A pudendal block usually works well to control pain during episiotomy repair.”

Correct Answer: 2 Rationale 1: Epidural anesthesia can be administered in a single dose or via continuous infusion.

Rationale 2: Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice indicated in the management of patients undergoing cesarean section.

Rationale 3: To provide analgesia for approximately 24 hours after the birth, the analgesia provider may inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the epidural space immediately after the birth Rationale 4: A pudendal block technique is given in the second stage of labor for the provision of perineal anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy repair.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Question 4 Type: MCSA The charge nurse is reviewing the plans of care for four laboring patients. Which care plan requires immediate reconsideration for revision?

1. Administration of epidural anesthesia to a woman who is in the first stage of labor and has a shellfish allergy 2. Administration of a spinal anesthetic to a woman who is scheduled for vaginal delivery of her baby 3. Administration of epidural anesthesia to a woman with a history of vomiting secondary to hyperemesis gravidarum 4. Administration of a spinal anesthetic to a woman with a history of irritable bowel syndrome (IBS) Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: A lumbar epidural relieves pain associated with the first and second stages of labor. An allergy to shellfish is not a contraindication to epidural anesthesia.

Rationale 2: Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for vaginal birth.

Rationale 3: Contraindications to epidural anesthesia include severe hypovolemia of any etiology. This patient with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia.

Rationale 4: Irritable bowel syndrome (IBS) does not represent a contraindication to spinal anesthesia.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Question 5 Type: MCMA Which of the following nursing actions can prevent or detect common side effects of epidural anesthesia?

Standard Text: Select all that apply.

1. Preloading the patient with a rapid infusion of IV fluids 2. Continuing the patient on p.o. fluids only to prevent hypotension 3. Monitoring the FHR for late deceleration and decrease in rate 4. Use of intermittent FHR monitoring so the patient can use the birthing ball Correct Answer: 1,3 Rationale 1: Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

Rationale 3: Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

Rationale 4: Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Question 6 Type: MCSA Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring patient in which of the following positions?

1. On her right side in the center of the bed with her back curved 2. Lying prone with a pillow under her chest 3. On her left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed with her back slightly curved and her feet on a stool Correct Answer: 4 Rationale 1: Especially in pregnant women, this position is not ideal for facilitating access to the epidural space.

Rationale 2: This position is not consistent with access to the epidural spaces.

Rationale 3: This position is not consistent with access to the epidural spaces.

Rationale 4: Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the epidural spaces to be accessed more easily.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Question 7 Type: MCSA The laboring patient requests pain medication. Her contractions are lasting 20–30 seconds and are occurring every 8–20 minutes. The nurse would explain that analgesics given at this time would likely cause: 1. Fetal respiratory depression.

2. Decreased analgesic effectiveness at the end of labor.

3. Maternal hypotension.

4. Prolonged labor.

Correct Answer: 4 Rationale 1: Pain medication given before established labor does not cause fetal respiratory depression unless the mother delivers within an hour of receiving the medication. This is not likely if labor is not established.

Rationale 2: Medication given early in the labor process does not become less effective at the end of labor.

Rationale 3: Analgesics might lower the blood pressure, but this effect does not cause the contraction pattern to be altered.

Rationale 4: Pain medication given before labor becomes established is likely to prolong the labor process.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 8 Type: MCSA During her hospital admission, the laboring patient explicitly refused all pain medications and a labor epidural.

Once dilated to 5 cm, the patient complains of intolerable discomfort and asks the nurse, “If I have an epidural, how will you make sure it doesn’t hurt my baby?” The best response by the nurse is: 1. “We’ll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural.”

2. “Epidural anesthesia is very safe and there are no potential side effects that can affect your baby.”

3. “We’ll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby.”

4. Before your epidural is placed, we’ll administer IV fluid to you in order to prevent the epidural from causing you problems.”

Correct Answer: 1 Rationale 1: Continuous electronic fetal monitoring to assess fetal status is indicated in the care of pregnant women who receive epidural anesthesia and allows for a more direct assessment of fetal status than does frequent monitoring of maternal BP and pulse, which are also indicated in the care of this patient.

Rationale 2: While proficient administration and monitoring of epidural anesthesia allows for a high degree of safety with this technique, maternal hypotension associated with epidural anesthesia may produce harmful fetal effects.

Rationale 3: While frequent monitoring of maternal blood pressure and pulse are indicated in the care of a patient who receives a labor epidural, continuous electronic fetal monitoring is also indicated for assessment of fetal status and allows for a more direct fetal assessment.

Rationale 4: While administration of a bolus of IV fluid is indicated in preparation for epidural placement and reduces the risk for maternal hypotension, this intervention neither guarantees the prevention of related complications nor allows for assessment of fetal status.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Question 9 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA The anesthesia provider has just administered an epidural anesthetic in a laboring patient and local anesthesia is continuously infusing via the epidural catheter. Suddenly, the patient asks, “Why are my ears ringing?” What is the most likely cause of the patient’s complaint?

1. Hypotension 2. Allergic reaction 3. Dehydration 4. Local anesthetic toxicity Correct Answer: 4 Rationale 1: Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing in the ears is associated with local anesthetic toxicity.

Rationale 2: Sensation of ringing in the ears is associated with local anesthetic toxicity.

Rationale 3: Sensation of ringing in the ears is associated with local anesthetic toxicity.

Rationale 4: Sensation of ringing in the ears is associated with local anesthetic toxicity.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Explain the possible complications of regional anesthesia in nursing care management of the laboring woman and her fetus.

Question 10 Type: MCSA The nurse is caring for a laboring patient who is receiving continuous epidural anesthesia via infusion. The maternal blood pressure decreases from 132/78 to 78/42. Which intervention should the nurse implement first?

1. Increase the flow rate of infusion of intravenous crystalloid solution.

2. Verify the patient is positioned to promote left uterine displacement.

3. Administer oxygen.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Administer ephedrine 5 to 10 mg intravenously.

Correct Answer: 1 Rationale 1: If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.

Rationale 2: If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.

Rationale 3: If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.

Rationale 4: If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Explain the possible complications of regional anesthesia in nursing care management of the laboring woman and her fetus.

Question 11 Type: MCSA During admission, a laboring patient tells the nurse, “I’m so afraid I’ll need a cesarean section. I don’t want to be asleep for surgery when my baby is born!” Which of the following nursing responses is most appropriate?

1. “If a cesarean section is needed, that doesn’t necessarily mean you’ll need to go to sleep for surgery.”

2. “Your anesthesia provider will require that you go to sleep for surgery.”

3. “We’ll do our best to make sure you deliver vaginally, so you don’t need to have a cesarean section.”

4. “If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly.”

Correct Answer: 1

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: While general anesthesia may be needed for cesarean birth and for surgical intervention with some complications, in modern obstetrics, general anesthesia is used in less than 1% of all obstetric births.

Rationale 2: General anesthesia may be needed for cesarean birth and for surgical intervention with some complications. However, in modern obstetrics, spinal anesthesia is often administered for delivery via cesarean section, while general anesthesia is used in less than 1% of all obstetric births.

Rationale 3: Reassuring the patient in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section.

Rationale 4: Reassuring the patient in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Explain the use and major complications of general anesthesia during labor in nursing care management of the woman in labor and her fetus.

Question 12 Type: MCSA A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following?

1. Observe fetal heart rate variability.

2. Rapidly infuse 500–1,000 ml of intravenous fluids.

3. Place the patient in the semi-Fowler’s position.

4. Teach the patient appropriate breathing techniques.

Correct Answer: 2 Rationale 1: Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common side effect of an epidural.

Rationale 2: Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure.

Rationale 3: Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Explain the possible complications of regional anesthesia in nursing care management of the laboring woman and her fetus.

Question 13 Type: MCSA After receiving nalbuphine hydrochloride (Nubain), a woman’s labor progresses rapidly, and the baby is born less than one hour later. The baby exhibits signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn?

1. Fentanyl (Sublimaze) 2. Butorphanol tartrate (Stadol) 3. Naloxone (Narcan) 4. Pentobarbital (Nembutal) Correct Answer: 3 Rationale 1: Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.

Rationale 2: Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.

Rationale 3: Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.

Rationale 4: Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Explain the use and major complications of general anesthesia during labor in nursing care management of the woman in labor and her fetus.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 14 Type: MCSA The patient at 39 weeks’ gestation is undergoing a Cesarean birth due to breech presentation. General anesthesia is being used. Which potential challenge is most relevant to the anesthesia care of this patient?

1. Hypotension due to the intense blockade of sympathetic fibers 2. Difficulty with maternal intubation 3. Broad ligament hematoma 4. Fetal depression that is fetal depression inversely proportional to maternal anesthetic depth and duration Correct Answer: 2 Rationale 1: Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of sympathetic fibers that results in a high incidence of hypotension.

Rationale 2: Difficulty with maternal intubation is a primary challenge of general anesthesia care for pregnant patients.

Rationale 3: Broad ligament hematoma is a complication associated with pudendal blockade.

Rationale 4: Fetal depression associated with general anesthesia is directly proportional to maternal anesthetic depth and duration.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Explain the use and major complications of general anesthesia during labor in nursing care management of the woman in labor and her fetus.

Question 15 Type: MCSA Following spinal anesthesia for delivery of her baby, a woman reports an inability to void urine. As the nurse palpates the woman’s bladder the woman says, “It’s been five hours since I had my spinal and I still can’t empty my bladder. Do I have nerve damage?” How should the nurse respond?

1. “Spinal anesthesia can sometimes cause nerve damage.”

2. “It may be several hours before you’re able to control your urination.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “You should be able to control your bladder by now. I’ll ask the anesthesia provider to visit with you.”

4. “You are probably dehydrated. Please increase your water intake.”

Correct Answer: 2 Rationale 1: Although nerve damage is a rare occurrence in relation to spinal anesthesia, there is no objective data to suggest that this woman has experienced nerve damage. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Rationale 2: Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Rationale 3: Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Rationale 4: There is no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, contraindications, techniques, and nursing care management of the laboring woman and her fetus.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 21 Question 1 Type: MCSA The nurse is caring for a patient at 30 weeks’ gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the patient needs additional teaching? “If I: 1. “Were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured.”

2. “Develop a urinary tract infection in my next pregnancy, I might rupture membranes early again.”

3. “Want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy.”

4. “Have bleeding in the third trimester of my next pregnancy, I might rupture membranes again.”

Correct Answer: 3 Rationale 1: Multifetal gestation increases the risk for PPROM. Rationale 2: A UTI increases the risk for PPROM. Rationale 3: There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM. Rationale 4: Second- and third-trimester bleeding increases the risk for PPROM. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO01 - Explain the possible causes, risk factors, and clinical therapy for preterm labor or premature rupture of the membranes in determining the hospital-based and community-based nursing care management of the woman and her fetus/newborn.

Question 2 Type: MCSA A clinical nurse coordinator is teaching a class of nursing students about surgical and postoperative care of the woman who undergoes cerclage. Which nursing student’s statement indicates the need for further clarification of the teaching?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “Sometimes cerclage can be performed on an outpatient basis.”

2. “If cerclage is performed emergently, the woman will usually be hospitalized for at least five days.”

3. “If the woman’s amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed.”

4. “After 37 weeks’ gestation, the woman’s cerclage may be cut in order to allow for vaginal delivery.”

Correct Answer: 3 Rationale 1: An uncomplicated elective cerclage may be done on an outpatient basis or the woman may be hospitalized and discharged after 24 to 48 hours. An emergency cerclage, however, requires hospitalization for 5 to 7 days or longer.

Rationale 2: An uncomplicated elective cerclage may be done on an outpatient basis or the woman may be hospitalized and discharged after 24 to 48 hours. An emergency cerclage, however, requires hospitalization for 5 to 7 days or longer.

Rationale 3: Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure.

Rationale 4: After 37 completed weeks’ gestation, the suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Describe the clinical therapies and appropriate nursing interventions for the mother with cervical insufficiency and her unborn fetus.

Question 3 Type: MCSA A 26-year-old woman who is pregnant with her first child is admitted to the obstetrics unit with a diagnosis of cervical insufficiency. Based upon the patient’s diagnosis, how is she most likely to describe her symptoms?

1. “I’ve been having contractions every four hours.”

2. “My cervical pain has gotten much worse over the past two days.”

3. “I’m not having any pain, but my contractions are getting stronger.”

4. “I’m not having any pain and I don’t feel any contractions.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 4 Rationale 1: Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix.

Rationale 2: Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix.

Rationale 3: Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix.

Rationale 4: Cervical insufficiency (formerly called incompetent cervix) is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Describe the clinical therapies and appropriate nursing interventions for the mother with cervical insufficiency and her unborn fetus.

Question 4 Type: MCSA The nurse has received an end of shift report in the high-risk maternity unit. Which patient should the nurse see first?

1. 26 weeks’ gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 2. 30 weeks’ gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 35 weeks’ gestation with grade I abruptio placentae in labor who has a strong urge to push 4. 37 weeks’ gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously Correct Answer: 1 Rationale 1: Bleeding with a placenta previa is a complication that can be life-threatening to both the mother and baby. This patient is the highest priority.

Rationale 2: Late decelerations are an abnormal finding, but put only the fetus at risk. This patient is not the highest priority.

Rationale 3: Grade I abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This patient is not the highest priority.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Although pregnancy-induced hypertension puts a woman at risk for developing abruptio placentae, there is no indication that this patient is experiencing this complication. This patient is not the highest priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

Question 5 Type: MCMA The nurse is planning an in-service educational program to talk about disseminating intravascular coagulation (DIC). The nurse should identify which of the following as risk factors for developing DIC? Standard Text: Select all that apply.

1. Diabetes mellitus 2. Abruptio placentae 3. Prolonged retention of a fetus after demise 4. Multiparity 5. Preterm labor Correct Answer: 2,3 Rationale 1: Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that triggers DIC. Rationale 2: Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC. Rationale 3: Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC. Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that triggers DIC. Rationale 5: Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that triggers DIC. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

Question 6 Type: MCSA The patient at 30 weeks’ gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes: 1. Limiting vaginal exams to only one per 24-hour period.

2. Evaluating the fetal heart rate with an internal monitor.

3. Monitoring for blood loss, pain, and uterine contractibility.

4. Assessing blood pressure every 2 hours.

Correct Answer: 3 Rationale 1: Vaginal exams are contraindicated because the exam can stimulate bleeding.

Rationale 2: Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor.

Rationale 3: Blood loss, pain, and uterine contractibility need to be assessed for patient comfort and safety.

Rationale 4: Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or p.r.n.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO02 - Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

Question 7 Type: MCMA A multigravida patient is admitted to labor and delivery in active labor. Nursing diagnoses that might apply to the patient with suspected abruptio placentae include: Standard Text: Select all that apply.

1. Fluid volume, risk for deficit related to hypovolemia.

2. Tissue perfusion, risk for altered related to blood loss.

3. Anxiety related to concern for own safety.

4. Knowledge deficit related to lack of information about inherited genetic defects.

Correct Answer: 1,2,3 Rationale 1: Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.

Rationale 2: Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.

Rationale 3: Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.

Rationale 4: Abruptio placentae is a premature separation of the placenta, not a genetic abnormality.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO02 - Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

Question 8 Type: MCSA The charge nurse is reviewing the physician’s notes describing the diagnosis of abruptio placentae in a patient who is currently admitted. The physician describes the woman’s placental separation as being “central.” Based upon this description, what can the nurse infer about the woman’s condition?

1. Blood is trapped between the woman’s placenta and the uterine wall, and she may have concealed bleeding.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. The total separation of the woman’s placenta from the uterine wall will lead to massive hemorrhage.

3. Blood is passing between the fetal membranes and the woman’s uterine wall, which will lead to some vaginal bleeding.

4. The slight separation of the woman’s placenta from the uterine wall will not produce any bleeding.

Correct Answer: 1 Rationale 1: With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding.

Rationale 2: With marginal placental separation, blood passes between the fetal membranes and the uterine wall and escapes vaginally. With central placental separation, blood is trapped between the placenta and uterine wall, and bleeding is concealed. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.

Rationale 3: With marginal placental separation, blood passes between the fetal membranes and the uterine wall and escapes vaginally. With central placental separation, blood is trapped between the placenta and uterine wall, and bleeding is concealed. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.

Rationale 4: With marginal placental separation, blood passes between the fetal membranes and the uterine wall and escapes vaginally. With central placental separation, blood is trapped between the placenta and uterine wall, and bleeding is concealed. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

Question 9 Type: MCSA The home health nurse is admitting a patient at 18 weeks who is pregnant with twins. Which nursing action is most important?

1. Teach the patient about foods that are good sources of protein.

2. Assess the patient’s blood pressure in her upper right arm.

3. Determine whether the pregnancy is a result of infertility treatment.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Collect a cervicovaginal fetal fibronectin (fFN) specimen.

Correct Answer: 1 Rationale 1: A diet containing 3,500 kcal (minimum) and 175 g protein is recommended for a woman with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth.

Rationale 2: Pre-eclampsia is not diagnosed until the 20th week of gestation. This patient is only at 18 weeks.

Further, blood pressure can be assessed in either arm when the patient is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm.

Rationale 3: Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those resulting from spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.

Rationale 4: Preterm labor is not diagnosed until 20 weeks. This patient is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the community-based and hospital-based nursing care management of the woman with multiple gestation.

Question 10 Type: MCSA In counseling a newly pregnant gravida 1 at 8 weeks’ twin gestation, the nurse teaches the woman about the need for increased caloric intake. The nurse would tell the woman that the minimum recommended intake should be: 1. 2,500 kcal and 120 grams protein.

2. 3,000 kcal and 150 grams protein.

3. 3,500 kcal and 175 grams protein.

4. 4,000 kcal and 190 grams protein.

Correct Answer: 3 Rationale 1: This is less than recommended for a twin-gestation pregnancy.

Rationale 2: This is less than recommended for a twin-gestation pregnancy.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This is the recommended caloric and protein intake in a twin-gestation pregnancy.

Rationale 4: This is more than recommended for a twin-gestation pregnancy.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the community-based and hospital-based nursing care management of the woman with multiple gestation.

Question 11 Type: MCSA When a woman who is experiencing a multiple fetal pregnancy asks, “What are the chances of having an uncomplicated pregnancy?” the nurse answers with which statement?

1. The perinatal mortality rate for monoamniotic siblings is 50%.

2. Twins are less likely to have complications than are singleton births.

3. Primiparous women pregnant with twins are less likely to develop complications.

4. Spontaneously conceived twins are less likely to develop complications.

Correct Answer: 4 Rationale 1: The perinatal mortality rate for monoamniotic siblings is 10–32%.

Rationale 2: Twins are more likely to have complications than are singleton births.

Rationale 3: Primiparous women with twin pregnancies are more likely to develop complications.

Rationale 4: This is true. Spontaneously conceived twins are less likely to develop complications.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO04 - Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the community-based and hospital-based nursing care management of the woman with multiple gestation.

Question 12 Type: MCSA The patient at 38 weeks’ gestation has been diagnosed with oligohydramnios. Which statement indicates that teaching has been effective?

1. “My gestational diabetes may have caused this problem to develop.”

2. “When I go into labor, I should come to the hospital right away.”

3. “This problem is common and will likely occur with my next pregnancy.”

4. “Women with this condition usually go into labor after their due date.”

Correct Answer: 2 Rationale 1: Gestational diabetes can lead to polyhydramnios but does not cause oligohydramnios.

Rationale 2: The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the patient with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop.

Rationale 3: Oligohydramnios occurs in 1–3% of pregnancies. It rarely recurs in subsequent pregnancies.

Rationale 4: The risk of fetal demise is increased with oligohydramnios. Labor is usually induced when the patient reaches term pregnancy to prevent fetal demise.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing care management of women with hydramnios and oligohydramnios.

Question 13 Type: MCMA The nurse is admitting a patient who was diagnosed with hydramnios. The patient asks why she has developed this condition. The nurse should explain that hydramnios is sometimes associated with: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Standard Text: Select all that apply.

1. Chest pain, dyspnea, tachycardia, and hypotension.

2. Postmaturity syndrome.

3. Renal malformation or dysfunction.

4. Maternal diabetes.

5. Large-for-gestational-age infants.

Correct Answer: 1,2,4 Rationale 1: Chest pain, dyspnea, tachycardia, and hypotension are symptoms of amniotic embolism, which occurs more commonly with hydramnios. Hydramnios occurs in 10–20% of pregnant diabetics.

Rationale 2: Renal malformation or dysfunction and postmaturity can cause oligohydramnios.

Rationale 3: Renal malformation or dysfunction and postmaturity can cause oligohydramnios.

Rationale 4: Hydramnios is not associated with maternal diabetes.

Rationale 5: Large-for-gestational-age infants and placenta previa are not associated with hydramnios.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing care management of women with hydramnios and oligohydramnios.

Question 14 Type: MCMA When caring for a laboring patient with oligohydramnios, the nurse should be aware that: Standard Text: Select all that apply.

1. There is an increased risk of cord compression.

2. There is less fluid available for the fetus to use during fetal breathing movements; therefore, pulmonary hypoplasia can develop, which could cause respiratory difficulties at birth.

3. Labor progress is often more rapid than average.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Early decelerations are more likely.

Correct Answer: 1,2,4 Rationale 1: Less amniotic fluid lessens the cushioning effect, and cord compression is more likely.

Rationale 2: Rationale 3: Labor progress is slower than average due to the decreased fluid volume.

Rationale 4: Decreased amniotic fluid can contribute to fetal head compression, which manifests itself in early decelerations.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing care management of women with hydramnios and oligohydramnios.

Question 15 Type: MCSA Hydramnios most likely would be suspected when: 1. There is less amniotic fluid than normal for gestation.

2. The fundal height increases disproportionately to the gestation.

3. The woman has a twin gestation.

4. The quadruple screen comes back positive.

Correct Answer: 2 Rationale 1: Hydramnios occurs when there is more amniotic fluid than normal for gestation.

Rationale 2: The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation.

Rationale 3: Hydramnios is not suspected simply by virtue of a twin gestation.

Rationale 4: A positive quadruple screen is not indicative of hydramnios.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing care management of women with hydramnios and oligohydramnios.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 22 Question 1 Type: MCSA A patient who sustained a difficult, lengthy labor and delivery is conversing with the nurse. Suddenly, the patient complains of chest pain and appears dyspneic. She is cyanotic and tachycardic, and her blood pressure has decreased to 78/36. What condition should the nurse suspect is developing?

1. Placenta accreta 2. Infection 3. Hypertensive crisis 4. Amniotic fluid embolus Correct Answer: 4 Rationale 1: Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium. The major complications of placenta accreta include maternal hemorrhage and failure of the placenta to separate following birth of the infant. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis.

Rationale 2: This patient’s symptoms have a severe, sudden onset that is consistent with amniotic fluid embolus.

Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis.

Rationale 3: The patient is hypotensive and is demonstrating signs and symptoms that are consistent with amniotic fluid embolus, including chest pain, dyspnea, tachycardia, hypotension and cyanosis.

Rationale 4: Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Summarize the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of the woman with an amniotic fluid embolus.

Question 2 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

A 20-year-old woman who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the patient’s labor?

1. Cephalopelvic disproportion (CPD) 2. Prolapsed cord 3. Placenta accreta 4. Occiput anterior (OA) fetal position Correct Answer: 1 Rationale 1: The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed.

Rationale 2: A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal bradycardia is a critical indicator of prolapsed cord. This patient is demsontrating prolonged labor, slow cervical dilatation and effacement, and delayed engagement of the presenting fetal part, which are consistent with cephalopelvic disproportion (CPD).

Rationale 3: Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is associated with maternal hemorrhage and failed placental separation after birth. This patient is demonstrating prolonged labor, slow cervical dilatation and effacement, and delayed engagement of the presenting fetal part, which are consistent with cephalopelvic disproportion (CPD).

Rationale 4: The occiput anterior (OA) fetal position is amenable to delivery and would not represent a barrier to labor. This patient is demonstrating prolonged labor, slow cervical dilatation and effacement, and delayed engagement of the presenting fetal part, which are consistent with cephalopelvic disproportion (CPD).

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Relate the various types of fetal malposition and malpresentation, risks, and clinical therapy to the nursing care management of each.

Question 3 Type: MCSA The nurse is making patient assignments for the next shift. Which patient is most likely to experience a complicated labor pattern?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. 34-year-old gravida 6 at 39 weeks’ gestation with twins 2. 22-year-old gravida 1 at 23 weeks’ gestation with ruptured membranes 3. 30-year-old gravida 3 at 41 weeks’ gestation and estimated fetal weight 7 pounds, 8 ounces 4. 43-year-old gravida 2 at 37 weeks’ gestation with hypertension Correct Answer: 1 Rationale 1: Twins at term will cause overdistention of the uterus, putting the patient at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern.

Rationale 2: Although this patient is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this patient has no risk factors for an abnormal labor pattern.

Rationale 3: This patient has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development.

Rationale 4: Hypertension does not impact labor pattern; this patient has no risk factors for either hypertonic or hypotonic labor pattern development.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Compare tachysystolic and hypotonic labor patterns, including risks, clinical therapy, and nursing care management.

Question 4 Type: MCSA Two hours ago, the 39-weeks’-gestation patient was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every five minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every three minutes with 40–50 seconds’ duration with intensity of 40 mmHg. The priority intervention would be: 1. Begin oxytocin after assessing for CPD. 2. Give Terbutaline to stop the preterm labor.

3. Start oxygen at 8 L/min.

4. Have anesthesia give the patient an epidural.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: The patient is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions.

Rationale 2: Terbutaline would not be recommended. The contraction pattern is incoordinate, but they need to be enhanced, not stopped.

Rationale 3: Oxygen will not hurt, but it is not the priority.

Rationale 4: An epidural will not change the incoordinate contraction pattern.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Compare tachysystolic and hypotonic labor patterns, including risks, clinical therapy, and nursing care management.

Question 5 Type: MCSA The primiparous patient is at 42 weeks’ gestation. What order should the nurse question?

1. Obtain biophysical profile today.

2. Begin nonstress test now.

3. Schedule labor induction for tomorrow.

4. Return to the clinic in one week.

Correct Answer: 4 Rationale 1: A biophysical profile is a commonly used assessment for the post-term fetus.

Rationale 2: The nonstress test is a commonly used assessment for the post-term fetus.

Rationale 3: Labor induction is likely to occur with post-term pregnancies because the aging placenta becomes less efficient at transporting oxygen and nutrients and because the risk of fetal macrosomia increases with length of gestation.

Rationale 4: A post-term pregnancy is high-risk. Fetal assessments must be obtained to verify fetal well-being or the need for delivery via induction or cesarean. One week is too long a time period between assessments.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Describe the risks and clinical therapy in determining the community-based and hospital-based nursing care management of post-term pregnancy for the childbearing family.

Question 6 Type: MCSA The multiparous patient at term has arrived to the labor and delivery unit in active labor with intact membranes.

Leopold’s maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What physician order is most important?

1. Artificially rupture membranes.

2. Apply internal fetal scalp electrode.

3. Monitor maternal blood pressure every 15 minutes.

4. Alert the surgical team of urgent cesarean.

Correct Answer: 4 Rationale 1: Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord.

Rationale 2: An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord.

Rationale 3: The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way.

Rationale 4: This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Relate the various types of fetal malposition and malpresentation, risks, and clinical therapy to the nursing care management of each.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 7 Type: MCSA The nurse should anticipate the labor pattern for a fetal occiput posterior position to be: 1. Shorter than average during the latent phase.

2. Prolonged with regard of the overall length of labor.

3. Rapid during transition.

4. Precipitous.

Correct Answer: 2 Rationale 1: Overall labor is often prolonged, not shorter.

Rationale 2: The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor.

Rationale 3: Overall labor is often prolonged, not more rapid.

Rationale 4: Overall labor is often prolonged, not precipitous.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Relate the various types of fetal malposition and malpresentation, risks, and clinical therapy to the nursing care management of each.

Question 8 Type: MCSA The patient has undergone an ultrasound, which estimated fetal weight at 4,500 g (9 pounds, 14 ounces). Which statement indicates that additional teaching is needed? “Because my baby is big: 1. “I am at risk for excessive bleeding after delivery.”

2. “His blood sugars could be high after he is born.”

3. “My perineum could experience trauma during the birth.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “His shoulders could get stuck and a collar bone broken.”

Correct Answer: 2 Rationale 1: Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk.

Rationale 2: Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus.

Rationale 3: Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus.

Rationale 4: Shoulder dystocia is more common among large fetuses, and a broken clavicle could result.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Explain the identification, risks, and clinical therapy in determining the nursing care management of the woman and fetus at risk for macrosomia.

Question 9 Type: MCSA The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100–105. Which nursing action is most important?

1. Change the mother’s position from Fowler’s to left lateral.

2. Insert a Foley catheter with the assistance of another nurse.

3. Notify the surgical team of an impending cesarean.

4. Decrease the IV of lactated Ringer’s solution to 50 ml/hour.

Correct Answer: 1 Rationale 1: Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow.

Rationale 2: If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.

Rationale 3: The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the patient is hypotensive. Decreasing the IV rate will not improve fetal heart tones.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Relate the maternal implications, clinical therapy, prenatal history, and conditions that may be associated with nonreassuring fetal status to the nursing care of the mother and fetus.

Question 10 Type: MCSA The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?

1. Assess the odor of the amniotic fluid.

2. Perform Leopold’s maneuver.

3. Obtain an order for pain medication.

4. Complete a sterile vaginal exam.

Correct Answer: 4 Rationale 1: Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.

Rationale 2: This assessment is not called for at this time.

Rationale 3: Pain medication is a low priority at this time.

Rationale 4: Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Describe the nursing care for the mother and fetus with a prolapsed umbilical cord.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 11 Type: MCSA The charge nurse is reviewing charting on patients in the maternal–child triage unit. Which entry requires immediate intervention?

1. Primip at 24 weeks diagnosed with polyhydramnios: “Patient reporting shortness of breath.”

2. Multip at 32 weeks: “Oligohydramnios per ultrasound secondary to fetal renal agenesis.”

3. Primip at 41 weeks: “Patient reports leaking clear fluid from her vagina for seven hours.”

4. Multip at 34 weeks diagnosed with oligohydramnios: “Cervix 6 cm, −2 station, up to walk in hallway.”

Correct Answer: 4 Rationale 1: Although this patient is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a lifethreatening emergency.

Rationale 2: Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This patient will be grieving but is not experiencing physical complications.

Rationale 3: Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This patient might be experiencing a complication, but it is a lower priority than the patient with the possibility of a prolapsed cord.

Rationale 4: Active labor in a preterm multip with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This patient should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This patient is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Summarize the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of the woman with an amniotic fluid embolus.

Question 12 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The patient at term has a suspected small pelvis. The fetus has an estimated weight of 4,200 g (9 pounds, 4 ounces). Spontaneous labor has begun, and the patient is now at 6 cm. The nurse understands that the most important nursing action for this patient is to: 1. Assist the patient to squat during the second stage.

2. Encourage oral fluids and carbohydrate intake.

3. Assess the cervix for change every eight hours.

4. Inform the couple that labor might be prolonged.

Correct Answer: 1 Rationale 1: Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.

Rationale 2: A patient with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean. This patient should either be given only clear liquids or be n.p.o. to reduce the risk of aspiration should a cesarean need to be performed.

Rationale 3: The cervix is normally assessed when the patient’s labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a patient was in the active phase of labor and cephalopelvic disproportion was a risk. Every eight hours is too far apart.

Rationale 4: Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Explain the types, maternal and fetal-neonatal implications, and clinical therapy in determining the nursing care management of the woman with cephalopelvic disproportion.

Question 13 Type: MCSA The patient gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. The nurse should prepare to: 1. Start an IV of lactated Ringer’s.

2. Apply anti-embolism stockings.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. Bottle-feed the infant.

4. Send the placenta to pathology.

Correct Answer: 1 Rationale 1: The patient undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary.

Rationale 2: Anti-embolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, anti-embolism stockings are not needed for this patient because manual removal of the placenta is not major surgery and does not lead to post-procedure immobility.

Rationale 3: The patient’s partner or family member, or a nursery nurse, can feed the infant. The patient is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time.

Rationale 4: The placenta might be sent to pathology after it is removed, but preparing the patient for manual removal of the placenta now is a higher priority.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO09 - Identify common complications of the third and fourth stages of labor.

Question 14 Type: MCSA The nurse is caring for a laboring patient with known cephalopelvic disproportion (CPD). The woman develops tachysystolic labor patterns. Which possible course of treatment should the nurse anticipate?

1. Oxytocin administration 2. Cesarean section 3. Nipple stimulation 4. Amniotomy Correct Answer: 2 Rationale 1: Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD), a cesarean birth is indicated, as vaginal delivery cannot be performed.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD), a cesarean birth is indicated, as vaginal delivery cannot be performed.

Rationale 3: Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD), a cesarean birth is indicated, as vaginal delivery cannot be performed.

Rationale 4: Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD), a cesarean birth is indicated, as vaginal delivery cannot be performed.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Compare tachysystolic and hypotonic labor patterns, including risks, clinical therapy, and nursing care management.

Question 15 Type: MCSA The patient has delivered a 4,200g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The patient asks the nurse where she tore. Which response is best? “The episiotomy extended and tore: 1. “Through your rectal mucosa.”

2. “Up near your urethra.”

3. “Into the muscle layer.”

4. “Through your rectal sphincter.”

Correct Answer: 4 Rationale 1: A fourth-degree laceration is through the rectal mucosa.

Rationale 2: A periurethral laceration is near the urethra.

Rationale 3: A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle.

Rationale 4: A third-degree laceration includes the rectal sphincter.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO09 - Identify common complications of the third and fourth stages of labor.

Question 16 Type: MCSA The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

1. Temperature 99.0°F 2. Platelet count 210,000/cmm 3. Fibrinogen level 50 mg/dL 4. Family refusing fetal autopsy Correct Answer: 3 Rationale 1: Women with intrauterine fetal demise can become infected, but this temperature is not high enough to indicate infection.

Rationale 2: Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this is a normal platelet count.

Rationale 3: Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200–400 mg/dL. This is a very low fibrinogen level and indicates that the patient is in DIC. Rationale 4: Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is a higher priority.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO10 - Explain the etiology, diagnosis, and phases of grief in determining the nursing care management of the family experiencing perinatal loss.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 23 Question 1 Type: MCSA The nurse is scheduling a patient for an external cephalic version (ECV). Which finding in the patient’s chart requires immediate intervention?

1. “Multip, transverse lie.”

2. “Primip, frank breech ballotable.”

3. “Multip, 32 weeks, complete breech.”

4. “Primip, failed ECV last week.”

Correct Answer: 3 Rationale 1: This patient has no contraindication to ECV. Rationale 2: This patient has no contraindication to ECV. Rationale 3: ECV is not attempted until 36 weeks. This patient is too early in her pregnancy for ECV. Rationale 4: Although this patient is less likely to have a successful ECV this week if it was unsuccessful last week, there is no contraindication to attempting the procedure.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Explain the methods, purpose, criteria, and contraindications of external version in determining nursing care management.

Question 2 Type: MCSA The clinical nurse coordinator is meeting with a group of nursing students in post conference to teach about caring for women who undergo artificial rupture of membranes (AROM) by way of amniotomy. Which nursing student’s statement indicates that the teaching has been effective?

1. “For women who undergo artificial rupture of membranes, vaginal examinations should be limited.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. “In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed.”

3. “Amniotomy is contraindicated for use in labor augmentation.”

4. “Women who undergo artificial rupture of membranes should be advised that they will experience a ‘dry birth.’”

Correct Answer: 1 Rationale 1: Following artificial rupture of membranes (AROM), because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal exams must be kept to a minimum to reduce the chance of introducing an infection.

Rationale 2: In all cases, the fetal heart rate (FHR) is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared.

Rationale 3: Amniotomy is an accepted method of labor augmentation.

Rationale 4: Women need to know that amniotic fluid is constantly produced because some women may worry that they will experience a “dry birth.”

Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Describe the use of amniotomy and the nursing care management of the woman and fetus.

Question 3 Type: MCSA Induction of labor is planned for a 31-year-old primip due to insulin-dependent diabetes. The patient is 39 weeks’ gestation. She reports that she feels as though her baby has “flipped” in her abdomen. Which nursing action is most important?

1. Evaluate fetal maturity.

2. Administer dinoprostone (Prepidil ) vaginal gel.

3. Implement continuous electronic fetal monitoring (EFM).

4. Notify the patient’s physician that the patient feels as though her baby has changed position.

Correct Answer: 4 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the patient will require additional evaluation by her physician before proceeding.

Rationale 2: Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the patient will require additional evaluation by her physician before proceeding.

Rationale 3: Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the patient will require additional evaluation by her physician before proceeding.

Rationale 4: Because malpresentation, such as breech, is a relative contraindication to induction of labor, the patient will require additional evaluation by her physician before proceeding.

Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Explain the indications, contraindications, labor readiness, and methods in determining the nursing care management for women during labor induction.

Question 4 Type: MCSA The nurse is teaching childbirth education classes. Teaching has been successful if the primiparous patient states: “I can reduce the likelihood that I’ll tear or need an episiotomy if I: 1. “Push in a semi-sitting position.”

2. “Make sure I push long and hard.”

3. “Begin regular perineal massage.”

4. “Pull back on my legs when pushing.”

Correct Answer: 3 Rationale 1: Semi-sitting or lithotomy position increases the likelihood of perineal lacerations.

Rationale 2: Short pushes during the expulsion of the head decrease the likelihood of perineal lacerations.

Rationale 3: Perineal massage has been shown to decrease the need for episiotomy in primiparous patients.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Pulling back on the legs while pushing tightens the perineal tissue, which in turn increases the likelihood of perineal lacerations.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Describe the indications for amnioinfusion and the nursing care of the woman during amnioinfusion.

Question 5 Type: MCSA The nurse is completing discharge teaching for a patient who delivered two days ago. Which statement indicates that further information is required?

1. “Because I have a midline episiotomy, I should keep my perineum clean.”

2. “Soaking in the tub will help my mediolateral episiotomy to heal.”

3. “I can take ibuprofen (Motrin) when my perineum starts to hurt.”

4. “The tear I have through my rectum is unrelated to my episiotomy.”

Correct Answer: 4 Rationale 1: Perineal hygiene is important when a patient has an episiotomy to prevent infection and facilitate healing.

Rationale 2: Warm tub baths are helpful to facilitate both comfort and healing of an episiotomy.

Rationale 3: Healing episiotomies can be very painful, and pain medication should be provided for patients experiencing pain.

Rationale 4: This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Delineate the measures to prevent episiotomy, factors that predispose women to episiotomy, and types of episiotomy in determining the nursing care management.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 6 Type: MCSA The patient requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the patient asks what kind of episiotomy was performed. What is the best response for the nurse to make? “The episiotomy”: 1. “Goes straight back toward your rectum.”

2. “Is from your vagina toward the urethra.”

3. “Is cut diagonally away from your vagina.”

4. “Extends from your vagina into your rectum.”

Correct Answer: 3 Rationale 1: Midline episiotomy is straight back from the vagina toward the rectum.

Rationale 2: Episiotomies are not cut anteriorly toward the urethra unless the patient has had a female circumcision.

Rationale 3: Mediolateral episiotomy is angled from the vaginal opening toward the buttock.

Rationale 4: Extension into the rectum is a fourth-degree laceration.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Delineate the measures to prevent episiotomy, factors that predispose women to episiotomy, and types of episiotomy in determining the nursing care management.

Question 7 Type: MCSA The patient is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore.

The patient is asking for her ice pack to be refreshed. The best response from the nurse is: 1. “I’ll get you one right away.”

2. “You only need to use one ice pack.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. “You need to leave it off for at least 20 minutes and then reapply.”

4. “I’ll bring you an extra so that you can change it when you are ready.”

Correct Answer: 3 Rationale 1: Providing an additional ice pack before 20 minutes have passed would increase the perineal edema.

Rationale 2: More than one ice pack must be used in order to apply ice for 20 minutes on, followed by 20 minutes off.

Rationale 3: Optimal effects from the use of an ice pack occur when it is applied for 20–30 minutes and then removed for at least 20 minutes before being reapplied.

Rationale 4: An ice pack that is provided now for use in 20 minutes would be melted before being used.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Delineate the measures to prevent episiotomy, factors that predispose women to episiotomy, and types of episiotomy in determining the nursing care management.

Question 8 Type: MCSA The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring patient who is undergoing a forceps delivery. Which action requires intervention?

1. Regional anesthesia is administered via pudendal block.

2. The patient is instructed to push between contractions.

3. Fetal heart tones are consistently between 110 and 115.

4. Bladder is emptied using a straight catheter.

Correct Answer: 2 Rationale 1: Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.

Rationale 2: The patient should only push during contractions, not between contractions.

Rationale 3: These are normal fetal heart tones. No intervention is needed.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Explain the indications, maternal and neonatal risks, and nursing care management during forceps-assisted birth.

Question 9 Type: MCSA The patient has been pushing for two hours and is exhausted. The physician is performing a vacuum extraction birth. What finding is expected?

1. The head is delivered after eight pulls during contractions.

2. A bruise is present on the occiput that does not cross the suture line.

3. The location of the vacuum is apparent on the fetal scalp after birth.

4. Positive pressure is applied by the vacuum extraction during contractions.

Correct Answer: 3 Rationale 1: Use of the vacuum extraction for eight contractions is too many and can create damage to the fetal head. If fetal descent does not occur with the first two pulls, the procedure should be discontinued, and cesarean birth should take place.

Rationale 2: This is a cephalohematoma and is a complication of vacuum extraction birth.

Rationale 3: Caput in the shape of the vacuum cup is usually present immediately after birth and resolves in 2–3 days.

Rationale 4: Negative pressure is suction, which is needed to use the vacuum extractor to facilitate birth.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Describe the nursing care management of the woman and neonate during vacuumassisted birth.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 10 Type: MCSA The patient has been pushing for two hours and is exhausted. The fetal head is visible between contractions. The physician informs the patient that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the patient needs additional information about vacuum extraction assistance?

1. “A small cup will be put onto the baby’s head, and a gentle suction will be applied.”

2. “I can stop pushing and just rest if the vacuum extractor is used.”

3. “The baby’s head might have a bruise from the vacuum cup.”

4. “The vacuum will be applied for a total of ten minutes or less.”

Correct Answer: 2 Rationale 1: The vacuum extractor is a small cup-shaped device that is applied to the scalp.

Rationale 2: Vacuum extraction is an assistive delivery, and the patient must continue with pushing efforts to accomplish the birth.

Rationale 3: The vacuum extractor might leave a bruise on the scalp where the device is placed.

Rationale 4: The vacuum extractor is applied to the scalp for up to 10 minutes total.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Describe the nursing care management of the woman and neonate during vacuumassisted birth.

Question 11 Type: MCSA The nurse is reviewing charts of patients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased healthcare costs in patients undergoing cesarean birth by request?

1. Increased abnormal placenta implantation in subsequent pregnancies 2. Decreased use of general anesthesia with greater use of epidural anesthesia Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. Prolonged anemia, requiring blood transfusions every few months 4. Coordination of career projects of both partners leading to increased income Correct Answer: 1 Rationale 1: Placenta implantation problems are more common after cesarean birth and increase healthcare costs because of the high risk care and testing required.

Rationale 2: Which anesthesia method is used is not a significant factor in health care costs of cesarean birth by request. The need for anesthesia, use of the operating suite, equipment use, personnel, and other factors are more responsible for greater costs of cesarean birth compared with vaginal birth.

Rationale 3: This is not a complication of cesarean birth by request.

Rationale 4: The income of the couple does not affect healthcare costs directly.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO08 - Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing care.

Question 12 Type: MCSA The patient had a classical uterine incision for her cesarean birth. The nurse knows that the patient understands implications for future pregnancies that are secondary to her classical uterine incision when the patient states: 1. “The next time I have a baby, I can try to deliver vaginally.”

2. “The risk of rupturing my uterus is too high for me to have any more babies.”

3. “Every time I have a baby, I will have to have a cesarean delivery.”

4. “I can only have one more baby.”

Correct Answer: 3 Rationale 1: Attempting a vaginal birth is contraindicated, and future births will be planned cesareans.

Rationale 2: Future pregnancies are not prohibited.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: A classical uterine incision is made in the upper uterine segment and holds an increased risk of rupture in subsequent pregnancy, labor, and birth.

Rationale 4: Future pregnancies are not limited to one.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing care.

Question 13 Type: MCSA After being in labor for several hours with no progress, the patient is diagnosed with cephalopelvic disproportion (CPD) and must have a cesarean section. The patient is being prepared for a cesarean delivery in the operating room. The doctor is present. The nurse knows that the last assessment the nurse should make just prior to the patient’s being draped for surgery is: 1. Maternal temperature.

2. Maternal urine output.

3. Vaginal exam.

4. Fetal heart tones.

Correct Answer: 4 Rationale 1: Maternal temperature is monitored by anesthesia personnel.

Rationale 2: Maternal urine output is not significant at this point.

Rationale 3: Vaginal exam is unnecessary when cephalopelvic disproportion (CPD) is present.

Rationale 4: Fetal heart tones are assessed just prior to the start of surgery because the supine position can lead to fetal hypoxia.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO08 - Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing care.

Question 14 Type: MCSA The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed?

1. “Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC.” 2. “My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down.”

3. “Because my hospital is so small and in a rural area, they won’t let me attempt a VBAC.” 4. “The rate of complications from VBAC is lower than the rate of complications from a cesarean.”

Correct Answer: 1 Rationale 1: Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classical vertical incisions on the uterus have a higher rate of rupture and should not be attempted.

Rationale 2: Non-repeating conditions such as any non-vertex presentation might make VBAC a viable option as long as this pregnancy is vertex.

Rationale 3: A repeat cesarean must be able to be performed immediately to safely attempt a VBAC. Many small and rural hospitals do not have surgical and anesthesia staff available at night, and on weekends and holidays, and therefore do not allow patients to have a VBAC. Rationale 4: The incidence of uterine rupture is 0.9%. Women who have a successful VBAC have lower incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO09 - Examine the risks, guidelines, and nursing care of the woman undergoing vaginal birth following cesarean birth.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 24 Question 1 Type: MCSA The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?

1. Respiratory rate 60, crackles present bilaterally 2. Pulse rate 145, systolic murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds Correct Answer: 4 Rationale 1: This respiratory rate is normal; crackles are commonly heard in the first few hours after birth as the infant reabsorbs the fluid in the lungs present at birth.

Rationale 2: This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale.

Rationale 3: This is a normal finding in an infant at 1 hour of life.

Rationale 4: Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Explain the respiratory and cardiovascular changes that occur during the newborn’s transition to extrauterine life and during stabilization in determining the nursing care of the newborn.

Question 2 Type: MCSA The newborn at 24 hours of age has a red blood cell count of 5.4 million per ml. Which of the following entries would the nurse expect to find in the newborn’s chart?

1. Cord clamping delayed until pulsation ceased Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. CBC drawn from the anterior surface of the left hand 3. Placental abruption noted to be 80% at time of delivery 4. Infant is breastfed 15–20 minutes every three hours Correct Answer: 1 Rationale 1: Delayed cord clamping can cause an increase of up to 61%, resulting in a slightly higher-thanaverage red blood cell count.

Rationale 2: Venous blood has lower red cell counts than do capillary blood samples.

Rationale 3: Maternal or fetal blood loss cause hypovolemia and low red blood cell counts (less than 5.2 million per ml).

Rationale 4: Breastfeeding does not impact red cell counts in the first day of life.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Compare the factors that modify the newborn’s blood values to the corresponding results.

Question 3 Type: MCMA The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective?

Standard Text: Select all that apply.

1. “We should make sure that we keep our home air-conditioned so the baby doesn’t overheat.”

2. “It is important that we dry the baby off as soon as we give him a bath or shampoo his hair.”

3. “When we change the baby’s diaper, we should change any wet clothing or blankets, too.”

4. “If the baby’s body temperature gets too low, he will warm himself up without any shivering.”

5. “Our baby will have a much faster rate of breathing if he is not dressed warmly enough.”

Correct Answer: 2,3,4,5 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Babies need to be kept warm. Cold ambient temperatures will increase the oxygen consumption of a newborn and can lead to respiratory distress.

Rationale 2: Drying a wet baby prevents evaporation, one mechanism of heat loss.

Rationale 3: Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss.

Rationale 4: Non-shivering thermogenesis is the mechanism used by newborns to warm themselves.

Rationale 5: A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Relate the process of thermogenesis in the newborn and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

Question 4 Type: MCSA The nurse is planning the care of a 1-day-old infant. Which of the following nursing interventions would protect the newborn from heat loss by convection?

1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette Correct Answer: 1 Rationale 1: Placing the newborn away from air currents reduces heat loss by convection.

Rationale 2: Pre-warming the examination table reduces heat loss by conduction.

Rationale 3: Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation.

Rationale 4: Removing wet linens that are not in direct contact with the newborn from the isolette reduces heat loss by radiation.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Relate the process of thermogenesis in the newborn and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

Question 5 Type: MCSA The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation?

1. Conjugated bilirubin is eliminated in the conjugated state.

2. Unconjugated bilirubin is neurotoxic and cannot cross the placenta.

3. Total bilirubin is the sum of the direct and indirect levels.

4. Antibiotics decrease the incidence of hyperbilirubinemia.

Correct Answer: 3 Rationale 1: Conjugated bilirubin can be transformed back into unconjugated bilirubin prior to excretion by βglucuronidase enzyme if gut bacteria have not transformed it into urobilinogen.

Rationale 2: Unconjugated bilirubin is neurotoxic but crosses the placenta during fetal life for the maternal GI system to conjugate and excrete.

Rationale 3: This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is also referred to as indirect.

Rationale 4: Because of the role of gut bacteria in converting conjugated bilirubin into urobilinogen, neonates who have been administered antibiotics have an increased incidence of hyperbilirubinemia.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO04 - Explain the steps involved in conjugation and excretion of bilirubin in the newborn.

Question 6 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA A telephone triage nurse gets a call from a postpartum patient who is concerned about jaundice. The patient’s newborn is 37 hours old. What data should the nurse gather first?

1. Stool characteristics 2. Fluid intake 3. Skin color 4. Bilirubin level Correct Answer: 3 Rationale 1: The stool characteristic of green coloration indicates excretion of bilirubin.

Rationale 2: Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best determined by the number of wet diapers per day.

Rationale 3: Yellow coloration of the skin and sclera is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice.

Rationale 4: Skin color begins to appear yellow once the serum levels of bilirubin are about 4–6 mg/dL. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Explain the steps involved in conjugation and excretion of bilirubin in the newborn.

Question 7 Type: MCSA The nurse is reviewing charts of newborns. Which infant requires immediate intervention?

1. 24-hour-old term male with total bilirubin level of 2.0 2. 3-day-old term bottle-fed female with bilirubin of 11.0 3. 2-week-old post-term breastfed male with bilirubin of 10.0 4. 12-hour-old preterm female exhibiting icterus and lethargy

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 4 Rationale 1: Total bilirubin levels under 3.0 are expected in the first 24 hours of life.

Rationale 2: Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11.0 is not treated with phototherapy, regardless of feeding method.

Rationale 3: Breast milk jaundice peaks at 2–3 weeks of age and commonly presents with a total bilirubin level of 5.0–10.0.

Rationale 4: Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life.

Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO05 - Identify the reasons why a newborn may develop hyperbilirubinemia (jaundice) and the nursing interventions that can decrease the probability or severity of jaundice.

Question 8 Type: MCSA A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education?

1. “I can’t believe he can already digest fats, carbohydrates, and proteins.”

2. “It is amazing that his whole digestive tract moves things along at birth.”

3. “Incredibly, his stomach capacity is already a cupful when he was born.”

4. “He will lose some weight but then miraculously regain it by about 10 days.”

Correct Answer: 3 Rationale 1: At birth, neonates can digest fats, simple carbohydrates, and proteins.

Rationale 2: Gastric emptying and intestinal peristalsis occur during in utero life; the first bowel movement usually occurs in the first day of life.

Rationale 3: A newborn’s stomach capacity is only 20–40 ml; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Neonates lose 5–10 % of their birth weight in the first days after life, especially if they are breastfed.

They should have regained the lost weight and should be back to their birth weight by 10 days of age.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Delineate the functional abilities of the newborn’s gastrointestinal tract and liver.

Question 9 Type: MCSA A postpartum patient calls the nursery to report that her 3-day-old newborn has passed a bright green stool. The nurse’s best response is: 1. “Take your newborn to the pediatrician.”

2. “There may be a possible food allergy.”

3. “Your newborn has diarrhea.”

4. “This is a normal occurrence.”

Correct Answer: 4 Rationale 1: It is not necessary for the patient to take her newborn to the pediatrician.

Rationale 2: The green color of stool is not due to food allergies.

Rationale 3: The green color of stool is not characterized as diarrhea, but is a transitional stool that consists of part meconium and part fecal material.

Rationale 4: By the third day of life, the newborn’s stools appear brown to green in color.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Delineate the functional abilities of the newborn’s gastrointestinal tract and liver.

Question 10 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The home care nurse is examining a 3-day-old infant. The skin on the child’s sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. The best response from the nurse is: 1. “The liver of an infant is not fully mature and doesn’t conjugate the bilirubin for excretion.”

2. “The infant received too many red blood cells after delivery because the cord was not clamped immediately.”

3. “The yellow color of your baby’s skin indicates that you are breastfeeding too often.”

4. “This is an abnormal finding related to your baby’s bowels not excreting bilirubin as they should.”

Correct Answer: 1 Rationale 1: Physiologic jaundice is a common occurrence and peaks on day 3 or 4.

Rationale 2: It happens in part because of the RBC destruction that infants experience combined with liver immaturity, which leads to less efficient conjugation of bilirubin for excretion.

Rationale 3: Frequent feeding, therefore, will decrease jaundice.

Rationale 4: Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Delineate the functional abilities of the newborn’s gastrointestinal tract and liver.

Question 11 Type: MCSA The nurse manager of the neonatal intensive care unit is preparing a handout for parents of ill newborns. Which statement should the nurse include?

1. Newborns can eliminate excess fluid as quickly as an adult.

2. The kidneys are fully functional by 30 weeks’ gestation.

3. Neonates have a tendency to become dehydrated.

4. Sugar is rarely present in the urine of a newborn.

Correct Answer: 3 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Newborns have difficulty eliminating excess fluid because of their relatively low glomerular filtration rate.

Rationale 2: Full nephron function doesn’t develop until 34–36 weeks.

Rationale 3: Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus can become dehydrated easily.

Rationale 4: Tubular reabsorption of glucose, sodium, amino acids, and bicarbonate is limited in newborns.

Glucosuria therefore develops.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Relate the development of the newborn’s kidneys to the newborn’s ability to maintain fluid and electrolyte balance.

Question 12 Type: MCSA The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary?

1. “Our baby was born with kidneys that are too small.”

2. “A baby’s kidneys don’t concentrate urine well for several months.”

3. “Feeding our baby frequently will help the kidneys function.”

4. “Kidney function in an infant is very different from in an adult.”

Correct Answer: 1 Rationale 1: Size of the kidneys is rarely an issue.

Rationale 2: Counting wet diapers indicates urine output in relation to fluid intake.

Rationale 3: Frequent feeding helps maintain the fluid volume.

Rationale 4: The ability to concentrate urine develops by 3–4 months of age. The inability to concentrate urine due to limited tubular reabsorption and lower glomerular filtration rate are the main differences between kidney function in a newborn and normal adult kidney function.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Relate the development of the newborn’s kidneys to the newborn’s ability to maintain fluid and electrolyte balance.

Question 13 Type: MCSA When reviewing laboratory results for a 1-day-old infant, the nurse notes that the infant’s IgM antibodies are elevated. Which is the least likely cause of the infant’s IgM antibody level elevation?

1. Maternal-fetal transfer of IgM while in utero 2. Placental leakage 3. Intrauterine exposure to syphilis 4. Intrauterine exposure to TORCH syndrome Correct Answer: 1 Rationale 1: Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks’ gestation. Elevated levels of IgM at birth may indicate placental leaks or, more commonly, antigenic stimulation in utero.

Rationale 2: Elevated levels of IgM at birth may indicate placental leaks.

Rationale 3: Elevations in IgM may be due to newborn exposure to an intrauterine infection such as syphilis.

Rationale 4: Elevations in IgM at birth may be due to newborn exposure to an intrauterine infection such as syphilis or TORCH syndrome (toxoplasmosis, rubella, cytomegalovirus, herpesvirus hominis type 2 infection).

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO08 - Describe the basic newborn immunologic response.

Question 14 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, “I should have known that something was wrong. Why didn’t I see that he was so sick?” The best reply is: 1. “Newborns have immature immune function at birth, and illness is very hard to detect.”

2. “Your mothering skills will improve with time. You should take the newborn class.”

3. “Your baby didn’t get enough active acquired immunity from you during the pregnancy.”

4. “The immunity your baby gets in utero doesn’t start to function until he is 4 to 8 weeks of age.”

Correct Answer: 1 Rationale 1: The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn.

Rationale 2: This response does not address the physiology of neonatal infection and is not therapeutic because it is blaming.

Rationale 3: The mother develops active acquired immunity, which is passed to the newborn transplacentally as passive acquired immunity. This immunity is to the illnesses and infections she has had or been immunized against.

Rationale 4: The passive acquired immunity a newborn receives from its mother is effective at birth and lasts from four weeks to eight months, depending on the specific antibody.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO08 - Describe the basic newborn immunologic response.

Question 15 Type: MCSA During a post conference, nursing students are simulating physical assessment of the newborn using a model.

Throughout the simulated assessment, students describe each of their actions. Which nursing student’s statement indicates the need for further teaching?

1. “I measured the newborn’s blood pressure using the Doppler technique.”

2. “I auscultated the infant’s heart tones for one minute.”

3. “I palpated peripheral pulses in all the newborn’s extremities.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “I obtained the infant’s heart rate by observing the cardiac monitor.”

Correct Answer: 4 Rationale 1: The measurement of blood pressure is best accomplished by using the Doppler technique with a size- and weight-appropriate cuff over the brachial artery.

Rationale 2: Apical pulse rates should be obtained by auscultation for a full minute, preferably when the newborn is asleep.

Rationale 3: Peripheral pulses of all extremities should also be evaluated to detect any inequalities or unusual characteristics.

Rationale 4: Physical assessment of the newborn’s heart rate requires auscultation of the apical pulse for a full minute.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO01 - Explain the respiratory and cardiovascular changes that occur during the newborn’s transition to extrauterine life and during stabilization in determining the nursing care of the newborn.

Question 16 Type: MCSA The new father asks the nurse to describe what his baby will experience while sleeping and awake. The best response is: 1. “Babies have several sleep and alert states. Keep watching and you’ll notice them.”

2. “You may have noticed that your child was in an alert awake state for an hour after his birth.”

3. “Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep.”

4. “Birth is hard work for babies; it takes them a week or two to recover and become more awake.”

Correct Answer: 3 Rationale 1: Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. This is not the best response.

Rationale 2: Although this statement is true, it does not respond to the father’s question about sleeping now.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This statement is true. Teaching the parents how to detect the two sleep stages helps them tune in to their infant’s behavioral states.

Rationale 4: Recovery from the birth process only takes a day or two. During that time, feedings should take place when the baby is in an alert state.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO09 - Explain the physiologic and behavioral characteristics of newborn neurologic function, patterns of behavior during the periods of reactivity, and possible nursing interventions.

Question 17 Type: MCSA During a community health class, the nurse is educating prenatal patients and their partners about normal newborn behavior. Which attendee’s statement indicates that teaching was effective? “I can expect that my newborn baby: 1. “Will be able to hear very well immediately after she is born.”

2. “Should be trained to breastfeed by being encouraged to suck on a pacifier before feedings.”

3. “Will have difficulty seeing me close up in the hours right after delivery.”

4. “Should be discouraged form sucking on a pacifier if he is bottle feeding.”

Correct Answer: 1 Rationale 1: Newborns have very acute hearing immediately after birth.

Rationale 2: Pacifiers should be offered to breastfed infants only after breastfeeding is well established or during prolonged times away from the mother, or when stressful or painful procedures are required.

Rationale 3: The newborn is nearsighted and has best vision at a distance of 8 to 15 inches.

Rationale 4: For bottle-fed infants, there is no reason to discourage nonnutritive sucking with a pacifier.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO10 - Describe the normal sensory-perceptual abilities and behavioral states seen in the newborn period.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 25 Question 1 Type: MCSA The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit: 1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline.

2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body.

3. Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest.

4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension.

Correct Answer: 3 Rationale 1: Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign beyond the midline is an indication of a preterm infant.

Rationale 2: Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is an indication of a preterm infant.

Rationale 3: All of these characteristics are indications of a preterm infant.

Rationale 4: 1 cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid recoil of the legs and arms are all indications of term-to-post-term infants.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe the physical and neuromuscular maturity characteristics assessed to determine gestational age of the newborn.

Question 2 Type: MCSA The nurse is observing a couple interacting with their 2-day-old child. Which of the mother’s statements suggests a potentially abnormal finding in the newborn?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “She looks like she’s a little bit cross-eyed.”

2. “There is some white-colored drainage coming from her vagina.”

3. “Her belly looks so round.”

4. “She has some small white specks on the roof of her mouth.”

Correct Answer: 3 Rationale 1: Transient strabismus (pseudostrabismus) or squinting caused by poor neuromuscular control of eye muscles that gradually regresses in 3 to 4 months may be seen in the newborn.

Rationale 2: A vaginal discharge composed of thick whitish mucus may be present during the first week of life.

Rationale 3: Abdominal distention is the first sign of many gastrointestinal abnormalities.

Rationale 4: On the hard palate and gum margins, Epstein’s pearls, small glistening white specks (keratincontaining cysts) that feel hard to the touch, are often present. They usually disappear in a few weeks and are of no significance.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03 - Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

Question 3 Type: MCSA The nurse is preparing new parents to be discharged with their newborn. The mother asks the nurse why the baby’s eyelids are so swollen. The best response by the nurse is: 1. “Swollen eyelids can happen because of the pressure associated with birth; the swelling should resolve in a few days.”

2. “Newborn babies cry a lot and, as with adults, crying can cause our eyelids to be swollen.”

3. “It’s likely that your baby is developing an infection of the eyelids; I’ll report this to the physician.”

4. “Swollen eyelids are uncommon in newborns and may be an indication of a more serious disorder; if this does not resolve in one week, you need to visit your pediatrician.”

Correct Answer: 1 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Rationale 2: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Rationale 3: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Rationale 4: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

Question 4 Type: MCSA The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to: 1. Contact the physician immediately.

2. Verify the presence of lanugo.

3. Document the findings.

4. Assess for rectal patency.

Correct Answer: 3 Rationale 1: There is no need to contact the physician. Overlapping fontanels and sutures are a common variation of normal.

Rationale 2: Lanugo is not related to overlapping fontanels and sutures, which are a common variation of normal.

Rationale 3: Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.

Rationale 4: Rectal patency is not related to overlapping fontanels and sutures, which are a common variation of normal.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

Question 5 Type: MCSA The nurse is preparing to assess a newborn’s neurological status. Which finding would require an immediate intervention?

1. At rest, the infant has partially flexed arms and her legs drawn up to the abdomen.

2. When the corner of the mouth is touched, the infant turns her head that direction.

3. Blinking occurs when the exam light is turned on over the infant’s face and body.

4. The right arm is flaccid while the infant brings her left arm and fist upwards to the head.

Correct Answer: 4 Rationale 1: This is the normal resting posture of the infant.

Rationale 2: This is the rooting reflex, a normal finding in a newborn.

Rationale 3: Blinking in response to bright lights is an expected finding.

Rationale 4: Asymmetrical movement is not an expected finding and could indicate neurological abnormality.

This should be reported to the physician immediately.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Explain the components of a newborn neurologic/neuromuscular status and reflexes assessment.

Question 6 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states: 1. “My baby may open her arms wide and pull her legs up to her tummy if she is passing gas.”

2. “If my baby curls his toes downward when I stroke the sole of his foot, he is normal.”

3. “When I put my finger in the palm of my daughter’s hand, she will curl her fingers and hold on.”

4. “I can get my baby to turn her head towards the right side if I lift her right arm over her head.”

Correct Answer: 3 Rationale 1: This is the Moro or startle reflex and will occur when the infant is startled by sudden movement or a loud noise.

Rationale 2: The Babinski reflex of a newborn should elicit a fanning of the toes and hyperextension.

Rationale 3: This is the palmar grasp reflex. The plantar surface of the foot has a similar reflex.

Rationale 4: This is the tonic neck reflex, but the head should turn toward the opposite arm, not the arm that is lifted.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Compare the normal neurologic/neuromuscular characteristics and reflexes of the newborn with the normal variations that may be present.

Question 7 Type: MCSA The nurse is working with a family that has just delivered their third child, at 33 weeks’ gestation. The mother tells the nurse, “This baby doesn’t turn his head and suck like the older two children did. Why?” The best response by the nurse is: 1. “Every baby is different. This is just one variation of normal that we see on a regular basis.”

2. “This baby might not have a rooting or sucking reflex because she is premature.”

3. “When she is wide awake and alert, she will probably root and suck even if she is early.”

4. “She may be too tired from the birthing process and need a couple days to recover.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 2 Rationale 1: Although each baby is unique and different from her siblings, this answer does not indicate that prematurity is the cause of the lack of root and suck reflexes.

Rationale 2: Preterm babies often have a poor or absent root and suck reflex. They also might not have a swallow reflex and might require tube feedings temporarily.

Rationale 3: This statement is true of term infants, but this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking.

Rationale 4: Although birth is stressful to newborns, and some require a day or two of recovery to become fully alert, this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Compare the normal neurologic/neuromuscular characteristics and reflexes of the newborn with the normal variations that may be present.

Question 8 Type: MCMA The nurse is planning an educational session for maternal–child health unit nurses to cross-train them for providing home-based care after discharge. Which statements indicate that additional teaching is required? “The behavioral assessment: Standard Text: Select all that apply.

1. “Should be done as soon after birth as possible.”

2. “Can be performed without input from parents.”

3. “May be incomplete in a one-hour home visit.”

4. “Includes orientation and motor activity.”

5. “May detect neurological anomalies.”

Correct Answer: 1,2 Rationale 1: The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Parental input is required to fully understand the infant’s behaviors that are not observed by the healthcare team.

Rationale 3: A full behavioral assessment requires seeing the infant in several sleep/alert stages, which is not likely to take place in a one-hour home visit.

Rationale 4: Orientation to visual and auditory clues and motor activity are portions of the behavioral assessment.

Rationale 5: The behavioral assessment findings may provide indicators of neurological anomalies.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Describe the components of the newborn behavioral assessment.

Question 9 Type: MCSA The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing action would be appropriate?

1. Place a gloved finger in the newborn’s mouth.

2. Take the vital signs.

3. Wait until the newborn stops crying.

4. Place a hot water bottle in the isolette.

Correct Answer: 1 Rationale 1: To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn’s mouth.

Rationale 2: Crying will increase heart rate and respiratory rate, so vitals should not be taken when the newborn is crying.

Rationale 3: Because assessment of vital signs needs to be done at regular intervals, waiting until the newborn stops crying might cause too long of a delay.

Rationale 4: A hot water bottle should not be placed next to the newborn because of a potential risk for burns.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Describe the components of the newborn behavioral assessment.

Question 10 Type: MCSA The nurse is teaching a class to parents about the components of newborn behavioral assessment. Which parent’s statement suggests that educational material has been accurately understood?

1. “My baby’s ability to shut down his natural response to the sound of a rattle is considered a part of the variations assessment.”

2. “Habituation includes an allover assessment of my baby’s body tone.”

3. “Observing my baby’s frequency of alert status and peaks of excitement is part of the self-quieting activity component.”

4. “Motor activity includes assessing my baby’s overall tone when he’s being handled.”

Correct Answer: 4 Rationale 1: Assessment of habituation includes observing the newborn’s ability to diminish or shut down innate responses to specific repeated stimuli, such as a rattle, bell, light, or heel pinprick.

Rationale 2: An allover assessment of the newborn’s body tone is considered to be part of motor activity.

Rationale 3: Variations include the newborn’s frequency of alert states, state changes, color changes, activity, and peaks of excitement.

Rationale 4: Assessment of motor activity includes assessing the infant’s overall use of tone while the baby is being handled.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Describe the components of the newborn behavioral assessment.

Question 11 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The parents of a newborn comment to the nurse that their infant seems to enjoy being held and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents’ learning. Which statement indicates that teaching was effective?

1. “Some babies are easier to deal with than others.”

2. “We are lucky to have a baby with a calm disposition.”

3. “Our baby spends more time in the active alert phase.”

4. “Cuddliness is a social behavior that some babies have.”

Correct Answer: 4 Rationale 1: Easier or more difficult to deal with is a judgment, not part of an assessment.

Rationale 2: Describing an infant as having a calm disposition is a judgment, not part of an assessment.

Rationale 3: The active alert phase of the sleep-awake cycle is characterized by motor activity.

Rationale 4: The Brazelton Neonatal Behavioral Assessment Scale looks at habituation, orientation to animate or inanimate visual or auditory stimuli, motor activity, self-quieting, cuddliness or social behaviors, and variations of each of these categories.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Describe the components of the newborn behavioral assessment.

Question 12 Type: MCSA The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or less. Which statement should the nurse include?

1. “The baby will respond to you the most if you look directly into your baby’s eyes and talk to him.”

2. “Each baby is different. Don’t try to compare your infant’s behavior to any other child’s behavior.”

3. “If the sound level around your baby is high, the baby will wake up and be fussy or cry.”

4. “If your baby is a cuddler, it is because you rocked and talked to him during your pregnancy.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1 Rationale 1: Holding the baby en face and speaking softly obtains the most response from the baby, including eye contact, smiling, and vocalization.

Rationale 2: Although each infant is unique, there are certain predictable norms to observe for when assessing for neurological normality or impairment.

Rationale 3: Some infants will become overstimulated when excessive noise is present, but more will habituate to the sound and sleep.

Rationale 4: Cuddling is a social behavior that correlates with personality, but has not been linked to any prenatal activities.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Compare the normal behavioral characteristics of the newborn with the normal variations that may be present.

Question 13 Type: MCSA The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?

1. 2-week-old infant who doesn’t make eye contact when talked to 2. 1-week-old infant who sleeps through the noise of an older sibling 3. 6-day-old infant who responds more to mother’s voice than to father’s voice 4. 3-week-old infant who has begun to suck on the fingers of her right hand Correct Answer: 1 Rationale 1: This is an abnormal finding. Infants who do not make eye contact when talked to could have an ophthalmic abnormality.

Rationale 2: This is habituation and is an expected behavior.

Rationale 3: It is not unusual for an infant to respond more to the higher-pitched speech of its mother Rationale 4: Self-comforting behaviors such as sucking on fists, thumbs, or fingers are normal findings.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO07 - Compare the normal behavioral characteristics of the newborn with the normal variations that may be present.

Question 14 Type: MCSA The nurse is assessing a newborn. The parents are present. Which statement is best?

1. “Your infant was born with several reflexes. Some help her eat and protect her. I will show you what they look like.”

2. “You will be most successful if you put your baby to breast when she has her eyes wide open and she is looking around.”

3. “The muscle tone of your baby will increase as she gets older. You’ll notice her head lagging less in a few weeks.”

4. “The umbilical cord stump will dry up and fall off in about two weeks. There might be a spot of blood when it falls off.”

Correct Answer: 2 Rationale 1: Although this is true, parents’ knowledge about reflexes is not critical to the survival of the infant.

Rationale 2: This statement is best because it is about the physical need of feeding. Infants feed best when they are in the active alert phase, characterized by quiet, eyes open, and looking calmly around.

Rationale 3: Although this statement is true, parents’ knowledge about neuromuscular development is not critical to the survival of the infant.

Rationale 4: Although this is true, parents’ knowledge about the cord falling off is not critical to the survival of the infant.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve parents in the care of the newborn.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 26 Question 1 Type: MCMA Which of the following actions must a nurse perform before weighing the newborn during the admission procedure?

Standard Text: Select all that apply.

1. Clean the scale 2. Take the infant’s temperature 3. Cover the scale 4. Zero the scale 5. Wrap the infant tightly in a blanket to prevent heat loss Correct Answer: 1,2,3,4 Rationale 1: This action should be performed to prevent cross infection.

Rationale 2: This action should be performed to monitor heat loss.

Rationale 3: This action should be performed to prevent cross infection.

Rationale 4: This action should be performed to ensure an accurate measurement.

Rationale 5: The nurse should remove all clothing and blankets to ensure an accurate measurement. To prevent heat loss, the infant should instead be placed under a radiant warmer.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Summarize the essential information to be obtained about the prenatal period and a newborn’s birth experience and immediate postnatal period.

Question 2 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse has received a shift change report on infants born within the last four hours. Which newborn should the nurse see first?

1. 37-week male, respiratory rate 45 2. 8 pound, 1 ounce female, pulse 150 3. Term male, grunting respirations 4. 39-week female, temperature 97.0°F Correct Answer: 3 Rationale 1: A normal respiratory rate is 30–60. This infant has no unexpected findings.

Rationale 2: A normal pulse is 110–160. This infant has no unexpected findings.

Rationale 3: Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately.

Rationale 4: A normal temperature is 96.8°F-97.7°F. This infant has no unexpected findings.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Explain how the physiologic and behavioral responses of the newborn during the first 4 hours after birth (admission and transitional period) determine the newborn’s nursing care.

Question 3 Type: MCSA The nurse assesses the following in a sleeping 1-hour-old, 39-weeks’-gestation newborn. The assessment data that would be of greatest concern would be: 1. Skin temperature 97.6°F 2. Respirations 68/min 3. Blood pressure 72/44 4. Heart rate 156 beats/min Correct Answer: 2 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: This is within the normal temperature range of 96.8–97.7°F. Rationale 2: Normal respiratory rate is 40–60 breaths/min. 68 could represent a less-than-expected transition.

Rationale 3: This blood pressure is within the normal range of 90–60/50–40 mmHg. Rationale 4: This heart rate is within the normal range of 120–160 beats/min.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Explain how the physiologic and behavioral responses of the newborn during the first 4 hours after birth (admission and transitional period) determine newborn’s nursing care.

Question 4 Type: MCSA Which of the following information is NOT recorded as a part of the initial newborn assessment?

1. Resuscitative measures required in the birthing area 2. Blood draw for PKU screening 3. Presence or absence of meconium-stained fluid 4. Parents’ desires regarding circumcision for a male infant Correct Answer: 2 Rationale 1: The condition of the newborn, including resuscitative measures required in the birthing area, should be recorded as part of the newborn assessment.

Rationale 2: Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth.

Rationale 3: The labor and birth record, including the presence or absence of meconium-stained fluid, should be recorded as part of the newborn assessment.

Rationale 4: Parent-newborn attachment information, including the parents’ desires regarding care, should be noted during the newborn assessment.

Global Rationale: Cognitive Level: Applying Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Summarize the essential information to be obtained about the prenatal period and a newborn’s birth experience and immediate postnatal period.

Question 5 Type: MCSA The parents of a newborn male ask the nurse if they should circumcise their son. The best response by the nurse is: “Circumcision: 1. “Should be undertaken to prevent problems in the future.”

2. “Might decrease the risk of developing a urinary tract infection.”

3. “Can sometimes cause complications. What questions do you have?”

4. “Is painful and should be avoided unless you are Jewish.”

Correct Answer: 3 Rationale 1: Although this is a common reason parents give for requesting circumcision, it is still an opinion not based in medical fact.

Rationale 2: Although this is a true statement, getting more information from the parents about their questions or concerns is better.

Rationale 3: Asking this question allows the nurse to determine what the questions or concerns are and address them specifically.

Rationale 4: Although circumcision can be painful, most providers administer a penile nerve root block to prevent or minimize procedural pain. Both Jewish and Muslim males are circumcised because of religious law or tradition.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO07 - Describe the nurse’s role in the care of the parents and newborn before, during, and after circumcision.

Question 6 Type: MCMA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse tells the mother that the doctor is preparing to circumcise her newborn. The mother verbalizes concern that the infant will be uncomfortable during the procedure. The nurse explains to the mother that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure can include: Standard Text: Select all that apply.

1. Non-nutritive sucking.

2. Stroking the head.

3. Swaddling.

4. Talking to the baby.

Correct Answer: 1,2,4 Rationale 1: This is an accepted method of soothing during the circumcision.

Rationale 2: This is an accepted method of soothing during the circumcision.

Rationale 3: The infant must be placed on a padded circumcision board without a diaper. A warm blanket can be applied to the upper body, but the infant cannot be swaddled.

Rationale 4: This is an accepted method of soothing during the circumcision.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO07 - Describe the nurse’s role in the care of the parents and newborn before, during, and after circumcision.

Question 7 Type: MCSA The nurse is discussing parent–infant attachment with a prenatal class. Which statement indicates that teaching was successful?

1. “I should avoid looking directly into the baby’s eyes to prevent frightening the baby.”

2. “My baby will be very sleepy immediately after birth, so he can go to the nursery.”

3. “Newborns cannot focus their eyes, so it doesn’t matter how I hold my new baby.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “Giving the baby his first bath can really give me a chance to get to know him.”

Correct Answer: 4 Rationale 1: Eye contact is an important aspect of parent–infant attachment and should be promoted, especially in the immediate time after birth.

Rationale 2: Babies are usually wide awake and alert and responsive in the first few hours after birth. Interacting with the newborn during this first period of reactivity facilitates parent–infant attachment.

Rationale 3: Newborns can focus at a distance of 7–8 inches, the distance from a baby being held to the parent’s face. Eye contact is an important aspect of parent–infant attachment and should be promoted, especially in the immediate time after birth.

Rationale 4: When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby’s behavior.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Identify opportunities to individualize parent teaching and enhance each parent’s abilities and confidence while providing infant care in the birthing unit.

Question 8 Type: MCSA The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the cultural background of the family. What statement is best?

1. “You appear to be Muslim. Do you want your son circumcised?”

2. “Let me explain how newborn care takes place here in the U.S.” 3. “Your baby is a U.S. citizen. You must be very happy about that.”

4. “Could you explain what your preferences are regarding childbearing?”

Correct Answer: 4 Rationale 1: Avoid making assumptions about clients based on appearance. It is much better to respectfully ask questions regarding preferences and practices.

Rationale 2: The nurse should not assume the family doesn’t understand the U.S. healthcare system. It is much better to respectfully ask questions regarding preferences and practices.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This is an assumption often based on the false idea that people from other countries only come to have their babies in the U.S. so they will be citizens and therefore eligible for federal aid. It is much better to respectfully ask questions regarding preferences and practices.

Rationale 4: Sensitive, nonjudgmental exploration of the family’s cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04 - Discuss how cultural practices of parents influence the nursing care management of the newborn.

Question 9 Type: MCSA The nurse is teaching a parenting class for pregnant couples that will deliver soon. Which statement best indicates that additional information is needed?

1. “Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother.”

2. “Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother’s circulation.”

3. “We can call the nurse help line any time of day or night if we have questions about our baby after we get home.”

4. “Car seats are installed the same way in different models of cars. Our friends can show us how to install it.”

Correct Answer: 4 Rationale 1: This is a true statement. Parents might believe there is something wrong if they are not taught about pseudomenstruation.

Rationale 2: This is a true statement and often a concern of parents.

Rationale 3: Most pediatrician offices, HMOs, hospitals, and physician groups have a nurse line staffed 24 hours a day, seven days a week to respond to questions and concerns of parents. When this service exists, parents should be made aware of it and provided with the phone number.

Rationale 4: Each model of car seat is installed differently in different makes of car. Directions for car seats should be followed carefully. Car dealerships often offer a car seat installation instruction service. A car seat that is installed incorrectly can be more dangerous than not using a car seat at all.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Describe common concerns of families regarding their newborns.

Question 10 Type: MCSA At birth, an infant weighed 8 pounds, 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds, 15 ounces. What explanation should the nurse give for the change in this newborn’s weight? “His weight loss is: 1. “Excessive.”

2. “Within normal limits.”

3. “Less than expected.”

4. “Unusual.”

Correct Answer: 2 Rationale 1: This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10% in term newborns.

Rationale 2: This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10% in term newborns.

Rationale 3: This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10% in term newborns.

Rationale 4: This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10% in term newborns.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Describe common concerns of families regarding their newborns.

Question 11 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Type: MCSA The nurse is ready to perform a discharge assessment for a 2-day-old male infant that has been circumcised.

Which of the following findings require immediate intervention?

1. The umbilical cord clamp has been removed.

2. The infant has had a dry diaper since the circumcision procedure.

3. The mother is ready to breastfeed on demand.

4. The infant maintains temperature when wrapped in a blanket.

Correct Answer: 2 Rationale 1: The umbilical cord clamp should be removed between 24 and 48 hours after birth to reduce the chance of tension injury to the area.

Rationale 2: If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow.

Rationale 3: This is a positive action that represents the mother’s readiness to care for her infant at home.

Rationale 4: The infant should be able to maintain body temperature without the presence of the radiant warmer.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify activities that should be included in a daily care plan for a normal newborn.

Question 12 Type: MCSA The nurse is planning home visits to the homes of new parents and their newborns. Which patient should the nurse see first?

1. 3-day-old male who received a hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with whitish adherent discharge on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 4 Rationale 1: This infant has no indications of unexpected findings.

Rationale 2: This infant is not at risk, but the appointment must be scheduled when the sign language interpreter is available.

Rationale 3: This is normal healing of a mucous membrane. The discharge should not be scrubbed off.

Rationale 4: Greenish or malodorous discharge from the umbilicus is not an expected finding. This family should be seen first because they are experiencing a complication.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Explain how the common concerns of families can be included in parent teaching during daily newborn and infant care and discharge planning.

Question 13 Type: MCSA The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information?

1. “The baby should be in the back seat.”

2. “Newborns must be in rear-facing car seats.”

3. “We need to read the owner’s manual before using the car seat.”

4. “How the straps go around the baby isn’t that important.”

Correct Answer: 4 Rationale 1: The safest place for a newborn is in a rear-facing car seat in the middle of the back seat.

Rationale 2: The safest place for a newborn is in a rear-facing car seat in the middle of the back seat.

Rationale 3: Each car seat is different; the owner’s manual contains instructions for proper use.

Rationale 4: Car seats for infants are mandatory in most states. Straps must be snug around the baby in order to be effective in protecting the baby in case of a crash.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO08 - Explain how the common concerns of families can be included in parent teaching during daily newborn and infant care and discharge planning.

Question 14 Type: MCMA A change in skin color requires further assessment of which of the following physiological functions?

Standard Text: Select all that apply.

1. Oxygenation 2. Bilirubin levels 3. Glucose levels 4. Hematocrit 5. Blood pressure Correct Answer: 1,2,3,4 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale: Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Identify activities that should be included in a daily care plan for a normal newborn.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 15 Type: MCSA The nurse is working with an adolescent mother and her newborn. As the nurse begins to gather the supplies needed to bathe the infant, the adolescent tells the nurse, “I’m really scared that I won’t take care of my baby correctly. My mother says I’ll probably hurt the baby because I’m too young to be a mother.” The best response by the nurse is: 1. “You are very young, and parenting will be a challenge for you.”

2. “Your mother was probably right. Be very careful with your baby.”

3. “Mothers have instincts that kick in when they get their babies home.”

4. “We can give the baby’s bath together. I’ll help you learn how to do it.”

Correct Answer: 4 Rationale 1: Although this statement is true, it does not teach the patient anything or increase her confidence in being able to care for her infant.

Rationale 2: This statement is very judgmental and does not teach the patient anything or increase her confidence in being able to care for her infant.

Rationale 3: Maternal instincts might indeed exist, but this patient has expressed a specific fear about being a safe mother. It is best to work with her to teach her skills and increase her confidence.

Rationale 4: This response is best because it both teaches the new mother skills she does not have and increases her confidence.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Identify opportunities to individualize parent teaching and enhance each parent’s abilities and confidence while providing infant care in the birthing unit.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 27 Question 1 Type: MCSA The nurse is teaching an early-parenting class to families expecting their first child soon. A patient asks the nurse if breast milk is really better than formula. The best response by the nurse is: 1. “Breast milk is the perfect food for human babies.

2. “Formula attempts to imitate the composition of breast milk. “ 3. “Breastfed babies grow faster because of breast milk.”

4. “Formula is harder to digest than is breast milk.”

Correct Answer: 2 Rationale 1: Although this statement is true, it is somewhat vague because it does not describe the nutritional composition of breast milk. In addition, this response is emotionally laden and judgmental of the use of formula, and therefore not therapeutic.

Rationale 2: This statement best answers the question about whether breast milk or formula is best. Breast milk is the “gold standard” on which formula is based. Formula attempts to provide nutrition that is similar to breast milk; however, breast milk composition is different in many ways.

Rationale 3: Although exclusively breastfed infants have the same or slightly higher weight gain than their formula-fed and mixed-fed peers in the first 3–4 months, the patient’s question is not about growth; it is about whether breast milk or formula is better.

Rationale 4: The patient’s question is not about digestion of formula and breast milk; the question is about which is better. It is best to answer a patient’s question directly.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Compare the nutritional values and compositions of human milk and formula preparations in relation to the nutritional needs of the newborn.

Question 2 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? “In the first 3– 4 months: 1. “Breastfed babies gain weight faster.”

2. “There is no difference in weight gain.”

3. “Bottle-fed babies grow faster.”

4. “Growth isn’t as important as your comfort with the method.”

Correct Answer: 1 Rationale 1: Once feeding is established, breastfed babies tend to gain weight faster than do bottle-fed babies and have a leaner body at the end of the first year.

Rationale 2: Breastfed babies have a leaner body at the end of the first year.

Rationale 3: Breastfed babies tend to gain weight faster than do bottle-fed babies.

Rationale 4: Although comfort with the feeding method is important, the question is specifically about growth and weight gain; it is not therapeutic to change the topic and not answer the question.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Explain the nutritional needs of and normal growth patterns of the newborn.

Question 3 Type: MCSA The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse’s education session was effective?

1. “I should only use soy-based formula for the first year.”

2. “I follow the instructions for mixing the powdered formula exactly.”

3. “I can reuse one bottle for several feedings.”

4. “The mixed formula can be left on the counter for a day.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 2 Rationale 1: Soy-based formulas are more expensive than whey-based formulas, and they are only needed by infants with milk allergies. No information is provided about milk allergy symptoms. Powdered formula is the cheapest, followed by concentrated formula; ready-to-feed formula is the most expensive.

Rationale 2: Powdered and concentrated formula must be mixed according to manufacturer’s guidelines. Formula that is too concentrated can lead to excess sodium intake, which creates increased thirst and overfeeding.

Rationale 3: Each bottle should contain only enough formula for one feeding, and any formula left after the feeding should be discarded to prevent bacterial growth.

Rationale 4: Once formula is mixed, it must be used within two hours or refrigerated.

Global Rationale: Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO01 - Compare the nutritional values and compositions of human milk and formula preparations in relation to the nutritional needs of the newborn.

Question 4 Type: MCMA Which statements by a breastfeeding class participant indicate that teaching was effective?

Standard Text: Select all that apply.

1. “Breastfed infants get more skin-to-skin contact and sleep better.”

2. “Breastfeeding raises the level of a hormone that makes me feel good.”

3. “Breastfeeding is complex and difficult, and I probably won’t succeed.”

4. “Breastfeeding is worthwhile, even if it costs more overall.”

5. “Breastfed infants have fewer digestive and respiratory illnesses.”

Correct Answer: 1,2,5 Rationale 1: This is a true statement.

Rationale 2: Every time an infant suckles, the prolactin level doubles; prolactin creates feelings of euphoria and relaxation.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Although there is skill involved in getting a baby to nurse successfully and coordinating the infant’s efforts with the maternal efforts, breastfeeding is not perceived as difficult by the majority of women who attempt to do so.

Rationale 4: Breastfeeding actually costs substantially less than formula feeding, even considering the need for increased calcium and protein intake during lactation.

Rationale 5: This is a true statement. Reduced infections are due to immunologic properties in breast milk and to the fact that breastfed infants are not put to bed with a bottle, a practice known to increase ear infections.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Explain the advantages and disadvantages of breastfeeding and formula-feeding in determining the nursing care of both mother/family and newborn.

Question 5 Type: MCSA The patient at 20 weeks’ gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the patient indicate that the teaching was successful?

1. “Formula-feeding gives the baby protection from infections.”

2. “Breast milk cannot be stored; it has to be thrown away after pumping.”

3. “Breastfeeding is more expensive than formula-feeding.”

4. “My baby has a lower risk of food allergies if I breastfeed.”

Correct Answer: 4 Rationale 1: Formula does not provide the baby with protection from infections like breast milk does.

Rationale 2: Breast milk can be refrigerated or frozen after pumping.

Rationale 3: Formula must be purchased, and therefore it is expensive.

Rationale 4: Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Explain the advantages and disadvantages of breastfeeding and formula-feeding in determining the nursing care of both mother/family and newborn.

Question 6 Type: MCSA The nurse is working with a new mother who delivered yesterday. The patient has chosen to breastfeed her infant.

Which demonstration of skill is the best indicator that the patient understands breastfeeding?

1. The patient puts the infant to breast when he is asleep to help wake him up.

2. The patient takes off her gown to achieve skin-to-skin contact.

3. The infant is held so that he turns his head to access the nipple.

4. The infant is crying when he is brought to the breast.

Correct Answer: 2 Rationale 1: Breastfeeding is more successful if the infant is in the alert-awake state when put to breast. Putting a newborn to breast is not likely to wake him up to feed.

Rationale 2: Skin-to-skin contact creates tactile sensations that increase the sucking of newborns.

Rationale 3: The infant should be held in a “tummy-to-tummy” position so that the head does not have to turn to find the nipple and access the breast.

Rationale 4: Crying is a late cue of hunger. Newborns should be put to breast when they begin rooting, lipsmacking, or tongue-thrusting behaviors.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Formulate guidelines for helping both breastfeeding and formula-feeding mothers to promote successful feeding of their infants in the hospital-based and community-based setting.

Question 7 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

A newborn appears pale and weak, and laboratory tests reveal the infant has iron deficiency anemia. The mother asks the nurse if it would better to breastfeed her infant or feed him a formula high in iron. What should the nurse’s response be?

1. Breastfeed, because breast milk has higher levels of iron compared to formula 2. Breastfeed, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 3. Formula-feed, because formula has higher levels of iron compared to breast milk 4. Formula-feed, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant Correct Answer: 2 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Global Rationale: Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Explain the advantages and disadvantages of breastfeeding and formula-feeding in determining the nursing care of both mother/family and newborn.

Question 8 Type: FIB Infants receive approximately 50% of their calories from ____________, even though breast milk contains more ________________ by weight.

Standard Text: Fill in the blanks with the correct answers.

Correct Answer: fat Rationale : Infants receive approximately 50% of their calories from fat.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Compare the nutritional value and composition of human milk and formula preparations in relation to the nutritional needs of the newborn.

Question 9 Type: SEQ A nurse is assisting a new mother to breastfeed. Put the following steps for breastfeeding in a logical sequence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Tickle the newborn’s lips with the nipple.

Choice 2. Bring the newborn to breast.

Choice 3. The newborn opens mouth wide.

Choice 4. Have the newborn face the mother tummy-to-tummy.

Choice 5. Position the newborn so the newborn’s nose is at level of the nipple.

Correct Answer: 3,5,4,2,1 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Formulate guidelines for helping both breastfeeding and formula-feeding mothers to promote successful feeding of their infants in the hospital-based and community-based setting.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 10 Type: MCSA The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should: 1. Offer a pacifier.

2. Burp the newborn.

3. Unwrap the newborn.

4. Stoke the newborn’s spine and feet.

Correct Answer: 2 Rationale 1: The newborn’s cries are indicative of an issue; a pacifier would not solve the problem.

Rationale 2: If a newborn has been crying prior to feeding, air might have been swallowed; therefore, the newborn should be burped before feeding. Time should be taken to calm the newborn prior to feeding.

Rationale 3: Unwrapping the newborn stimulates the newborn.

Rationale 4: Stroking the spine and feet stimulate the newborn.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Formulate guidelines for helping both breastfeeding and formula-feeding mothers to promote successful feeding of their infants in the hospital-based and community-based setting.

Question 11 Type: MCSA The nurse is completing the discharge teaching of a young first-time mother. Which statement requires immediate intervention?

1. “I will put my baby to bed with his bottle so he doesn’t get hungry during the night.”

2. “My baby will probably have a bowel movement each breastfeeding and will wet often.”

3. “Nursing every 1½–2 hours is normal, for a total of 8–12 feedings every day.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. “I will drink yarrow tea from my grandmother to prevent my milk from coming in.”

Correct Answer: 1 Rationale 1: Putting a baby to bed with a propped bottle is a choking hazard and should never be done.

Rationale 2: Breastfed infants have more frequent bowel movements than do bottle-fed infants. Both should have at least five wet diapers per day.

Rationale 3: This is a true statement. Breast milk is easier to digest than formula; therefore, infants eat more frequently.

Rationale 4: Yarrow is one of the anti-galactogogues (herbs that decrease lactation) and is used by formulafeeding women to decrease milk supply.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Describe ways to educate parents about their infant’s nutrition needs and normal growth patterns.

Question 12 Type: MCSA A nurse conducts an infant assessment on the second day after birth. A physical assessment of the newborn reveals the infant has dry lips and a dry oral cavity and has had only one wet diaper rather than the expected two.

What is the primary nursing diagnosis for this infant?

1. Risk for Imbalanced Nutrition: Less than body requirements related to mother’s increased caloric need 2. Ineffective breastfeeding related to mother’s lack of knowledge about breastfeeding techniques 3. Risk for infection related to impaired skin integrity 4. Imbalanced Nutrition: Less than body requirements related to dehydration as evidenced by dry mucus membranes and decreased urine output Correct Answer: 4 Rationale 1: The infant has progressed beyond a risk diagnosis as evidenced by the signs of dehydration. Instead, this infant should receive the actual diagnosis of imbalanced nutrition.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Although dehydration is often caused by ineffective breastfeeding, there is no evidence that this is related to the mother’s lack of knowledge about breastfeeding techniques. A maternal assessment would be needed to make this diagnosis.

Rationale 3: Dry lips and mouth may lead to impaired skin integrity, but this is not the primary nursing diagnosis that needs immediate intervention.

Rationale 4: The infant is displaying signs of dehydration, which most often occurs when the infant is not receiving enough fluids through breastfeeding or bottle-feeding. Newborns require 140-160 ml/kg/day of fluids to prevent dehydration because the newborn has a decreased ability to concentrate urine and their overall metabolic rate is high.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO03 - Explain the nutritional needs of and normal growth patterns of the newborn.

Question 13 Type: MCSA A nurse is evaluating the diet plan of a breastfeeding mother and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the breast milk can be adversely affected by this aspect of the mother’s nutrition. Which of the following strategies should be recommended to the mother?

1. Stop breastfeeding.

2. Provide newborn supplements to the newborn.

3. Offer whole milk.

4. Supplement with skim milk.

Correct Answer: 2 Rationale 1: The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn.

Rationale 2: The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn.

Rationale 3: Whole milk and skim milk are not recommended during the first year of life.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Whole milk and skim milk are not recommended during the first year of life.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Describe ways to educate parents about their infant’s nutrition needs and normal growth patterns.

Question 14 Type: MCSA A nurse is conducting a breastfeeding assessment for a primipara mother. The infant has not yet learned how to latch on strongly, and the mother begins to get frustrated. In addition, the infant seems unsettled and uninterested in eating. The mother comments that she thinks her frustration is causing her milk to spoil. How should the nurse handle this statement?

1. Agree with the mother’s statement and teach her relaxation techniques to reduce her frustration.

2. Assure the mother that there is no evidence that milk composition changes based on the mother’s emotional state. The infant is fussy because he can sense the mother’s frustration.

3. Tell the mother that the delayed let-down resulting from her frustration is causing the infant to suck in air rather than milk.

4. Remind the mother that spoiled milk will cause cramping in the infant’s stomach, contributing to his fussy demeanor.

Correct Answer: 2 Rationale 1: Although teaching the mother relaxation techniques is an appropriate response, there is no evidence that milk composition changes based on the mother’s emotional state. Therefore, the nurse should not agree with this statement.

Rationale 2: Infants can sense the mother’s emotions, so the mother should be taught relaxation techniques to reduce her frustration and enhance the feeding experience.

Rationale 3: A delayed let-down response will not cause the infant to suck air instead of milk through the nipple.

Rationale 4: There is no evidence that milk composition changes based on the mother’s emotional state, so the infant will not be consuming spoiled milk. If the infant has stomach cramping, it will be for another reason that will need to be investigated more thoroughly.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO04 - Explain the influence of cultural values on infant feeding practices.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 28 Question 1 Type: MCSA The nurse is caring for pregnant patients. Which of these clients should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity?

1. 37-year-old G8 P2323, works in a chemical factory 2. 23-year-old primip, low socioeconomic status, unmarried 3. 16-year-old primip, began prenatal care at 30 weeks 4. 28-year-old G2 P1001, history of gestational diabetes Correct Answer: 1 Rationale 1: This patient is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.

Rationale 2: The main risk factor for this patient is her low socioeconomic status.

Rationale 3: This patient has two risk factors: young age and late onset of prenatal care.

Rationale 4: This patient has gestational diabetes history as her only risk factor.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Explain factors present at birth that indicate an at-risk newborn.

Question 2 Type: MCSA Small-for-gestational-age infants often have complications at birth, but they may also experience long-term complications. The long-term effect that is most likely to occur in SGA infants is: 1. Change from thin and underweight as a child to overweight or obese as adolescents 2. Poor fine motor coordination Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. Paralysis below the hips 4. Permanent disfiguration Correct Answer: Rationale 1: This long-term effect is often seen in children with fetal alcohol syndrome, not SGA. Rationale 2: SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss.

Rationale 3: Many infants with myelomeningocele will suffer life-long paralysis below the site of the cyst.

Paralysis is not generally associated with SGA infants.

Rationale 4: Although it may occur, disfiguration is not commonly associated with SGA infants. Instead, disfiguration is more likely to remain in infants with congenital anomalies such as cleft lip/cleft palate, even after corrective surgery.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02 - Compare the underlying etiologies of the physiologic complications of small-forgestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns, and the nursing care management for each.

Question 3 Type: MCSA A 38-week newborn is found to be small for gestational age. Which of the following nursing interventions should be included in the care of this newborn?

1. Monitor for feeding difficulties.

2. Assess for facial paralysis.

3. Monitor for signs of hyperglycemia.

4. Maintain a warm environment.

Correct Answer: 4 Rationale 1: LGA newborns are more difficult to arouse to a quiet alert state and can have feeding difficulties.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: LGA newborns often are prone to birth trauma, such as facial paralysis, due to cephalopelvic disproportion.

Rationale 3: SGA newborns are more prone to hypoglycemia.

Rationale 4: Hypothermia is a common complication of the SGA newborn; therefore, the newborn’s environment must remain warm to decrease heat loss.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Compare the underlying etiologies of the physiologic complications of small-forgestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns, and the nursing care management for each.

Question 4 Type: MCSA A 7 pound, 14 ounce girl was born to an insulin-dependent type 2 diabetic mother two hours ago. The infant’s blood sugar is 45mg/dl. The best nursing action is: 1. Recheck the blood sugar in four hours.

2. Begin an IV of 10% dextrose.

3. Feed the baby one ounce of formula.

4. Document the findings in the chart.

Correct Answer: 4 Rationale 1: Infants of diabetic mothers should be fed frequently and should have their blood sugar assessed frequently. Four hours is too long a time frame.

Rationale 2: 45mg/dl is considered a normal blood sugar reading for a neonate. No IV is needed.

Rationale 3: Feeding would be appropriate if the infant’s blood sugar was below 40, but this infant’s reading is 45 mg/dl.

Rationale 4: A blood sugar of 45 mg/dl is a normal finding; documentation is an appropriate action.

Global Rationale: Cognitive Level: Analyzing Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Explain the impact of maternal diabetes mellitus on the newborn.

Question 5 Type: MCSA An infant was born at 31-weeks’ gestation and weighed 1430 g. What is the correct initial feeding regimen for this infant?

1. 10 mg/kg/day of premature formula 24 kcal/oz.

2. 20 mg/kg/day of premature formula 24 kcal/oz.

3. 40 mg/kg/day of postdischarge formula 22 kcal/oz.

4. 50 mg/kg/day of term formula 20 kcal/oz.

Correct Answer: 2 Rationale 1: This is the correct initial feeding regimen for preterm infants with a birth weight under 1250 g.

Rationale 2: This is the correct initial feeding regimen for preterm infants with a birth weight between 1251 and 1500 g.

Rationale 3: This is the correct initial feeding regimen for preterm infants with a birth weight between 1801 and 2500 g.

Rationale 4: This is the correct initial feeding regimen for preterm infants with a birth weight over 2500 g.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05 - Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management.

Question 6 Type: MCSA The pregnant patient at 41 weeks is scheduled for labor induction. She asks the nurse if induction is really necessary. What response by the nurse is best?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. “Babies can develop postmaturity syndrome, which increases their chances of having complications after birth.”

2. “When infants are born two or more weeks after their due date, they have meconium in the amniotic fluid.”

3. “Sometimes the placenta ages excessively, and we want to take care of that problem before it happens.”

4. “The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger.”

Correct Answer: 1,2 Rationale 1: This statement is correct.

Rationale 2: Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome.

Rationale 3: Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name.

Rationale 4: Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04Compare the characteristics and potential complications that influence nursing management of the post-term newborn and the newborn with postmaturity syndrome.

Question 7 Type: MCMA The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed?

Standard Text: Select all that apply.

1. “Our baby will be in an isolette to keep him warm.”

2. “Breathing might be harder for our baby because he is early.”

3. “The growth of our baby will be faster than if he were term.”

4. “Tube feedings will be required because his stomach is small.”

5. “Because he came early, he will not produce urine for two days.”

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3,4,5 Rationale 1: Preterm infants have little subcutaneous fat and have difficulty maintaining their body temperature.

An isolette or overhead warmer is used to keep the baby warm.

Rationale 2: Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants.

Rationale 3: Preterm infants grow more slowly than do term infants.

Rationale 4: Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration.

Rationale 5: Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO05 - Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management.

Question 8 Type: MCSA The nurse is caring for an infant with abdominal contents protruding out approximately at the location of the umbilicus. What is the primary mechanism used to differentiate between omphalocele or gastroschisis?

1. With omphalocele, the abdominal contents are covered with a sac; with gastroschisis, the abdominal contents are not covered by a sac.

2. With omphalocele, the abdominal contents are not covered with a sac; with gastroschisis, the abdominal contents are covered by a sac.

3. With omphalocele, the abdominal contents protrude to the right of an intact umbilical cord; with gastroschisis, the abdominal contents protrude into the base of the umbilical cord.

4. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord.

Correct Answer: 4 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis.

Rationale 2: If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis.

Rationale 3: This is the opposite description of gastroschisis and omphalocele. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord.

Rationale 4: This is a correct way to differentiate between omphalocele and gastroschisis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO06 - Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies.

Question 9 Type: MCSA The nurse is assessing a 36-week gestational age newborn. Upon auscultation, she hears a late systolic murmur in the left intrascapular area with no femoral pulse but increased brachial pulses. What treatment should this infant receive?

1. Indomethacin with surgical ligation.

2. Lanoxin with surgical closure with a Dacron patch.

3. Prostaglandin E1 and surgical resection of the aorta.

4. Palliative surgery to increase blood flow to the lungs followed by corrective surgery.

Correct Answer: 3 Rationale 1: This treatment is used with patent ductus arteriosus. This infant has coarctation of aorta, which should be treated with prostaglandin E1 and surgical resection of the aorta.

Rationale 2: This treatment is used for ventricular septal defect. This infant has coarctation of aorta, which should be treated with prostaglandin E1 and surgical resection of the aorta.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This is the correct treatment for an infant with coartation of aorta.

Rationale 4: This treatment is used for tetralogy of Fallot. This infant has coarctation of aorta, which should be treated with prostaglandin E1 and surgical resection of the aorta.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO09 - Identify physical examination findings during the early newborn period that would make the nurse suspect a congenital cardiac defect of congestive heart failure.

Question 10 Type: MCSA The nurse is caring for a newborn in the special care nursery. The infant is positioned prone and has hydrocephalus. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with: 1. Omphalocele.

2. Gastroschisis.

3. Diaphragmatic hernia.

4. Myelomeningocele.

Correct Answer: 4 Rationale 1: Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with omphalocele.

Rationale 2: Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal organs’ being located on the outside of the body. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with this condition.

Rationale 3: Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in bowel and sometimes stomach extending upward through the defect and being located in the chest cavity. Respiratory distress is the primary symptom. Surgical repair is required for normal respiratory function if the lungs have not been compromised by crowding from abdominal organs. Positioning should be high Fowler’s to facilitate respiratory efforts. Hydrocephalus is not associated with this condition.

Rationale 4: Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed.

Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection.

The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06 - Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies.

Question 11 Type: MCSA Parents have been told their child has fetal alcohol syndrome. Which statement indicates that additional teaching is required?

1. “Our baby’s heart murmur is from this syndrome.”

2. “He might be a fussy baby because of this.”

3. “His face looks like it does due to this problem.”

4. “Cuddling and rocking will help him stay calm.”

Correct Answer: 4 Rationale 1: Ventral and atrial septal defects are common in babies with FAS. Rationale 2: FAS babies are easily overstimulated and have feeding difficulties, leading to more crying than an average baby.

Rationale 3: Facial characteristics of the FAS child include a broad and flat nasal bridge, wide-set eyes, small chin, and smooth philtrum.

Rationale 4: FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO07 - Explain the special care needed by an alcohol- or drug-exposed newborn.

Question 12 Type: MCMA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The nurse is caring for a newborn born to a drug-addicted mother. Which of the following assessment findings would be common for this newborn?

Standard Text: Select all that apply.

1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Depressed respiratory effort 5. Transient tachypnea Correct Answer: 1,3,5 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale: Newborns born to drug-addicted mothers exhibit hyperirritability, exaggerated reflexes, and transient tachypnea.

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Explain the special care needed by an alcohol- or drug-exposed newborn.

Question 13 Type: MCMA Which of the following should be considered potentially infectious when providing nursing care for a newborn with an HIV-positive mother?

Standard Text: Select all that apply.

1. Soiled linens Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Urine 3. Blood 4. Mask worn while caring for infant 5. Feces Correct Answer: 1,2,3,5 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale: Body fluids such as blood, urine, and feces are considered potentially infectious. Therefore, soiled linens are also potentially infectious. A mask is not routinely used when caring for an infant exposed to HIV and will likely not be contaminated if used.

Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Safety and Infection Control Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO08 - Relate the consequences of maternal HIV/AIDS on the management of and issues for caregivers of infants at risk for HIV/AIDS in the neonatal period.

Question 14 Type: MCSA The family of a newborn has just been told their infant has tetralogy of Fallot. The family does not seem to understand the explanation given by the physician. What statement by the nurse is best?

1. “With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby’s body.”

2. “The baby’s aorta has a narrowing in a section near the heart that makes the left side of the heart work harder.”

3. “The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart.”

4. “Your baby’s heart doesn’t circulate blood well because the left ventricle is smaller and thinner than normal.”

Correct Answer: 1 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Tetralogy of Fallot is a cyanotic heart defect that is comprised of four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. Deoxygenated blood is shunted from the right ventricle through the VSD into the left ventricle, bypassing the lungs and circulating deoxygenated blood.

Rationale 2: This describes coarctation of the aorta, which is not a cyanotic heart defect but an obstructive defect to systemic blood flow.

Rationale 3: This describes transposition of the great vessels.

Rationale 4: This describes hypoplastic left heart syndrome.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO09 - Identify physical examination findings during the early newborn period that would make the nurse suspect a congenital cardiac defect of congestive heart failure.

Question 15 Type: MCSA The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been found to have the condition. Which statement indicates that teaching was effective?

1. “This condition occurs more frequently among Japanese people.”

2. “We must be very careful to avoid most proteins to prevent brain damage.”

3. “This condition will resolve itself by the time my child reaches the age of 5.”

4. “The thyroid gland of our baby isn’t functioning properly.”

Correct Answer: 2 Rationale 1: Japanese people have a very low rate of PKU disease; it is most common among northern Europeans.

Rationale 2: PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. High phenylalanine levels cause brain damage and severe neurologic abnormalities.

Rationale 3: PKU is a genetic disorder, so the child will have the condition for his or her entire life.

Rationale 4: Congenital hypothyroidism is the disorder of low thyroid function at birth.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO10 - Explain the special care needed by a newborn with an inborn error of metabolism.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 29 Question 1 Type: MCSA A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?

1. Begin chest compressions.

2. Deep suction the airways.

3. Begin bag-and-mask ventilation.

4. Assess blood pressure.

Correct Answer: 3 Rationale 1: Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established.

Rationale 2: This would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid.

Rationale 3: When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure.

Rationale 4: Establishment of airway and breathing take priority over assessment of blood pressure.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO01 - Describe how to identify infants in need of resuscitation and the appropriate method of resuscitation based on the antepartum/labor record and physiologic indicators.

Question 2 Type: MCSA The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. His mother had preeclampsia. His respiratory rate is 80; he is grunting and has nasal flaring. What is the most likely cause of this infant’s condition?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate Correct Answer: 2 Rationale 1: There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome.

Rationale 2: The infant is term and born by cesarean. He is most likely experiencing transient tachypnea of the newborn.

Rationale 3: The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome.

Rationale 4: The infant is not premature. Prematurity alone does not cause respiratory distress; the lack of surfactant causes respiratory distress syndrome.

Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO02 - Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, and meconium aspiration syndrome) in the newborn and the nursing care related to each type.

Question 3 Type: MCSA A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which of the following data supports the nurse’s assessment?

1. Decreased urine output 2. Increased pulmonary vascular resistance 3. Increased PCO2 4. Increased urination Correct Answer: 4 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: As fluid moves out of the lungs and into the bloodstream, alveoli open, and kidney perfusion increases, thereby increasing urine output.

Rationale 2: Pulmonary vascular resistance increases with hypoxia.

Rationale 3: Increased PCO2 results from alveolar hypoventilation.

Rationale 4: Increased urination could be an indication that the newborn’s condition is improving.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, and meconium aspiration syndrome) in the newborn and the nursing care related to each type.

Question 4 Type: MCSA The nurse is caring for an infant who delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?

1. Vasoconstriction and pallor 2. Blood glucose level of 45 3. Room temperature IV running 4. Positioned under radiant warmer Correct Answer: 3 Rationale 1: Vasoconstriction is the first physiologic response to a lowering temperature and will cause pallor.

Rationale 2: This is an adequate blood sugar in a neonate. Less than 40 is hypoglycemic.

Rationale 3: IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room temperature IV fluids will increase the cold stress.

Rationale 4: Radiant warmers are used to gradually increase the neonate’s temperature.

Global Rationale: Cognitive Level: Analyzing Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03 - Discuss the types of metabolic abnormalities (cold stress and hypoglycemia), their effects on the newborn, and their nursing interventions.

Question 5 Type: SEQ Place the following nursing interventions related to resuscitation in the correct order according to complexity of the method and seriousness of the infant’s condition.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Chest compressions Choice 2. 21% oxygen in a positive-pressure ventilator Choice 3. Rub the infant’s back with a blanket.

Choice 4. Administer epinephrine.

Choice 5. 100% oxygen in a positive-pressure ventilator Correct Answer: 3,2,5,1,4 Rationale 1: Chest compressions should only be performed if the infant’s heart rate is below 60 beats/minute despite 30 seconds of effective positive-pressure ventilation.

Rationale 2: If rubbing the back does not establish adequate breathing, the infant should be placed on 21% oxygen with a positive-pressure ventilator.

Rationale 3: Rubbing the infant’s back is the least invasive therapy and should be attempted before any other resuscitation method.

Rationale 4: Epinephrine should be administered when the heart rate remains below 60 beats/minute despite 4560 seconds of chest compressions and ventilation.

Rationale 5: Oxygen should be increased from 21% to 100% before chest compressions begin.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO01 - Describe how to identify infants in need of resuscitation and the appropriate method of resuscitation based on the antepartum/labor record and physiologic indicators.

Question 6 Type: MCSA The patient with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. The best response by the nurse is: 1. “The RhoGAM you received at 28 weeks’ gestation did not prevent alloimmunization.”

2. “Your body has made antibodies against the baby’s blood that are destroying her red blood cells.”

3. ““The red blood cells of your baby are breaking down because you both have type O blood.”

4. “Your baby’s liver is too immature to eliminate the red blood cells that are no longer needed.”

Correct Answer: Rationale 1: Although this statement is true, the term “alloimmunization” is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology.

Rationale 2: This is a correct statement.

Rationale 3: Mother and baby’s both having type O blood is not a problem. ABO incompatibility occurs if the mother is O and the baby is A or B. Rationale 4: The infant’s liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Explain how Rh incompatibility or ABO incompatibility can lead to the development of hyperbilirubinemia.

Question 7 Type: MCSA The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates that she understands how to provide care for an infant undergoing intensive phototherapy?

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Urine-specific gravity is assessed each voiding.

2. Eye coverings are left off to help keep the baby calm.

3. Temperature is checked every six hours.

4. The infant is taken out of the isolette for diaper changes.

Correct Answer: 1 Rationale 1: This action is correct; urine concentration as indicated by raising urine-specific gravity indicates a need for additional fluids.

Rationale 2: Eyes should be covered at all times.

Rationale 3: Every six hours is too infrequent; the temperature should be assessed every four hours to prevent hyper- or hypothermia.

Rationale 4: The infant’s care should be clustered to keep the infant under the lights as much as possible. The diaper should have been changed while under the lights in the isolette.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Identify nursing responsibilities and rationale in caring for the newborn receiving phototherapy.

Question 8 Type: MCSA A diabetic mother has just given birth to a baby boy. The baby appears lethargic and has a high-pitched cry. The initial plasma glucose level was 19 mg/dL. What is the proper nursing action for this infant?

1. Wait 30 minutes and re-test plasma glucose levels.

2. Have the mother breastfeed the infant.

3. Start an IV with D5W dextrose solution.

4. Start an IV with D10W dextrose solution.

Correct Answer: 4

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: This infant is suffering from severe hypoglycemia. Aggressive treatment with D10W dextrose by IV is recommended.

Rationale 2: This is an appropriate nursing action if the infant’s plasma glucose levels are between 25 and 40 mg/dl. This infant needs more aggressive treatment.

Rationale 3: D5W dextrose is primarily use to either prevent hypoglycemia or titrate down the concentration of administered glucose when the infant is transitioning off the glucose. A higher concentration of glucose is required for severely hypoglycemic infants.

Rationale 4: This is the proper nursing action. Infants with severe hypoglycemia should be aggressively treated with IV infusion of D10W dextrose.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: L03 - Discuss the types of metabolic abnormalities (cold stress and hypoglycemia), their effects on the newborn, and their nursing implications.

Question 9 Type: MCSA A mother called the maternity ward four days after the birth of her baby girl. She tells the nurse that she has noticed her infant’s skin tone is yellow and asks if she should bring the infant to the hospital. What is the most likely cause of the infant’s skin tone?

1. Pathologic jaundice 2. Acute bilirubin encephalopathy 3. Physiologic jaundice 4. Hemolytic disease of the newborn Correct Answer: 3 Rationale 1: Pathologic jaundice usually appears before 24 hours of life and is the result of a more serious underlying condition.

Rationale 2: Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with physiologic jaundice.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Most infants will develop physiologic jaundice 4-5 days after birth as a result of a shortened red blood cell lifespan, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or poorly established hydration from initial breastfeeding.

Rationale 4: Hemolytic disease of the newborn occurs as a result of blood incompatibility between the mother and infant and is usually diagnosed shortly after birth.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Differentiate between physiologic and pathologic jaundice according to the timing of onset (in hours), cause, possible sequelae, and specific management.

Question 10 Type: MCSA The nurse assesses that a newborn’s skin has a ruddy appearance, and the peripheral pulses are decreased. The nurse suspects polycythemia. Which of the following lab reports might indicate polycythemia?

1. Venous hemoglobin level higher than 26 g/dL 2. Bilirubin level of 6 mg/dL 3. Venous hemoglobin level lower than 12 g/dL 4. Blood glucose level of 44 mg/dL Correct Answer: 1 Rationale 1: A venous hemoglobin level higher than 26 g/dL indicates polycythemia.

Rationale 2: Bilirubin level is within normal range.

Rationale 3: A venous hemoglobin level lower than 12 g/dL indicates anemia.

Rationale 4: Blood glucose levels are within normal range.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO07 - Describe the causes and nursing care management of infants with anemia and polycythemia.

Question 11 Type: MCSA The newborn has been diagnosed with sepsis. What indications would lead the nurse to suspect this condition?

1. Respiratory distress syndrome developed 48 hours after birth.

2. Temperature of 97.0°F two hours after warming the infant from 97.4°F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea develop when the infant is 36 hours old.

Correct Answer: 2 Rationale 1: Respiratory distress developing at 12–24 hours of age might indicate sepsis.

Rationale 2: Temperature instability is often seen with sepsis. Fever is rare in a newborn.

Rationale 3: Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if skin is cool and clammy.

Rationale 4: Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of life.

Global Rationale: Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO09 - Describe the nursing assessments that would lead the nurse to suspect newborn sepsis and the related nursing care of the newborn with an infection.

Question 12 Type: MCMA A 42-year-old mother was diagnosed with placenta previa, and her baby was delivered by cesarean section at 32 weeks. At birth, the infant has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds.

Which of the following interventions are needed?

Standard Text: Select all that apply.

1. Monitor the infant’s cardiac and respiratory status.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Have isotonic saline ready for transfusion.

3. Draw several vials of blood for laboratory testing.

4. Start the infant on iron supplements.

5. Have O-negative packed red cells ready for a transfusion.

6. Start the infant on phototherapy.

Correct Answer: 1,4,5 Rationale 1: This is an appropriate nursing intervention. Monitoring the infant’s cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment.

Rationale 2: Isotonic saline transfusion is used to treat polycythemia, not anemia. This treatment would worsen the patient’s condition.

Rationale 3: Blood draws should be kept to a minimum for patients suffering from anemia.

Rationale 4: Iron supplements should be given to help increase red blood cell production.

Rationale 5: Patients with severe anemia will need a blood transfusion. If the infant’s blood type is not known, Onegative packed red cells can be used for transfusions. If the infant’s blood type is known, the appropriate typed and crossmatched packed red cells should be used.

Rationale 6: Phototherapy should only be started if the infant has jaundice.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO07 - Describe the causes and nursing care management of infants with anemia and polycythemia.

Question 13 Type: MCSA One day after giving birth vaginally, a patient develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex II infection. The expected care for her neonate includes: 1. Meticulous hand washing and antibiotic eye ointment administration.

2. Intravenous acyclovir (Zovirax) and contact precautions.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. Cultures of blood and CSF and serial chest X-rays every 12 hours.

4. Parental rooming-in and four intramuscular injections of penicillin.

Correct Answer: 2 Rationale 1: Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or Chlamydia.

Rationale 2: These are appropriate cares for an infant at risk for developing herpes simplex II infection.

Rationale 3: These cultures are appropriate, but chest X-rays are not indicated. Chest X-rays are obtained if the neonate is thought to have group B strep pneumonia.

Rationale 4: Parental rooming-in is encouraged, but penicillin does not treat viral illness. Penicillin is the drug of choice for syphilis infections.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO10 - Relate the expected assessment findings of selected maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (HSV or CMV), and Chlamydia, to the nursing care management for each of the affected infants in the neonatal period.

Question 14 Type: MCSA The mother of a severely premature infant is being allowed to see her baby for the first time. The infant has an IV, a feeding tube, and is receiving phototherapy. He is also hooked up to cardiac and respiratory monitors. What information or instructions should the mother NOT receive before seeing her infant?

1. The mother should not touch her infant because the baby’s skin is fragile and could be easily hurt.

2. The mother should not hold the infant before thoroughly washing her hands.

3. The mother should be told what her infant will look like.

4. The mother should receive a description of the equipment that is hooked up to her child.

Correct Answer: 1 Rationale 1: Physical contact between the mother and infant will facilitate bonding and should be encouraged.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: If the mother is going to hold her infant, she will need to thoroughly wash her hands to decrease the risk of infection.

Rationale 3: The nurse should prepare the mother for what her infant will look like, especially if the infant is hooked up to several machines or tubes.

Rationale 4: Seeing her child for the first time can be emotionally difficult for a mother, but a description of the equipment and its purpose will help the mother understand the care her child is receiving and help ease her anxiety.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO11 - Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk infants.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 30 Question 1 Type: MCSA The nurse has received an end of shift report on the postpartum unit. Which patient should she see first?

1. Multip, second day post-cesarean, moderate lochia serosa 2. Primip, day of delivery, fundus firm 2 cm above umbilicus 3. Multip, first postpartum day, 4 cm diastasis recti abdominis 4. Primip, first postpartum day, hypoactive bowel sounds all quadrants Correct Answer: 2 Rationale 1: This patient is not experiencing any unexpected findings.

Rationale 2: This patient is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding.

Rationale 3: This finding is normal, especially in a multiparous patient.

Rationale 4: Bowel sounds are often decreased after delivery.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01 - Describe the basic physiologic changes that occur in the postpartum period as a woman’s body returns to its pre-pregnant state, and the related nursing care.

Question 2 Type: MCSA The nurse expects an initial weight loss for the average postpartum patient to be: 1. 5–8 pounds.

2. 10–12 pounds.

3. 12-15 pounds.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. 15–20 pounds.

Correct Answer: 2 Rationale 1: 5–8 pounds might be the loss after a preterm birth.

Rationale 2: 10–12 pounds is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid.

Rationale 3: 12–15 pounds is close, but it does not match the usual weight of placenta, amniotic fluid, and fullterm infant weight.

Rationale 4: 15–20 pounds might be the loss from a multiple birth.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe the basic physiologic changes that occur in the postpartum period as a woman’s body returns to its pre-pregnant state, and the related nursing care.

Question 3 Type: MCSA To assess healing of the uterus at the placental site, the nurse assesses: 1. Lab values.

2. Blood pressure.

3. Uterine size.

4. Type, amount, and consistency of lochia.

Correct Answer: 4 Rationale 1: Lab values is incomplete as an answer because it does not indicate which lab values are in question.

Rationale 2: Blood pressure varies slightly in the normal postpartum woman and would not affect the placental site.

Rationale 3: Uterine size alone is not enough to assess the placenta site.

Rationale 4: Type, amount, and consistency of lochia determine the stage of healing of the placenta site, which occurs by a process of exfoliation.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO01 - Describe the basic physiologic changes that occur in the postpartum period as a woman’s body returns to its pre-pregnant state, and the related nursing care.

Question 4 Type: MCSA A Jewish patient delivers a healthy baby boy on Thursday afternoon, and she is set to be discharged on Saturday morning. Why might this present a problem for the patient?

1. Jewish custom is to have the infant circumcised two days after birth.

2. The woman will expect to be in the hospital at least seven days after delivery.

3. Saturday is considered the Sabbath and she will not be able to leave the hospital that day.

4. The husband cannot touch his wife while she is experiencing vaginal discharge, so he will not be able to assist his wife to and from the vehicle.

Correct Answer: 3 Rationale 1: Jewish custom is to have the infant circumcised eight days after birth, not two days after birth.

Jewish couples will need to return to the hospital for circumcision of the infant after discharge.

Rationale 2: The woman will expect to be cared for by her family for the first seven days after delivery. This does not need to take place in the hospital and should not interfere with discharge from the hospital.

Rationale 3: The Sabbath is sacred for Jews, and Jewish custom prohibits travel, writing, and the use of electricity on the Sabbath. Therefore, the woman will not travel home or sign any discharge forms until after the Sabbath.

Rationale 4: If the patient had a normal delivery and healthy baby, she will be able to walk on her own. Therefore, this would not interfere with the woman’s discharge from the hospital.

Global Rationale: Cognitive Level: Understanding Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO03 - Explain the impact of cultural influence on providing nursing care during the postpartum period.

Question 5 Type: MCSA On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be due to: 1. The taking-hold phase.

2. Postpartum hemorrhage.

3. The taking-in phase.

4. Epidural anesthesia Correct Answer: 3 Rationale 1: The taking-hold phase occurs by the second or third day, when the mother is ready to resume control of life and is open to teaching.

Rationale 2: Postpartum hemorrhage is a serious complication and will need medical intervention.

Rationale 3: The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest.

Rationale 4: Epidural anesthesia is a pharmacological approach to pain control.

Global Rationale: Cognitive Level: Understanding Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO02 - Describe the psychologic adjustments that normally occur during the postpartum period and the related nursing care and support.

Question 6 Type: MCMA The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this patient?

Standard Text: Select all that apply.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Be sure she gets a kosher diet.

2. Expect that most visitors will be women.

3. Uncover only the necessary skin when assessing.

4. The patient will avoid cold air and water after birth.

5. She will prefer a male physician.

Correct Answer: 2,3 Rationale 1: A kosher diet is appropriate for Jewish women, not Muslims. Although many of the dietary laws are similar, kosher is not appropriate for a Muslim patient.

Rationale 2: This is true because women are not in the company of men to whom they are not married whenever possible.

Rationale 3: Modesty is very important to Muslims. Use the bed covers to drape the patient while performing the postpartum assessment.

Rationale 4: Hispanic, African, and Asian women are likely to avoid cold air and water after delivery, but Muslim women do not follow this same belief.

Rationale 5: Because of modesty and the restrictions against touching and being touched by males who are not the spouse, most Muslim women highly prefer female care providers.

Global Rationale: Cognitive Level: Understanding Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03 - Explain the impact of cultural influence in providing nursing care during the postpartum period.

Question 7 Type: MCSA The nurse is observing a new graduate’s assessment of a postpartum patient. Which action by the student nurse should prompt a corrective intervention by the preceptor nurse?

1. Ask the patient to void, and don clean gloves.

2. Discussing the effectiveness of patient comfort measures while performing the perineal assessment.

3. Instructing the patient’s visitors to leave the room prior to beginning the assessment.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

4. Requesting that the patient lie flat in bed with her head on a pillow prior to the fundal assessment.

Correct Answer: Rationale 1: Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids.

Rationale 2: The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures.

Rationale 3: The nurse should allow the patient to choose whether visitors leave or remain in the room during the assessment.

Rationale 4: The supine position prevents a falsely high assessment of fundal height.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Differentiate the physiologic and psychologic components of a systematic normal postpartum assessment.

Question 8 Type: SEQ Put the following components specific to postpartum examination of a patient in the proper sequential order.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. L-lochia Choice 2. E-emotional Choice 3. H-Homans’/hemorrhoids Choice 4. B-breast Choice 5. E-episiotomy/laceration/edema Choice 6. U-uterus Choice 7. B-bowel Choice 8. B-bladder Correct Answer: 4,6,8,7,1,5,3,2 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Rationale 6: Rationale 7: Rationale 8: Global Rationale: The components for remembering the sequential order are based on the mnemonic BUBBLEHE. Start at the head and consistently assess each part using the same technique and order.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO04 - Differentiate the physiologic and psychologic components of a systematic normal postpartum assessment.

Question 9 Type: MCSA The nurse is performing a postpartum assessment on a newly delivered patient. When checking the fundus, there is a gush of blood. The patient asks why that is happening. The best response is: 1. “We see this from time to time. It’s not a big deal.”

2. “The gush is an indication that your fundus isn’t contracting.”

3. “Don’t worry. I’ll make sure everything is fine.”

4. “Blood has pooled in the vagina while you were in bed.”

Correct Answer: 4 Rationale 1: Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not answer the patient’s question.

Rationale 2: The fundus might be contracting well. The gush is from pooled lochia in the vagina.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: This response is not therapeutic because it focuses on the nurse and has a “don’t worry” aspect that most patients find demeaning.

Rationale 4: Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semi-sitting in bed, which leads to a gush when fundal massage is undertaken.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO05 - Describe the normal characteristics and common concerns of the mother considered in a postpartum assessment.

Question 10 Type: MCSA The postpartum nurse is caring for a first-time mother who is unable to breastfeed her baby. While assessing the patient’s breasts the day after birth, which teaching point should the nurse include?

1. The let-down reflex 2. Lactation suppression 3. The purpose of fundal massage 4. The cause of afterpains Correct Answer: 2 Rationale 1: The let-down reflex is an important teaching point for breastfeeding patients.

Rationale 2: It is important to teach non-breastfeeding patients about lactation suppression after delivery but before discharge.

Rationale 3: The purpose of fundal massage should be addressed when assessing the uterus and fundus, not when assessing the breasts.

Rationale 4: Afterpains can be stimulated by breastfeeding, and they are more common in multiparas. Therefore, the nurse will likely not need to teach a non-breastfeeding primipara about afterpains.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03 - Explain the impact of cultural influence on providing nursing care during the postpartum period.

LO05 - Describe the normal characteristics and common concerns of the mother considered in a postpartum assessment.

Question 11 Type: MCSA Every time the nurse enters the room of a postpartum patient who gave birth three hours ago, the patient asks something else about her birth experience. The nurse would: 1. Answer questions quickly and try to divert her attention to other subjects.

2. Review documentation of the birth experience and discuss it with her.

3. Contact the physician to warn him the patient might want to file a lawsuit due to her preoccupation with her birth experience.

4. Submit a referral to Social Services because you are concerned about obsessive behavior.

Correct Answer: 2 Rationale 1: Answering questions quickly and trying to divert her attention to other subjects trivializes her questions and does not allow her to sort out the reality from her subjective experience.

Rationale 2: Review documentation of the birth experience and discuss it with her so the patient can integrate the experience. Three hours after birth, the mother needs to talk about her perceptions of her labor and delivery.

Rationale 3: Contacting the physician to warn him that the patient might want to file a lawsuit due to her preoccupation with her birth experiences is not warranted.

Rationale 4: Submitting a referral to Social Services because you are concerned about obsessive behavior is an incorrect action because this behavior is normal.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02 - Describe the psychologic adjustments that normally occur during the postpartum period and the related nursing care and support.

Question 12 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

During her interactions with a primipara mother, the nurse notices that the mother rarely interacts with the infant unless the infant begins to cry vigorously. She appears relieved when a nurse comes to check on the infant. What is the appropriate nursing intervention for this patient?

1. Ask the mother if she has previous experience caring for babies, and then teach her how to interact appropriately with her infant.

2. Contact Social Services with concerns of neglect.

3. Provide the care the infant needs while continuing to evaluate the mother’s actions.

4. Take the infant to the nursery so it can receive more consistent care.

Correct Answer: 1 Rationale 1: Many primipara mothers will be hesitant to care for the infant because they feel inadequate. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention.

Rationale 2: The mother may only need some education on how to care for her infant. If the nurse consistently teaches the mother and encourages mother-infant interaction and the mother continues to ignore the child, then it may be appropriate to contact Social Services in extreme circumstances.

Rationale 3: While this action does provide for the needs of the child while he or she is in the hospital, it does not help the mother know how to care for her child once she returns home.

Rationale 4: Instead of encouraging mother-infant bonding, this action may emotionally distance the mother from her child even more. It may also confirm the mother’s feelings of inadequacy.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO06 - Examine the physical and developmental tasks that the mother must accomplish during the postpartum period.

Question 13 Type: MCSA During the first several months after birth, the mother and infant begin to know each other. This relationship progresses through several phases. Which of the following actions are to be expected in the phase of mutual regulation?

1. The infant grasps his or her mother’s finger while nursing.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. The infant begins to seek out the mother over other individuals.

3. The mother spends more time making eye-to-eye contact with the infant.

4. The mother vocalizes feelings of frustration with her infant.

Correct Answer: 4 Rationale 1: Actions that make the infant more attractive to the mother, such as grasping a finger, usually occurs during the acquaintance phase.

Rationale 2: When the relationship between mother and infant reaches reciprocity, the infant will seek to interact with the mother more.

Rationale 3: Holding the infant in the en face position is likely to occur most often in the acquaintance phase.

Rationale 4: The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

Question 14 Type: MCSA The nurse is to begin the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?

1. Describe the likely reaction of siblings to the new baby.

2. Discuss adaptation to grandparenthood by her parents.

3. Determine if father–infant attachment is taking place.

4. Assist the mother in identifying behavior cues of the baby.

Correct Answer: 4 Rationale 1: This is not appropriate because the baby has no siblings.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 2: Adaptation to grandparenthood is a task for her parents and not a high priority for teaching to the new mother.

Rationale 3: Although father–infant attachment is important, the mother is the main patient, and teaching her directly is a higher priority.

Rationale 4: Helping the mother to identify her baby’s behavior cues facilitates the acquaintance phase of maternal–infant attachment.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06 - Examine the physical and developmental tasks that the mother must accomplish during the postpartum period.

Question 15 Type: MCSA The nurse is performing an assessment of early attachment. During the assessment, the nurse needs to answer the question “Does the mother seem pleased with her baby’s appearance and sex?” Which action of the mother might help answer this question?

1. The mother enfolds the infant in her arms.

2. The mother feeds the infant every 2-3 hours as instructed.

3. The mother points out family traits she sees in the newborn.

4. The mother asks questions about how to properly bathe her infant.

Correct Answer: 3 Rationale 1: This action can be used to assess if the mother is attracted to her newborn and is forming emotional attachments with the newborn.

Rationale 2: This action can be used to assess the ability of the mother to care for the infant’s needs as they arise.

Rationale 3: This action will help determine if the mother is pleased with her baby’s appearance. She may point out both positive and negative traits.

Rationale 4: This action helps assess the mother’s willingness to learn how to care for her infant.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO07 - Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 31 Question 1 Type: MCSA The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 FB ↓ U, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1–10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this patient?

1. Acute pain related to perineal trauma 2. Risk for deficient fluid volume related to uterine bleeding and nausea 3. Readiness for enhanced family coping 4. Knowledge deficit related to newborn care Correct Answer: 2 Rationale 1: Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit.

Rationale 2: Adequate fluid volume is a critical Physiological need; therefore, this is the highest-priority nursing diagnosis.

Rationale 3: Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit.

Rationale 4: Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the Physiological need for adequate fluid volume.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO01: Formulate nursing diagnoses and nursing care based on the findings of the “normal” postpartum assessment.

Question 2 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

During a home care visit, the new mother complains of breast engorgement. Which intervention is most appropriate for recommendation by the home care nurse?

1. “Apply an ice compress to your breast before nursing.”

2. “Encourage your baby to suckle for an average of 5 minutes per feeding.”

3. “Apply warm compresses to your breast after you finish feeding your baby.”

4. “When you aren’t nursing, wear a well-fitted nursing bra at all times, even when you sleep.”

Correct Answer: 4 Rationale 1: Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother.

Rationale 2: For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours.

Rationale 3: Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother.

Rationale 4: The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO11: Delineate interventions to address the common concerns of breastfeeding mothers following discharge.

Question 3 Type: MCSA The postpartum patient delivered 4 hours ago. She has a mediolateral episiotomy and large hemorrhoids. She is rating her pain at 7 on a scale of 1–10. She has a history of anaphylactic reaction to Tylenol (acetaminophen).

Which nursing action would be best?

1. Offer the patient 800 mg Advil (ibuprofen) orally with food.

2. Provide two Percocet (oxycodone with acetaminophen) by mouth.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

3. Encourage use of Dermoplast topical anesthetic spray.

4. Run very warm water into the tub and assist her into the bath.

Correct Answer: 1 Rationale 1: This is the best option, because the patient is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief.

Rationale 2: This medication is contraindicated because of the patient’s allergic reaction to acetaminophen.

Rationale 3: Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a patient has moderately severe pain.

Rationale 4: Ice packs would be better at this stage, because they will cause vasoconstriction to reduce edema and pain relief.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO02: Discuss nursing interventions to promote postpartum maternal comfort, rest, and well-being.

Question 4 Type: MCSA On the second day postpartum, the patient experiences engorgement. To relieve her discomfort, the nurse should encourage the patient to: 1. Remove her bra.

2. Apply heat to her breasts.

3. Apply ice packs to her breasts.

4. Limit breastfeeding to twice daily.

Correct Answer: 3 Rationale 1: Removing her bra will only serve to increase breast milk production.

Rationale 2: Applying heat will promote breast milk production.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 3: Applying ice packs to the breasts relieves discomfort through the numbing effect of ice.

Rationale 4: Limiting breastfeeding to b.i.d. actually would decrease the flow of breast milk eventually, and would not serve to decrease the discomfort of mother or infant.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02: Discuss nursing interventions to promote postpartum maternal comfort, rest, and well-being.

Question 5 Type: MCMA The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time?

Standard Text: Select all that apply.

1. Administer analgesics as needed.

2. Encourage the patient to ambulate to the bathroom to void.

3. Encourage leg exercises every 2 hours.

4. Encourage the patient to cough and deep-breathe every 2–4 hours.

5. Encourage the use of breathing, relaxation, and distraction.

Correct Answer: 1,3,4,5 Rationale 1: Administering analgesics as needed, encouraging leg exercises every 2 hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient’s nursing care needs, which are similar to those of other surgical patients.

Rationale 2: Encouraging her to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours.

Rationale 3: Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient’s nursing care needs, which are similar to those of other surgical patients.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient’s nursing care needs, which are similar to those of other surgical patients.

Rationale 5: Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient’s nursing care needs, which are similar to those of other surgical patients.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02: Discuss nursing interventions to promote postpartum maternal comfort, rest, and well-being.

Question 6 Type: MCSA The community health nurse is presenting a seminar to new mothers about breastfeeding. When discussing weaning, which new mother’s statement suggests a need for further teaching?

1. “Slow weaning should take place over a period of several months.”

2. “By weaning my baby slowly, I’m giving him time to change his eating method at his own pace.”

3. “If I wean my baby slowly, I am less likely to develop breast engorgement.”

4. “Slowly weaning my baby is recommended to allow time for psychological adjustment.”

Correct Answer: 1 Rationale 1: During slow weaning, over a period of several weeks the mother substitutes more cup feedings or bottle feedings for breastfeedings.

Rationale 2: The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychological adjustment.

Rationale 3: The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychological adjustment.

Rationale 4: The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychological adjustment.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO11: Delineate interventions to address the common concerns of breastfeeding mothers following discharge.

Question 7 Type: MCSA The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness?

1. Normal newborn nursery centrally located to all patient rooms 2. A kitchen with refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a patient bed and rocking chair 4. A nursing model based on providing couplet care Correct Answer: 4 Rationale 1: Rooming-in better promotes family wellness than does having newborns in the nursery.

Rationale 2: Although having snacks is good for postpartum patients, some cultures prohibit drinking cold liquids after birth; warm liquids must also be available for optimal family wellness.

Rationale 3: Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better.

Rationale 4: Couplet care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03: Explain factors that affect postpartum family wellness in the provision of nursing care and patient teaching.

Question 8 Type: MCSA Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The patient having her second child is scheduled for a cesarean birth because the baby is in a breech presentation.

The patient states, “I’m wondering what will be different this time compared with my first birth, which was vaginal.” What response is best?

1. “We’ll take good care of you and your baby. You’ll be home before you know it.”

2. “You’ll be wearing long stockings to prevent blood clots from forming in your legs.”

3. “You will have a lot of pain, but there are medications that we give when it gets bad.”

4. “You won’t be able to nurse until the baby is 12 hours old, because of your epidural.”

Correct Answer: 2 Rationale 1: This response focuses on the nurse, and does not provide specific information to answer the patient’s question. This is a poor response.

Rationale 2: Anti-embolism stockings are used until the patient is up and walking to prevent thrombus formation.

Rationale 3: Focusing on the pain is a negative emphasis. In addition, pain medications work best when they are taken as the pain is intensifying; medication should not be delayed until the pain is severe, as less relief will be obtained.

Rationale 4: Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother’s ability to breastfeed. She might need some assistance with positioning the infant due to bed rest, but should be encouraged to breastfeed as soon as possible.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04: Compare the postpartum nursing needs of the woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally.

Question 9 Type: MCMA The nurse is caring for a patient who delivered by cesarean birth. The patient received a general anesthetic. The nurse would encourage which of the following in order to prevent or minimize abdominal distention?

Standard Text: Select all that apply.

1. Increased intake of cold beverages Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Leg exercises every 2 hours 3. Abdominal tightening 4. Ambulation 5. Eating a high-protein general diet Correct Answer: 2,3,4 Rationale 1: Increased intake of cold beverages and eating a high-protein general diet would increase the distention through increase of gas and constipation.

Rationale 2: Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or minimize abdominal distention in a surgical patient who received a general anesthetic.

Rationale 3: Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or minimize abdominal distention in a surgical patient who received a general anesthetic.

Rationale 4: Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or minimize abdominal distention in a surgical patient who received a general anesthetic.

Rationale 5: Increased intake of cold beverages and eating a high-protein general diet would increase the distention through increase of gas and constipation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO04: Compare the postpartum nursing needs of the woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally.

Question 10 Type: MCSA The nurse is caring for a 15-year-old patient that gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?

1. The patient’s mother is included in all discussions and demonstrations.

2. The father of the baby is encouraged to change a diaper and give a bottle.

3. The nurse explains the characteristics and cues of the baby during the assessment.

4. A discussion on contraceptive methods is the first topic of teaching.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 3 Rationale 1: Although the parents of adolescents are often involved with child care and childrearing, this action is only appropriate if the patient desires to have her mother present for teaching and discussions.

Rationale 2: Involvement of the father is important, but having the mother learn more about her new baby and what the behavior cues are is a higher priority.

Rationale 3: This helps the patient learn about her baby and understand him as an individual, and facilitates maternal–infant attachment. This is the highest priority.

Rationale 4: Young teens are statistically more likely to have another child during their adolescence, but establishing a rapport and facilitating understanding of and attachment to the newborn is a higher priority.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO05: Examine the nursing needs of the childbearing adolescent during the postpartum period.

Question 11 Type: MCSA The nurse is preparing to receive a newly delivered patient. The patient is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?

1. Assign the patient a room on the GYN surgical floor instead of the postpartum floor.

2. Prepare to have teaching done in time for discharging the patient at 24 hours postdelivery.

3. Make an effort to not bring up the topic of the baby, and discuss the mother’s health instead.

4. Ask the patient if she wants to feed her baby, and how much contact she wants to have.

Correct Answer: 4 Rationale 1: Patients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead.

Rationale 2: Not all patients who relinquish their infants want early discharge. Make no assumptions, but assess instead.

Rationale 3: The patient’s preferences determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: Assess the patient’s preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother.

Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO06: Describe possible approaches to sensitive, holistic nursing care for the woman who relinquishes her newborn.

Question 12 Type: MCMA The nurse is caring for a patient who plans to relinquish her baby for adoption. The nurse would implement which of the following approaches to care?

Standard Text: Select all that apply.

1. Encourage the patient to see and hold her infant.

2. Encourage the patient to express her emotions.

3. Respect any special requests for the birth.

4. Acknowledge the grieving process in the patient.

5. Allow for access to the infant if the patient requests it.

Correct Answer: 2,3,4,5 Rationale 1: Encouraging the patient to see and hold her infant does not respect the patient’s right to refuse interaction, and might make her feel guilty for not wanting to see the infant.

Rationale 2: Encouraging the patient to express emotions, respecting any special request for the birth, acknowledging the grieving process, and allowing for access to the infant at patient’s requests all are aspects of providing care for the patient who decides to relinquish her infant.

Rationale 3: Encouraging the patient to express emotions, respecting any special request for the birth, acknowledging the grieving process, and allowing for access to the infant at patient’s requests all are aspects of providing care for the patient who decides to relinquish her infant.

Rationale 4: Encouraging the patient to express emotions, respecting any special request for the birth, acknowledging the grieving process, and allowing for access to the infant at patient’s requests all are aspects of providing care for the patient who decides to relinquish her infant.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 5: Encouraging the patient to express emotions, respecting any special request for the birth, acknowledging the grieving process, and allowing for access to the infant at patient’s requests all are aspects of providing care for the patient who decides to relinquish her infant.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO06: Describe possible approaches to sensitive, holistic nursing care for the woman who relinquishes her newborn.

Question 13 Type: MCSA The maternal home care nurse is orienting a new nurse. During orientation, they are discussing maternal psychological adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal patients?

1. “Because emotional disorders and imbalances are a very sensitive subject, we try not to offend patients by routinely bringing up the topic of postpartum depression.”

2. “For women with a history of depression, we include education about postpartum depression.”

3. “Teaching about postpartum depression is a routine part of education for all maternal patients.”

4. “If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic.”

Correct Answer: 3 Rationale 1: Teaching content should include information on role changes and psychological adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

Rationale 2: Teaching content should include information on role changes and psychological adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

Rationale 3: Teaching content should include information on role changes and psychological adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

Rationale 4: Teaching content should include information on role changes and psychological adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

Global Rationale: Cognitive Level: Analyzing Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO03: Explain factors that affect postpartum family wellness in the provision of nursing care and patient teaching Question 14 Type: MCSA During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate?

1. “Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychological approach to family bonding.

2. “Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on his stomach.”

3. “Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines.”

4. “If you practice cosleeping, your baby should be placed on a comforter, as opposed to directly on the mattress.”

Correct Answer: 3 Rationale 1: The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety guidelines.

Rationale 2: The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Families who practice cosleeping require appropriate teaching measures, which include following safety guidelines such as making sure the baby is sleeping on his or her back.

Rationale 3: The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures.

Cosleeping families should be counseled to follow specific safety guidelines Rationale 4: Safety guidelines related to cosleeping include placing the infant on a firm mattress, never on comforters, pillows, or a waterbed.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO12: Describe the assessment and care of the newborn during postpartum home care.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Chapter 32 Question 1 Type: MCMA The nurse is preparing a community education class on healthy pregnancy. Which statements should be included?

Standard Text: Select all that apply.

1. Eating a well-balanced diet helps prevent pregnancy complications.

2. Stress management and support systems are important in pregnancy.

3. Prenatal care can be obtained at any point in the pregnancy.

4. Complications during a prior pregnancy do not recur.

5. Exercising regularly facilitates feeling better in pregnancy.

Correct Answer: 1,2,5 Rationale 1: Good overall nutrition helps reduce the incidence of many pregnancy complications, including anemia, preterm labor, and delivery complications such as shoulder dystocia.

Rationale 2: Patients with high stress levels and poor support systems are more likely to develop postpartum depression and have problems parenting.

Rationale 3: Early and regular prenatal care is important to provide education that can help prevent complications, and to detect complications as they develop.

Rationale 4: Many complications of pregnancy have a tendency to recur, including postpartum hemorrhage, postpartum depression, preterm labor, and premature rupture of membranes.

Rationale 5: Regular exercise during pregnancy helps prevent hypertension and gestational diabetes, helps reduce length of labor, and helps patients feel good.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: LO01: Identify the nurse’s impact in both the hospital and community-based settings in assessing predisposing factors of postpartum complications, implementing preventive care, and teaching for selfhelp.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Question 2 Type: MCSA A patient is 3 days postop from a cesarean birth. She has tenderness, localized heat, and redness of the left leg.

She is afebrile. As a result of these symptoms, she most likely will be: 1. Encouraged to ambulate freely.

2. Given aspirin 650 mg by mouth.

3. Given Methergine IM. 4. Placed on bed rest.

Correct Answer: 4 Rationale 1: That would increase the inflammation.

Rationale 2: Aspirin 650 mg by mouth has anticoagulant properties, but usually is not necessary unless complications occur.

Rationale 3: Methergine is given only for postpartum hemorrhage, and would only cause vasoconstriction of an already inflamed vessel.

Rationale 4: These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest and elevation of the affected limb, analgesics, and use of elastic support hose.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO01: Identify the nurse’s impact in both the hospital and community-based settings in assessing predisposing factors of postpartum complications, implementing preventive care, and teaching for selfhelp.

Question 3 Type: MCSA The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago.

When the patient stands up, blood runs down her legs and pools on the floor. The patient turns pale and feels weak. The first action of the nurse is to: 1. Assist the patient to empty her bladder.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

2. Help the patient back to bed to check her fundus.

3. Assess her blood pressure and pulse.

4. Begin an IV of Lactated Ringer’s infusion.

Correct Answer: 2 Rationale 1: The patient might be experiencing a postpartum hemorrhage. Her fundus is not contracting well.

Although this might be due to a full bladder, the best first step is to massage the fundus.

Rationale 2: Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss.

Rationale 3: Massaging the fundus is the top priority because of the excessive blood loss. Blood pressure and pulse do not change until 1000–2000 ml of blood has been lost. Massaging the fundus will prevent further blood loss.

Rationale 4: Massaging the fundus is the top priority because of the excessive blood loss. An IV might need to be started if the patient becomes symptomatic.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02: Explain the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late postpartum hemorrhage.

Question 4 Type: MCMA A patient is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications?

Standard Text: Select all that apply.

1. Methergine 2. Stadol 3. Misoprostol 4. Betamethasone Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Correct Answer: 1,3 Rationale 1: Methergine is a drug of choice for postpartum hemorrhage.

Rationale 2: Stadol is an analgesic, and is not used for postpartum hemorrhage.

Rationale 3: Misoprostol is commonly administered rectally for postpartum hemorrhage.

Rationale 4: Betamethasone is a glucocorticoid used for preterm labor in an attempt to decrease respiratory distress in the preterm infant.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO02: Explain the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late postpartum hemorrhage.

Question 5 Type: MCSA The postpartum patient who delivered 2 days ago has developed endometritis. Which charting entry would the nurse expect to find in this patient’s chart?

1. “Cesarean birth performed secondary to arrest of dilation.”

2. “Rupture of membranes occurred 2 hours prior to delivery.”

3. “External fetal monitoring used throughout labor.”

4. “Patient has history of pregnancy-induced hypertension.”

Correct Answer: 1 Rationale 1: Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical exams necessary to assess for arrest of dilation are another risk factor for postpartum infection.

Rationale 2: Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum endometritis.

Rationale 3: Internal fetal monitoring (both internal fetal scalp electrode and intrauterine pressure catheter) are risk factors for postpartum endometritis.

Rationale 4: Pregnancy-induced hypertension is not a risk factor for development of postpartum endometritis.

Global Rationale: Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 6 Type: MCSA The patient at 3 days postpartum has come to the maternity clinic with complaints of urinary urgency and dysuria.

Which statement is most important for the nurse to make?

1. “Void into this sterile cup without touching the inside of the cup.”

2. “Be sure to wipe from back to front after you have a bowel movement.”

3. “Call the clinic if you develop nausea and vomiting or constipation.”

4. “Decrease your fluid intake for a few days, but eat a lot of vegetables.”

Correct Answer: 1 Rationale 1: A clean-catch urine sample will need to be obtained for urinalysis to determine if the patient has developed a urinary tract infection.

Rationale 2: Patients should be taught to wipe from front to back after bowel movements in order to prevent contamination of the urethra and bladder with normal bowel flora.

Rationale 3: A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever and flank pain. Constipation is not associated with urinary tract infections.

Rationale 4: Patients should increase their fluid intake but decrease their consumption of carbonated beverages.

Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables do not help clear or prevent urinary tract infections.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 7 Type: MCSA Which method of initial assessment would best indicate whether a patient has a urinary complication?

1. Urine pH 2. Calculation of urine output 3. Urine-specific gravity 4. Calculation of intake Correct Answer: 2 Rationale 1: Urine pH and urine-specific gravity can be used to identify certain conditions, but would not be part of the initial assessment.

Rationale 2: Calculation of output would provide a better assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection.

Rationale 3: Urine pH and urine-specific gravity can be used to identify certain conditions, but would not be part of the initial assessment.

Rationale 4: Monitoring intake is an intervention that may help prevent urinary complications but calculating the intake itself would not indicate a complication.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 8 Type: MCSA

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

The postpartum multipara is breastfeeding her new baby. The patient states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. The best response of the nurse is: 1. “Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple to unblock that duct.”

2. “Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again.”

3. “Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area.”

4. “Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe.”

Correct Answer: 1 Rationale 1: A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis.

Rationale 2: It is not unusual for mothers to develop complications similar to those experienced in prior pregnancies.

Rationale 3: Warm packs, not cold packs, should be applied to areas that are warm, red, or hardened.

Rationale 4: The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for catching early onset of the infection. Massaging the area to unplug the duct and relieve milk stasis is much more effective.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 9 Type: MCMA A nurse suspects that a postpartum patient has mastitis. The following assessment provides what data to support this assessment?

Standard Text: Select all that apply.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

1. Shooting pain in her nipple during breastfeeding.

2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple.

4. Nipple soreness when the infant latches on.

Correct Answer: 1,2,3 Rationale 1: Mastitis is characterized by late-onset nipple pain, followed by shooting pain during and between feedings.

Rationale 2: Mastitis is characterized by late-onset nipple pain, followed by shooting pain during and between feedings.

Rationale 3: The skin of the affected breast becomes pink, flaking, and pruritic.

Rationale 4: Nipple soreness, engorgement, and the letdown reflex do not share these symptoms.

Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 10 Type: MCSA The postpartum patient has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? The patient: 1. The postpartum patient has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? The patient: 2. Develops pain and swelling in her left lower leg.

3. Appears anxious, and describes pressure in her chest.

4. Becomes upset that she can’t go home yet.

Correct Answer: 3 Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 1: This is a risk factor for the development of thrombophlebitis, but neither a predictor nor an indication of complications.

Rationale 2: Development of bilateral thrombophlebitis is a complication, but not the top priority.

Rationale 3: Anxiety and sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention.

Rationale 4: Although the nurse provides patient care with the aim of keeping patients satisfied and comfortable, becoming upset is a psychosocial issue, and far less important than development of a pulmonary embolus.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 11 Type: MCSA The nurse is revising the care plan of a 26-year-old woman who has developed mastitis. Which nursing diagnosis is most appropriate for inclusion in this patient’s updated plan of care?

1. Ineffective Peripheral Tissue Perfusion related to obstructed venous return 2. Risk for Trauma related to lack of information about appropriate breastfeeding practices.

3. Deficient Knowledge related to self-care after discharge on anticoagulant therapy 4. Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction Correct Answer: 2 Rationale 1: In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices.

Rationale 2: In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices.

Rationale 3: In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Rationale 4: In relation to the patient’s mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: LO 03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 12 Type: MCSA The nurse is calling postpartum patients. Which patient should be seen immediately? The patient at 4 weeks postpartum who: 1. Describes feeling sad all the time.

2. Reports hearing voices talking about the baby.

3. States she has no appetite and wants to sleep all day.

4. Says she needs a refill on her sertraline (Zoloft) next week.

Correct Answer: 2 Rationale 1: While this may indicate postpartum blues or postpartum depression, and is not the highest priority.

Rationale 2: This is an indication the patient is experiencing postpartum psychosis, and is the highest priority, because the voices might tell her to harm her baby.

Rationale 3: This is an indication the patient is experiencing may be experiencing postpartum depression, but is not the highest priority.

Rationale 4: A patient on medications needs refills on time, but right now she has medication, and therefore is not a high priority.

Global Rationale: Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Question 13 Type: MCSA The maternal nurse educator is conducting a presentation for antepartum patients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in her teaching content?

1. Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized by mild depression interspersed with happier feelings.

2. Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks.

3. Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum.

4. Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror.

Correct Answer: 3 Rationale 1: As many as 50% to 70% of mothers develop adjustment reaction with depressed mood, which is also known as postpartum blues, or as maternal or baby blues. Unlike postpartum depression, this condition is characterized by mild depression interspersed with happier feelings.

Rationale 2: Postpartum blues typically manifest as mild symptoms that are transient and self-limiting.

Postpartum depression is severe and poses major threats to the woman and the infant, as well as to the father/partner.

Rationale 3: Women with a history of postpartum psychosis or depression or other risk factors should be referred to a mental health professional for counseling and biweekly visits between the second and sixth week postpartum for evaluation.

Rationale 4: Post-traumatic stress disorder or PTSD (also called post-traumatic stress syndrome) is associated with exposure to an extremely traumatic event involving direct personal experience with actual or threatened death or serious injury, and evokes a reaction of intense fear, helplessness, or horror.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.

Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder Question 14 Type: MCSA The charge nurse is reviewing the plan of care for maternal patients currently admitted for postpartum care.

During the course of her chart review, which intervention requires immediate consideration for revision?

1. Daily prothrombin time (PT) measurements for coagulation assessment in a woman receiving heparin for treatment of thrombophlebitis.

2. Use of the REEDA scale for assessment every 8 hours in the care of a patient diagnosed with puerperal infection.

3. Misoprostol (Cytotec) administration to a patient who demonstrates uterine atony and bleeding after receiving oxytocic medications.

4. Inserting a straight catheter to drain the overdistended bladder of a woman during the early postpartum period of her care.

Correct Answer: 1 Rationale 1: Prothrombin time (PT) evaluates the anticoagulation effects of Coumadin; the effects of heparin are assessed by way of activated partial thromboplastin time (aPTT).

Rationale 2: The nurse should inspect the woman’s perineum every 8 to 12 hours for signs of early infection. The REEDA scale helps the nurse remember to consider redness, edema, ecchymosis, discharge, and approximation.

Rationale 3: Misoprostol (Cytotec) is used to prevent and treat uterine atony after failed attempts to control bleeding with oxytocics.

Rationale 4: Overdistention in the early postpartum period is often managed by draining the bladder with a straight catheter as a one-time measure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: LO03: Develop a nursing care plan that reflects the etiology, pathophysiology, current clinical therapy, nursing management, and preventive management for the woman with reproductive tract infection, urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

Ladewig, Contemporary Maternal-Newborn Nursing, 8/E Test Bank Copyright 2014 by Pearson Education, Inc.