TEST BANK MATERNAL- NEWBORNNURSING THE CRITICAL COMPONENTS OF NURSING CARE, 3RD EDITION, ROBERTA DUR

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Chapter 1: Trends and Issues

MULTIPLE CHOICE 1. The nurse is caring for a patient who is in labor with her first child. The patient’s mother is present for support and notes that things have changed in the delivery room since she last gave birth in the early 1980s. Which current trend or intervention may the patient’s mother find most different?

1. Fetal monitoring throughout labor 2. Postpartum stay of 10 days 3. Expectant partner and family in operating room for cesarean birth 4. Hospital support for breastfeeding ANS: 4 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 1. Discuss current trends in the management of labor and birth Page: 4 Heading: Table 1-1: Past and Present Trends Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate

1

2 3

4

Feedback This is incorrect. Fetal monitoring during labor began in the late 1970s. As such, this likely would have occurred during the mother’s labor and delivery during the 1980s.

This is incorrect. In the past, the average hospital postpartum stay was 10 days.

Presently, the average postpartum stay is 48 hours or less.

This is incorrect. In the past, expectant partners and families were excluded from the labor and birth experience. Present trends involve the expectant partner and family in the labor and birth experience, including presence in the operating room for cesarean births.

This is correct. Hospital support for breastfeeding, including a lactation consultant and employment of the Baby-Friendly Hospital Initiative, were both enacted during the early 1990s.

PTS:

1

CON: Evidence-Based Practice

2. A patient with a history of hypertension is giving birth. During delivery, the staff was not able to stabilize the patient’s blood pressure. As a result, the patient died shortly after delivery. This is an example of what type of death?

1. Early maternal death 2. Late maternal death

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3. Direct obstetric death 4. Indirect obstetric death ANS: 4

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Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 2. Discuss current trends in maternal and infant health outcomes.

Page: 7 Heading: Trends > Maternal Death and Mortality Rates Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Hard

1

2 3 4

PTS:

Feedback This is incorrect. Early maternal death is not an example of maternal death.

Examples of maternal death include late maternal death, indirect obstetric death, direct obstetric death, and pregnancy-related death.

This is incorrect. Late maternal death occurs 42 days after termination of pregnancy from a direct or indirect obstetric cause.

This is incorrect. Direct obstetric death results from complications during pregnancy, labor, birth, and/or postpartum period.

This is correct. Indirect obstetric death is caused by a preexisting disease, or a disease that develops during pregnancy.

1

CON: Ante/Intra/Post-partum

3. The nurse is providing education to a patient who has given birth to her first child and is being discharged home. The patient expressed concern regarding infant mortality and sudden infant death syndrome (SIDS). The patient had an uncomplicated pregnancy, labor, and vaginal delivery. She has a body mass index of 25 and has no other health conditions.

The infant is healthy and was delivered full-term. What will be most helpful thing to explain to the patient?

1. Uses of extracorporeal membrane oxygenation therapy (ECMO) 2. Uses of exogenous pulmonary surfactant 3. The Baby-Friendly Hospital Initiative 4. The Safe to Sleep campaign ANS: 4 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 3. Identify leading causes of infant death.

Page: 7 Heading: Trends > Infant Mortality Rates Integrated Processes: Nursing process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

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1

Feedback This is incorrect. EMCO has been cited as one of the factors that has reduced infant mortality among preterm infants.

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2

3 4

This is incorrect. Although advances in medical treatments have decreased infant mortality, exogenous pulmonary surfactant is primarily used to reduce mortality of preterm infants.

This is incorrect. The Baby-Friendly Hospital Initiative was developed to support breastfeeding and is not directly linked to reduced infant mortality or SIDS. This is correct. The Back to Sleep campaign and the Safe to Sleep campaigns were designed to promote healthy infant sleeping habits. The decrease in SIDS from 1995 to 2015 was attributed to the Safe to Sleep campaign.

PTS:

1

CON: Health Promotion

4. The nurse is caring for a 14-year-old patient who is 32 weeks pregnant. After complaining of genital sores and discomfort, the patient tests positive for syphilis. The fetus is at increased risk of which condition?

1. Diabetes 2. Blindness 3. Pneumonia 4. Hypertension ANS: 4 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 10 Heading: Issues > Teen Pregnancy > Implications of Teen Pregnancy and Birth Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Moderate

1 2 3 4

Feedback This is incorrect. Maternal obesity increases a child’s risk of developing childhood obesity and diabetes.

This is correct. Neonatal blindness, maternal death, and neonatal death are all associated with a patient who contracts syphilis during pregnancy.

This is incorrect. Chlamydial pneumonia is associated with maternal chlamydia.

This is incorrect. Teen mothers may have a higher risk of contracting sexually transmitted illnesses and hypertension during pregnancy; however, maternal syphilis is not associated with fetal hypertension.

PTS:

1

CON: Ante/Intra/Post-partum

5. The nurse is caring for a 15-year-old female who is pregnant with her first child. In her previous prenatal visit, the patient tested negative for chlamydia, syphilis, gonorrhea, and HIV. Based on the information provided, which condition is the patient’s baby at higher risk for?

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1. Intestinal problems 2. Neonatal conjunctivitis 3. Blindness

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4. Pneumonia ANS: 1 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 11 Heading: Issues > Teen Pregnancy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Difficult

1

2 3 4

PTS:

Feedback This is correct. Infants born to teen mothers are at increased risk for various conditions related to prematurity, including infant death, intestinal problems, and/or respiratory distress syndrome.

This is incorrect. Infants born to teen mothers who have gonorrhea are at increased risk of neonatal conjunctivitis and blindness.

This is incorrect. Infants born to teen mothers with syphilis and gonorrhea are at increased risk of blindness.

This is incorrect. Infants born to teen mothers with chlamydia may be at increased risk of developing chlamydial pneumonia.

1

CON: Health Promotion

6. The nurse is caring for a 23-year-old patient who arrives at the clinic for a pregnancy test.

The test confirms the patient is pregnant. The patient states, ―I do not need to stop smoking my electronic cigarette because it will not harm my baby.‖ Which is the best response by the nurse?

1. ―You are correct. Electronic cigarettes are not harmful during pregnancy.‖ 2. ―Tobacco products, including electronic cigarettes, should not be used during pregnancy due to risking nicotine toxicity.‖ 3. ―According to the FDA, although electronic cigarettes are safe for you, they can cause harm to the fetus during pregnancy.‖ 4. ―Electronic cigarettes are considered harmful only in the first trimester.‖ ANS: 2 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 12 Heading: Issues > Tobacco and Electronic Cigarette Use During Pregnancy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Moderate

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Feedback

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This is incorrect. Electronic cigarettes can be harmful during pregnancy.

This is correct. Pregnant women should not use tobacco products or electronic cigarettes during pregnancy.

This is incorrect. Electronic cigarettes are not controlled by the FDA and may be harmful to both mother and fetus.

This is incorrect. Electronic cigarettes are considered harmful during pregnancy.

1 2 3 4 PTS:

1

CON: Ante/Intra/Post-partum

7. The nurse is caring for a 16-year-old patient who is 32 weeks pregnant with her first child, who is male. The patient’s mother has accompanied her to today’s visit. During the nursing assessment, the patient mentions that she is no longer in a relationship with the baby’s father but her mother plans to help her. However, the patient’s mother asks whether this will have any impact on the child. Which should the nurse indicate the child is at increased risk of during his adolescence?

1. Hypertension 2. Diabetes 3. Alcohol abuse 4. Intraventricular bleeding ANS: 3 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 12 Heading: Issues > Teen Pregnancy > Implications of Teen Pregnancy and Birth Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Moderate

1 2 3

4

Feedback This is incorrect. Teen mothers, rather than their children, are at increased risked of hypertension during pregnancy.

This is incorrect. Children born to mothers who are obese have an increased risk of developing childhood obesity and childhood diabetes.

This is correct. Statistics have shown that adolescent boys without an involved father may be at higher risk of incarceration, dropping out of school, and abusing drugs or alcohol.

This is incorrect. Children born to teen mothers are at increased risk for health problems associated with low birth weight, including intraventricular bleeding.

PTS:

1

CON: Ante/Intra/Post-partum

8. The nurse is caring for a patient at 7 weeks gestation. The nurse suspects that a pregnant patient may have been using marijuana. With consent, the nurse confirms via urine drug

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screen. Which statement by the nurse is most appropriate?

1. ―Did you smoke marijuana when pregnant with your other child?‖ 2. ―To avoid negative effects on your baby, you’ll need to stop using marijuana

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during your last trimester.‖ 3. ―Using marijuana while pregnant can have a negative effect on the neurological development of your baby.‖ 4. ―Marijuana use while pregnant greatly increases your risk of miscarriage.‖ ANS: 3 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 3. Identify leading causes of infant death.

Page: 13 Heading: Issues > Substance Abuse During Pregnancy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Moderate

1 2 3 4

PTS:

Feedback This is incorrect. Whether or not the woman used marijuana during her previous pregnancy is not relevant to her current care.

This is incorrect. Marijuana should not be used at any point during pregnancy.

This is correct. Marijuana use during pregnancy may have a negative effect on the neurological development of the fetus.

This is incorrect. There currently is no research linking marijuana use to increased risk of miscarriage.

1

CON: Ante/Intra/Post-partum

9. The nurse is counseling a female patient about alcohol use during pregnancy. Which statement by the patient demonstrates successful patient teaching?

1. ―I will limit my drinking to just one alcoholic beverage per day.‖ 2. ―It’s best for my baby if I avoid drinking during pregnancy.‖ 3. ―An occasional drink on special occasions is okay.‖ 4. ―Drinking alcohol is only acceptable in the first trimester.‖ ANS: 2 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 3. Identify leading causes of infant death.

Page: 13 Heading: Issues > Substance Abuse During Pregnancy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Moderate

1

Feedback This is incorrect. Alcohol should not be consumed while pregnant.

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2

This is correct. Drinking alcohol while pregnant can cause low birth weight, fetal alcohol syndrome, mental retardation, and intrauterine growth restriction.

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3 4 PTS:

This is incorrect. Alcohol should not be consumed while pregnant.

This is incorrect. Alcohol should not be consumed while pregnant.

1

CON: Ante/Intra/Post-partum

10. The nurse is educating the pregnant patient with a body mass index (BMI) of 33. The nurse knows that teaching has been effective when the patient states which of the following?

1. ―My child may be at increased risk for birth injury.‖ 2. ―My child may have a decreased risk of developing childhood diabetes.‖ 3. ―I will probably give birth vaginally.‖ 4. ―I have a lower risk of developing gestational hypertension.‖ ANS: 1 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 13 Heading: Issues > Obesity Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Difficult

1 2 3 4

PTS:

Feedback This is correct. Shoulder dystocia and other birth injuries are associated with infant macrosomia (large size) due to maternal obesity.

This is incorrect. Children born to mothers who are obese are at increased risk of developing childhood obesity and diabetes.

This is incorrect. Pregnant patients who are obese are at increased risk of cesarean birth.

This is incorrect. Pregnant patients who are obese have an increased risk of developing gestational diabetes and gestational hypertension.

1

CON: Ante/Intra/Post-partum

11. A pregnant woman weighs 90.9 kg. The nurse is educating the patient on complications that the patient may be at risk for during pregnancy. Which response by the patient indicates that she understands?

1. ―Due to my weight, there is a possibility that I may develop gestational diabetes.‖ 2. ―I am not overweight, but I am still at risk for gestational diabetes.‖ 3. ―My mother had preeclampsia during one of her pregnancies.‖ 4. ―I will need to do a glucose tolerance test in my second trimester.‖ ANS: 1 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 13

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Heading: Issues > Obesity Integrated Processes: Nursing Process

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Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Difficult

1 2 3 4

PTS:

Feedback This is correct. The patient is at risk for gestational diabetes due to being obese during pregnancy.

This is incorrect. The patient is overweight.

This is incorrect. This response is not related to the question.

This is incorrect. The patient will need to get the glucose tolerance test in the second trimester, but this response does not relate to the question.

1

CON: Ante/Intra/Post-partum

12. The nurse is taking a history of a mother who admits to cocaine drug use. Which action should the nurse take first?

1. Refer the patient to a drug abuse program.

2. Screen the infant for side effects associated with cocaine use.

3. Educate the patient of the risks associated with cocaine use during pregnancy.

4. Advise the patient that her baby will be okay even with the history of cocaine use.

ANS: 3 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 3. Identify leading causes of infant death.

Page: 13 Heading: Issues > Substance Abuse During Pregnancy Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Difficult

1 2 3 4

PTS:

Feedback This is incorrect. This is appropriate, but not the first action the nurse should take.

This is incorrect. The infant is not screened for side effects of maternal drug use until delivery.

This is correct. The patient should be educated on possible risks associated with drug use.

This is incorrect. It is not appropriate to tell a patient ―your baby will be okay‖ in any circumstance.

1

CON: Ante/Intra/Post-partum

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13. A pregnant patient with a BMI of 35 is concerned about health effects she and her baby may face during pregnancy. During routine testing, the patient tested negative for sexually transmitted illnesses (STIs) and indicated that she is in a committed, long-term relationship with the child’s father. Which of the following is accurate?

1. The patient’s infant is at increased risk of neonatal blindness.

2. The patient’s infant has a decreased risk of birth injury.

3. The patient will have increased risk of wound infection.

4. The patient will have a decreased risk of preeclampsia.

ANS: 3 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 14 Heading: Issues > Obesity Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Difficult

1 2 3 4

Feedback This is incorrect. Infants born to mothers with certain sexually transmitted illnesses (STIs) are at increased risk of neonatal blindness.

This is incorrect. Infants born to obese pregnant women have increased risk of birth injury related to macrosomia.

This is correct. Obese pregnant patients are at increased risk for wound infections.

This is incorrect. Obese pregnant patients have an increased risk of developing certain conditions, including gestational diabetes, gestational hypertension, and preeclampsia.

PTS:

1

CON: Ante/Intra/Post-partum

14. The nurse has made it a goal to increase the rate at which women begin prenatal care in the first trimester. The nurse relates this decision to national goals for better maternal and infant outcomes. What guidelines will the nurse use to guide her maternal health goals?

1. WHO Maternal care guidelines 2. State Practice Acts 3. AWHONN white papers 4. Healthy People 2020 ANS: 4 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 5. Identify the primary maternal and infant goals of Healthy People 2020.

Page: 15 Heading: Maternal and Child Health Goals

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Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance

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Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1 2 3 4

PTS:

Feedback This is incorrect. The WHO guidelines are too broad for this purpose, and the nurse will need to use national goals.

This is incorrect. State practice acts specify legal requirements rather than health promotion goals.

This is incorrect. AWHONN white papers will present positions but not necessarily detail health promotion goals.

This is correct. The national goals for improving maternal and infant health are found in Healthy People 2020.

1

CON: Health Promotion

15. A nursing student is asked to set goals that will decrease the fetal death outcomes during delivery. What guidelines will the nursing student use to assist in setting her goals?

1. WHO Maternal care guidelines 2. Healthy People 2020 3. AWHONN white papers 4. State Practice Act ANS: 2 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 5. Identify the primary maternal and infant goals of Healthy People 2020.

Page: 15 Heading: Maternal and Child Health Goals Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1 2 3

4

Feedback This is incorrect. The WHO guidelines are too broad for this purpose and the nurse will need to use national goals.

This is correct. The national goals for improving maternal and infant health are found in Healthy People 2020.

This is incorrect. AWHONN white papers will present positions but not necessarily detail health promotion goals.

This is incorrect. State practice acts specify legal requirements rather than health promotion goals.

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PTS:

1

CON: Health Promotion

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MULTIPLE RESPONSE 1. A woman has recently given birth to an infant born at 35 weeks and 5 days gestation. What long-term effects should the nurse be concerned about with the infant being born at this gestation? Select all that apply.

1. Cerebral palsy 2. Respiratory disorders 3. Developmental delays 4. Visual impairments 5. Hearing impairments ANS: 1, 2, 3, 4, 5 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 1. Discuss current trends in the management of labor and birth.

Page: 6 Heading: Trends > Preterm Births Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate

1 2 3 4 5

Feedback This is correct. Cerebral palsy is a long-term effect of preterm birth.

This is correct. Respiratory disorders are a long-term effect of preterm birth.

This is correct. Developmental delays are a long-term effect of preterm birth.

This correct. Visual and hearing impairment is a long-term effect of preterm birth.

This is correct. Hearing impairments are a long-term effect of preterm birth.

PTS:

1

CON: Health Promotion

2. An infant was recently born weighing 1,498 grams. The nurse understands that the birth weight of this infant is an important indicator of what? Select all that apply.

1. Morbidity rate 2. Prenatal care 3. Mortality rate 4. Infant health outcome 5. Postpartum care ANS: 1, 3, 4 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 1. Discuss current trends in the management of labor and birth.

Page: 6 Heading: Trends > Neonatal Birth Weight Rates Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying]

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Concept: Ante/Intra/Post-partum Difficulty: Moderate

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1 2 3 4 5

Feedback This is correct. Morbidity rate is an outcome of low birth weight.

This is incorrect. Prenatal care is not an outcome of low birth weight.

This is correct. Mortality rate is an outcome of low birth weight.

This is correct. Infant health is an outcome of low birth weight.

This is incorrect. Postpartum care is not an outcome of low birth weight.

PTS:

1

CON: Ante/Intra/Post-partum

3. The nurse is taking the history of a gravida 2 para 1 patient. Which findings in the patient’s history warrant further action? Select all that apply.

1. Anemia 2. Severe hemorrhage 3. Infections 4. Malnutrition 5. Eclampsia ANS: 1, 2, 3, 5 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 2. Discuss current trends in maternal and infant health outcomes.

Page: 9 Heading: Trends > Maternal Death and Mortality Rates Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum Difficulty: Difficult

1 2 3 4 5

Feedback This is correct. Anemia is a primary cause of maternal death.

This is correct. Severe hemorrhage is a primary cause of maternal death.

This is correct. Infection is a primary cause of maternal death.

This is incorrect. Malnutrition is not a primary cause of maternal death.

This is correct. Eclampsia is a primary cause of maternal death.

PTS:

1

CON: Ante/Intra/Post-partum

4. A nurse is caring for a single teen mother who has just given birth to her first child. The patient notes that the child’s father ―wants no relationship with his son.‖ The patient goes on to express concerns about the short- and long-term impact of her teen pregnancy on herself and on her child. Which statements made by the nurse are accurate? Select all that apply.

1. ―You are more likely than others to have additional children before you turn 20.‖ 2. ―You may have difficulty completing high school or college.‖ 3. ―Your child is less likely to experience behavioral problems.‖ 4. ―Your child is at increased risk of abusing alcohol when he is a teenager.‖

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5. ―You may not earn enough money to independently support yourself and your child.‖

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ANS: 1, 2, 4 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 4. Discuss current maternal and infant health issues.

Page: 10 Heading: Issues > Teen Pregnancy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Health Promotion Difficulty: Moderate

1

2 3 4 5

Feedback This is correct. Teen mothers are more likely to have additional children than their peers. Roughly 17% of all teen mothers will have at least one more birth before the age of 20.

This is correct. Only half of teen mothers earn their high school diploma by age 22. Less than 2% of teen mothers finish college by age 30.

This is incorrect. Children of teen mothers are more likely to experience behavioral problems.

This is correct. Teenage males without an involved father have a higher risk of abusing alcohol or drugs.

This is correct. Around one-fourth of teen mothers begin receiving welfare within 3 years of the birth of their first child. 66% of teen mothers are poor.

PTS:

1

CON: Health Promotion

5. The nurse is caring for a woman who is pregnant. The patient reports that she has also smoked less than five cigarettes per day and that she has continued to smoke during her pregnancy. Routine prenatal examination and diagnostics have indicated she tested negative for sexually transmitted infections and has a BMI of 25. Based on statistics, which is likely true about the patient and the developing fetus? Select all that apply.

1. She will breastfeed her infant.

2. She is probably aged 20–24.

3. She likely has earned a college degree.

4. Her child may have impaired brain development.

5. Her child is more likely to be born prematurely.

ANS: 2, 4, 5 Chapter: Chapter 1 Trends and Issues Chapter Learning Objective: 3. Identify leading causes of infant death.

Page: 12 Heading: Issues > Tobacco and Electronic Cigarette Use During Pregnancy Integrated Processes: Nursing Process Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Ante/Intra/Post-partum

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Difficulty: Moderate

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PTS:

This is incorrect. Mother who smoke during pregnancy are less likely to breastfeed their infants.

This is correct. Only 4.5% of mothers over 35 smoke during pregnancy, which is the lowest smoking prevalence rate of age ranges listed. Mothers aged 20–24 have the highest prevalence of smoking during pregnancy (13%).

This is incorrect. Statistics indicate that mothers with less than a high school diploma have the highest prevalence of smoking during pregnancy (14.1%).

Patients with a bachelor’s degree or higher have the lowest prevalence of smoking during pregnancy (0.9%).

This is correct. Fetal brain development may be impaired when the mother continues to smoke throughout pregnancy.

This is correct. Tobacco exposure during development is toxic to developing fetuses. It may contribute to a variety adverse effects, including abruptio placenta and premature birth.

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CON: Ante/Intra/Post-partum

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Chapter 2: Ethics and Standards of Practice Issues Multiple Choice 1. An ethical dilemma unique to perinatal nursing is the: a. Innate conflict between maternal and fetal rights b. Intensive use of technology c. Shortage of health-care resources d. Risk of violation of the principle of veracity ANS: a Feedback a. A unique aspect of maternity nursing is that the nurse advocates for two individuals: the woman and the fetus.b. The use of technology is not unique to perinatal nursing.c. Currently, in the United States, decisions in perinatal nursing are not based on resources available.d. In perinatal nursing, the obligation to tell the truth is generally adhered to.

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate2. The

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American Nurses Association Code of Ethics for Nurses directs nurses to provide patient care that is: a. Curative b. Utilitarian c. Negotiable d. Respectful ANS: d Feedback a. Adaptation rather than cure is the goal of nursing.b. Nursing does not define the value of a person by his or her utility.c. The Code of Ethics outlines the nursing profession’s nonnegotiable ethical standard.d. Respect for the inherent dignity, worth, and uniqueness of every individual is part of the Code of Ethics.KEY: Integrated Process: Caring | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 3. Evidence-based practice is the integration of the best: a. Randomized clinical trials, clinical expertise, and patients’ requestsb. Research evidence, clinical expertise, and patients’ valuesc. Quantitative research, clinical expertise, and patients’ preferencesd. Research findings, clinical experience, and patients’ preferences ANS: b Feedback a. Evidence-based practice is the use of evidence that may include research beyond randomized clinical trials.b. These elements are the accepted definition of evidence-based practice.c. Qualitative research, as well as quantitative research, contributes to evidence-based practice.d. Clinical expertise, as well as clinical experience, defines evidence-based practice.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: EasyMultiple Response 4. Infants whose mothers were obese during pregnancy are at higher risk for which of the following? (Select all that apply.) a. Childhood diabetesb. Heart defects

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c. Hypospadias d. Respiratory distress

ANS: a, b, c Fetuses and/or infants of women who were obese during pregnancy are at higher risk for spina bifida, health defects, anorectal atresia, hypospadias, intrauterine fetal death, birth injuries related to macrosomia, and childhood obesity and diabetes.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

Chapter 3: Genetics, Conception, Fetal Development, and ReproductiveTechnology Multiple Choice 1. The color of a person’s hair is an example of which of the following? a. Genome b. Sex-link ANS: d Feedback

inheritance c. Genotype d. Phenotype

a. Genome is an organism’s complete set of DNA.b. Sex-link inheritance refers to genes or traits that are located only on the X chromosome.c. Genotype refers to a person’s genetic mak eup.d. Correct. Phenotype refers to how genes are outwardly expressed, such as eye color, hair color, and height.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

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2. Which of the following statements by a pregnant woman indicates she needs additional teaching on ways to reduce risk s to her unborn child from the potential effects of exposure to toxoplasmosis? a. ―I will avoid rare lamb. b. ―I will wear a mask when cleaning my cat’s litter box. c. ―I understand that exposure to toxoplasmosis can cause blindness in the baby. d. ―I will avoid rare beef.‖ ANS: b Feedback a. Exposure occurs when the protozoan parasite found in cat feces and uncook ed or rare beef and lamb is ingested.b. Correct. Pregnant women and women who are attempting pregnancy should avoid contact with cat feces. Exposure occurs when the protozoan parasite found in cat feces and uncook ed or rare beef and lamb is ingested. Wearing a mask will not decrease the risk through ingestion of the parasite.c. Exposure to toxoplasmosis can cause fetal death, mental retardation, and blindness.d. Exposure occurs when the protozoan parasite found in cat feces and uncook ed or rare beef and lamb is ingested.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 3. The fetal circulatory structure that connects the pulmonary artery with the descending aorta is k nown as which of the following? a. Ductus venosus b. Foramen ovale c. Ductus arteriosus d. Internal iliac artery ANS: c Feedback a. The ductus venosus connects the umbilical vein to the inferior vena cava.b. The foramen ovale is the opening between the right and left atria.c. Correct.d. The internal iliac artery connects the external iliac artery to the umbilical artery.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity

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| Client Need: Physiological Adaptation | Difficulty Level: Easy 4. A woman at 40 week s’ gestation has a diagnosis of oligohydramnios. Which of the following statements related to oligohydramnios is correct? a. It indicates that there is a 25% increase in amniotic fluid.b. It indicates that there is a 25% reduction of amniotic fluid.c. It indicates that there is a 50% increase in amniotic fluid.d. It indicates that there is a 50% reduction of amniotic fluid.

ANS: d Feedback a. Oligohydramnios is a decrease, not an increase in amniotic fluid.b. Oligohydramnios is a 50% reduction in amniotic fluid.c. Oligohydramnios is a decrease, not an increase in amniotic fluid.d. Correct. Oligohydramnios refers to a decreased amount of amniotic fluid of less than 500 mL at term or 50% reduction of normal amounts.KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Moderate 5. A diagnostic test commonly used to assess problems of the fallopian tubes is: a. Endometrial biopsyb. Ovarian reserve testingc. Hysterosalpingogramd. Screening for sexually transmitted infections ANS: c Feedback a. Endometrial biopsy provides information on the response of the uterus to hormonal signals.b. Ovarian reserve testing is used to assess ovulatory functioning.c. Correct.

Hysterosalpingogram provides information on the endocervical canal, uterine cavity, and fallopian tubes.d. STIs can cause adhesions within the fallopian tubes, but screening cannot confirm that adhesions are present.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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6. The nurse is interviewing a gravid woman during the first prenatal visit. The woman confides to the nurse that she lives with a number of pets. The nurse should advise the woman to be especially careful to refrain from coming in contact with the stool of which of the pets? a. Catb. Dogc. Hamsterd. Bird ANS: a Feedback a. The patient should refrain from coming in direct contact with cat feces. Cats often harbor toxoplasmosis, a teratogenic illness.b. No pathology has been associated with the feces of pet dogs.c. No pathology has been associated with the feces of pet hamsters.d.

No pathology has been associated with the feces of pet birds.

KEY: Integrated Process: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Application | Content Area: Antepartum Care; Disease Prevention | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 7. A client is to tak e Clomiphene Citrate for infertility. Which of the following is the expected action of this medication? a. Decrease the symptoms of endometriosisb. Increase serum progesterone levelsc.

Stimulate release of FSH and LHd. Reduce the acidity of vaginal secretions ANS: c Feedback a. Clomiphene Citrate will not reduce a client’s symptoms of endometriosis.b.

Clomiphene Citrate will not increase a client’s progesterone levels.c. Clomiphene Citrate stimulates release of FSH and LH.d. Clomiphene Citrate will not reduce the acidity of vaginal secretions.

KEY: Integrated Process: Nursing Process: Evaluation | Cognitive Level: Comprehension | Content Area: Pharmacological and Parenteral Therapies: Expected Effects/Outcomes |

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Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate 8. The nurse tak es the history of a client, G2 P1, at her first prenatal visit. The client is referred to a genetic counselor, due to her previous child having a diagnosis of .

a. Unilateral amblyopiab. Subdural hematomac. Sick le cell anemiad. Glomerular nephritis ANS: c Feedback a. Amblyopia rarely results from a genetic predisposition.b. A subdural hematoma does not result from a genetic defect.c. Sick le cell anemia is an autosomal recessive illness.

This client needs to be seen by a genetic counselor.d. Glomerular nephritis does not result from a genetic defect.

KEY: Integrated Process: Communication and Documentation; Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Collaboration with Interdisciplinary Team; Health History; Referrals | Client Need: Health Promotion and Maintenance; Safe and Effective Care Environment: Referrals | Difficulty Level: Moderate 9. A nurse is teaching a woman about her menstrual cycle. The nurse states that is the most important change that happens during the secretory phase of the menstrual cycle. a. Maturation of the graafian follicleb. Multiplication of the fimbriaec. Secretion of human chorionic gonadotropind. Proliferation of the endometrium ANS: d Feedback a. The maturation of the graafian follicle occurs during the follicular phase.b. There is no

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such thing as the multiplication of the fimbriae.c. Human chorionic gonadotropin is secreted by the fertilized ovum during the early week s of a pregnancy.d. The proliferation of the endometrium occurs during the secretory phase of the menstrual cycle.

KEY: Integrated Processes: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Knowledge | Content Area: Health and Wellness | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 10. An ultrasound of a fetus’ heart shows that ―normal fetal circulation is occurring.‖ Which of the following statements is consistent with the finding? a. A right to left shunt is seen between the atria.b. Blood is returning to the placenta via the umbilical vein.c. Blood is returning to the right atrium from the pulmonary system.d.

A right to left shunt is seen between the umbilical arteries.

ANS: a Feedback a. This is correct. The foramen ovale is a duct between the atria. In fetal circulation, there is a right to left shunt through the duct.b. Blood returns to the placenta via the umbilical arteries.c. Most of the blood bypasses the pulmonary system. The blood that does enter the pulmonary system returns to the left atrium.d. There is no duct between the umbilical arteries.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Comprehension | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 11. The clinic nurse k nows that the part of the endometrial cycle occurring from ovulation to just prior to menses is k nown as the: a. Menstrual phaseb. Proliferative phasec. Secretory phased. Ischemic phase ANS: c Feedback

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a. The menstrual phase is the time of vaginal bleeding, approximately days 1 to 6.b. The proliferative phase ends the menses through ovulation, approximately days 7 to 14.c. The secretory phases occurs from the time of ovulation to the period just prior to menses, or approximately days 15 to 26.d. The ischemic phase occurs from the end of the secretory phase to the onset of menstruation, approximately days 27 to 28.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 12. A clinic nurse explains to the pregnant woman that the amount of amniotic fluid present at 24 week s’ gestation is approximately: a. 500 mLb. 750 mLc. 800 mLd. 1000 mL ANS: c Amniotic fluid first appears at about 3 week s. There are approximately 30 mL of amniotic fluid present at 10 week s’ gestation, and this amount increases to approximately 800 mL at 24 week s’ gestation. After that time, the total fluid volume remains fairly stable until it begins to decrease slightly as the pregnancy reaches term.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 13. Information provided by the nurse that addresses the function of the amniotic fluid is that the amniotic fluid helps the fetus to maintain a normal body temperature and also: a. Facilitates asymmetrical growth of the fetal limbsb. Cushions the fetus from mechanical injuryc. Promotes development of muscle toned. Promotes adherence of fetal lung tissue ANS: b Feedback a. Amniotic fluid allows for symmetrical fetal growth.b. Amniotic fluid cushions the fetus from mechanical injury.c. Amniotic fluid does not promote muscle tone.d. Amniotic fluid prevents adherence of the amnion to the fetus.

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 14. During preconception counseling, the clinic nurse explains that the time period when the fetus is most vulnerable to the effects of teratogens occurs from: a. 2 to 8 week sb. 4 to12 week sc. 5 to 10 week sd. 6 to 15 week s ANS: a The period of organogenesis lasts from approximately the second until the eighth week of gestation during which time the embryo undergoes rapid growth and differentiation.

During organogenesis, the embryo is extremely vulnerable to teratogens such as medications, alcohol, tobacco, caffeine, illegal drugs, radiation, heavy metals, and maternal (TORCH) infections. Structural fetal defects are most lik ely to occur during this period because exposure to teratogens either before or during a critical period of development of an organ can cause a malformation.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Easy 15. A major fetal development characteristic at 16 week s’ gestation is: a. The average fetal weight is 450 gramsb. Lanugo covers entire bodyc. Brown fat begins to developd. Teeth begin to form ANS: d Feedback a. The average fetal weight at 16 week s is 200 grams.b. Lanugo is present on the head.c. Brown fat begins to develop at 20 week s.d. This is the correct answer.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Moderate 16. Karen, a 26-year-old woman, has come for preconception counseling and ask s about caring for her cat as she has heard that she ―should not touch the cat during pregnancy.‖

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The clinic nurse’s best response is: a. It is best if someone other than you changes the cat’s litter pan during pregnancy so that you have no risk of toxoplasmosis during pregnancy.b. It is important to have someone else change the litter pan during pregnancy and also avoid consuming raw vegetables.c. Have you had any ―flu-lik e‖ symptoms since you got your cat? If so, you may have already had toxoplasmosis and there is nothing to worry about.d.

Toxoplasmosis is a concern during pregnancy, so it is important to have someone else change the cat’s litter pan and also to avoid consuming uncook ed meat.

ANS: d Feedback a. The nurse should also explain that the patient should not eat uncook ed meat as it is a potential source for toxoplasmosis.b. Raw vegetables are not a source for toxoplasmosis.c. This is not an accurate way to diagnose if the woman has had toxoplasmosis.d. Women need to be aware that Toxoplasma gondii, a single-celled parasite, is responsible for the infection toxoplasmosis. The majority of individuals who become infected with toxoplasmosis are asymptomatic, although when present, symptoms are described as ―flu lik e‖ and include glandular pain and enlargement and myalgia. Severe toxoplasmosis infection may cause damage to the fetal brain, eyes, or other organs. Toxoplasmosis is usually acquired by consuming raw or poorly cook ed meat that has been contaminated with T. gondii. Toxoplasmosis may also be acquired through close contact with feces from an infected animal (usually cats) or soil that has been contaminated with T. gondii.

KEY: Integrated Processes: Caring | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 17. A couple who has sought infertility counseling has been told that the man’s sperm count is very low. The nurse advises the couple that spermatogenesis is impaired when which of the following occur? a. The testes are overheated.b. The vas deferens is ligated.c. The prostate gland is enlarged.d. The flagella are segmented.

ANS: a

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Feedback a. Spermatogenesis occurs in the testes. High temperatures harm the development of the sperm.b. When the vas deferens is ligated, a man has had a vasectomy and is sterile. The sterility is not due to impaired spermatogenesis, but rather to the inability of the sperm to migrate to the woman’s reproductive track .c. The enlarged prostrate has no effect on spermatogenesis.d. The flagella are the ―tails‖ of the sperm.

They are normally divided into the middle segment and an end segment.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 18. A nurse work ing with an infertile couple has made the following nursing diagnosis: Sexual dysfunction related to decreased libido. Which of the following assessments is the lik ely reason for this diagnosis? a. The couple has established a set schedule for their sexual encounters.b. The couple has been married for more than 8 years.c. The couple lives with one set of parents.d. The couple has close friends who gave birth within the last year.

ANS: a Feedback a. Couples who ―schedule‖ intercourse often complain that their sexual relationship is unsatisfying.b. Years of marriage are not directly related to a couple’s sexual relationship.c. The fact that the couple lives with one set of parents is unlik ely related to their sexual relationship.d. Although it can be very difficult to be around couples who have become pregnant or have healthy babies, this factor is not usually related to a couple’s sexual relationship.

KEY: Integrated Process: Critical Think ing | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

True/False 19. The perinatal nurse explains to the student nurse that in the fetal circulation, the lowest level of oxygen concentration is found in the umbilical arteries.

ANS: True

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The highest oxygen concentration (PO2 = 30–35 mm Hg) is found in the blood returning from the placenta via the umbilical vein; the lowest oxygen concentration occurs in blood shunted to the placenta where reoxygenation tak es place. The blood with the highest oxygen content is delivered to the fetal heart, head, neck , and upper limbs, and the blood with the lowest oxygen content is shunted toward the placenta.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy Fill-in-the-Blank 20. After birth, the perinatal nurse explains to the new mother that hormone responsible for stimulating milk production.

is the

ANS: prolactinFollowing birth and delivery of the placenta, there is an abrupt decrease in estrogen. This event triggers an increased secretion of prolactin (the hormone that stimulates milk production) by the anterior pituitary gland. The posterior pituitary and hypothalamus play a role in the production and secretion of oxytocin, a hormone that causes release of milk from the alveoli.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 21. During prenatal class, the childbirth educator describes the two membranes that envelop the fetus. The contains the amniotic fluid, and the is the thick , outer membrane.

ANS: amnion; chorionThe embryonic membranes (chorion and amnion) are early protective structures that begin to form at the time of implantation. The thick chorion, or outer membrane, forms first. It develops from the trophoblast and encloses the amnion, embryo, and yolk sac. The amnion arises from the ectoderm during early embryonic development. The amnion is a thin, protective structure that contains the amniotic fluid.

With embryonic growth, the amnion expands and comes into contact with the chorion.

The two fetal membranes are slightly adherent and form the amniotic sac.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content

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Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 22. The perinatal nurse is teaching nursing students about fetal circulation and explains that fetal blood flows through the superior vena cava into the right via the .

ANS: atrium; foramen ovaleBlood flows through the vein from the placenta to the fetus.

Most of the blood bypasses the liver and then enters the inferior vena cava by way of the ductus venosus, a vascular channel that connects the umbilical vein to the inferior vena cava. The blood then empties into the right atrium, passes through the foramen ovale (an opening in the septum between the right and left atrium) into the left atrium, and then moves into the right ventricle and on into the aorta. From the aorta, blood travels to the head, upper extremities, and lower extremities.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 23. The perinatal nurse explains to the student nurse that the growing embryo is called a beginning at 8 week s of gestational age.

ANS: fetusMajor organs are being formed (organogenesis) during the first week s following fertilization. During this time, the developing organism is called an embryo. Bythe end of 8 week s, the embryo has sufficiently developed to be called a fetus.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 24. The perinatal nurse defines a as any substance that adversely affects the growth and development of the embryo/fetus.

ANS: teratogenTeratogens (drugs, radiation, and infectious agents that can cause development of abnormal structures in an embryo) and a variety of internal and external developmental events may cause structural and functional defects.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content

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Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Easy 25. is when sperm and oocytes are mixed outside the woman’s body and then placed into the fallopian tube via laparoscopy.

ANS: Gamete intrafallopian transferGamete intrafallopian transfer, also referred to as GIFT, is used when there is a history of failed infertility treatment for anovulation, or unexplained infertility, or low sperm count.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Moderate Multiple Response 26. A woman seek s care at an infertility clinic. Which of the following tests may this woman undergo to determine what, if any, infertility problem she may have? (Select all that apply.) a. Chorionic villus samplingb. Endometrial biopsyc. Hysterosalpingogramd. Serum FSH analysis ANS. b, c, d Feedback a. Chorionic villus sampling is done to assess for genetic disorders of the fetus. b. Endometrial biopsy is performed about 1 week following ovulation to detect the endometrium’s response to progesterone.c. Hysterosalpingogram is used to determine if fallopian tubes are patent.d. Serum FSH levels are used to assess ovarian function.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 27. A couple who has been attempting to become pregnant for 5 years is seek ing assistance from an infertility clinic. The nurse assesses the clients’ emotional responses to their infertility. Which of the following responses would the nurse expect to find? (Select all that apply.)

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a. Anger at others who have babies.b. Feelings of failure because they cannot mak e a baby.c. Sexual excitement because they want to conceive a baby.d. Guilt on the part of one partner because he or she is unable to give the other a baby.

ANS: a, b, d Feedback a. Infertile couples often feel anger toward couples who have babies.b. Infertile couples often express feelings of personal failure.c. Infertile couples undergoing infertility testing and treatment often express an aversion to sex.d. Guilt is often expressed by the couple.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 28. Which of the following places a couple at higher risk for conceiving a child with a genetic abnormality? (Select all that apply.) a. Maternal age over 35 yearsb. Partner who has a genetic disorderc. Maternal type 1 diabetesd. Paternal heart disease ANS: a, bFertility decreases after 35 years. A partner contributes half of the chromosomal mak eup, and genetic disorders can be inherited. Maternal diabetes can have an effect on the fetus/neonate, such as causing complications such as macrosomia and hypoglycemia, but these are not genetic disorders. Paternal heart disease can place the neonate at risk for heart disease later in life, but this is not referred to as a genetic disorder, such as is trisomy 21 and hemophilia.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 29. The ovarian cycle includes which of the following phases? (Select all that apply.)a.

Follicular phaseb. Secretory phasec. Ovulatory phased. Luteal phasee. Menstrual phase ANS: a, c, d Follicular phase, ovulatory phase, and luteal phase are part of the ovarian cycle. Secretory

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and menstrual phases are part of the endometrial cycle.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Easy 30. A couple is undergoing an infertility work up. The semen analysis indicates a decreased number of sperm and immature sperm. Which of the following factors can have a potential effect on sperm maturity? (Select all that apply.) a. The man rides a bik e to and from work each day.b. The man tak es a calcium channel block er for the treatment of hypertension.c. The man drink s 6 cups of coffee a day.d. The man was treated for prostatitis 12 months ago and has been symptom free since treatment.

ANS: a, bThe daily riding of a bik e can be the cause of prolonged heat exposure to the testicles. Prolonged heat exposure is a gonadotoxin. A number of medications, such as calcium channel block ers, can have an effect on sperm production. Coffee has not been associated with low sperm counts. Prostatitis or other infections within the last 3 months may have an effect on the sperm analysis. This man’s episode of prostatitis was 12 months prior.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 31. The clinic nurse recognizes that pregnant women who are in particular need of support are those who (select all that apply): a. Are experiencing a second pregnancyb. Are awaiting genetic testing resultsc. Are experiencing a first pregnancyd. Are trying to conceal this pregnancy as long as possible ANS: b, dA second pregnancy is not an indication of a woman in need of additional support. A support system may be lack ing for women who are trying to conceal a pregnancy or for women who are trying to k eep the news of their pregnancy from relatives or friends until results from genetic tests are k nown. These individuals may need additional support from their nurses and other health-care providers, as they are placed in a powerless situation while awaiting results and face a pregnancy that may be in jeopardy.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:

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frequent meals of dry, bland foods and include high-protein snack s in their diet.

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Chapter 4: Physiological Aspects of AntepartumCare(FREE) Chapter 4: Physiological Aspects of Antepartum Care Multiple Choice 1. Folic acid supplementation during pregnancy is to:a. Improve the bone density of pregnant women b. Decrease the incidence of neural tube defects in the fetus c. Decrease the incidence of Down syndrome in the fetusd. Improve calcium uptake in pregnant women ANS: b Feedback a. Folic acid is not related to bone density. b. Correct. The use of folic acid has decreased the incidence of neural tube defects by 50%. c. The use of folic acid is not associated with a reduction in Down syndrome. d. Folic acid is not related to calcium uptake in women.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate 2. The positive signs of pregnancy are:a. All physiological and anatomical changes of pregnancyb. All subjective signs of pregnancyc. All those physiological changes perceived by the woman herselfd. The objective signs of pregnancy that can only be attributed to the fetus ANS: d Feedback a. Physiological and anatomical changes of pregnancy are presumptive signs of pregnancy. b. All subjective signs of pregnancy are the probable signs of pregnancy. c. All those physiological changes perceived by the woman herself are presumptive signs of pregnancy. d. Correct. Positive signs of pregnancy are the objective signs of pregnancy that can only be attributed to the fetus, such as fetal heart tones.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Easy 3. During a routine prenatal visit in the third trimester, a woman reports she is dizzy and lightheaded when she is lying on her back. The most appropriate nursing action would be to:a.

Order an EKG. b. Report this abnormal finding immediately to her care provider. c. Teach the woman to avoid lying on her back and to rise slowly because of supine hypotension. d. Order a nonstress test to assess fetal well-being.

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ANS: c Feedback a. This is a normal occurrence in pregnancy and does not indicate pathology. The probable cause of the problem is supine hypotension. b. This is a normal finding that does not warrant immediate notification to her care provider. c. Correct. Teaching the woman to avoid lying on her back because of occlusion of the vena cava with the gravid uterus causes supine hypotension syndrome. d. Antenatal testing is not indicated with supine hypotension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 4. Blood volume expansion during pregnancy leads to: a. Iron-deficiency anemiab. Maternal iron stores being insufficient to meet the demands for iron in fetal developmentc. Plasma fibrin increase of 40% and fibrinogen increase of 50%d. Physiological anemia of pregnancy ANS: d Feedback a. Iron-deficiency anemia is treated with iron supplementation. Iron-deficiency anemia is defined as hemoglobin of less than 11 g/dL and hematocrit less than 33%. b. Maternal iron stores that are insufficient to meet the demands for iron in fetal development result in iron-deficiency anemia. c. Hypercoagulation that occurs during pregnancy is to decrease the risk of postpartum hemorrhage. These changes taking place are not related to blood volume expansion. d. Correct. Physiological anemia of pregnancy, also referred to as pseudo-anemia of pregnancy, is due to hemodilution. The increase in plasma volume is relatively larger than the increase in RBCs that results in decreased hemoglobin and hematocrit values.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 5. Intimate partner violence (IPV) against women consists of actual or threatened physical or sexual violence and psychological and emotional abuse. Screening for IPV during pregnancy is recommended for:a. Pregnant women with a history of domestic violenceb. All pregnant womenc. All low-income pregnant womend. Pregnant adolescents ANS: b Feedback a. Intimate partner violence is underreported by women, necessitating universal screening. b. Correct. AWHONN advocates for universal screening for domestic violence for all pregnant women. Homicide is the most likely cause of death for pregnant or recently pregnant women, and a significant portion of those homicides are committed by their intimate partners. One in six pregnant women reported physical or sexual abuse during pregnancy, seriously impacting maternal and fetal health and infant birth weight. c. IPV crosses all ethnic, racial, religious, and socioeconomic levels. d. IPV crosses all ethnic, racial, religious, and socioeconomic levels.

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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

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6. A woman presents to the prenatal clinic at 30 weeks’ gestation reporting dysuria, frequency, and urgency with urination. Appropriate nursing actions include:a. Obtain clean-catch urine to assess for a possible urinary tract infection.b. Reassure the woman that the signs are normal urinary changes in the third trimester.c. Teach the woman to decrease fluid intake to manage these symptoms.d. Perform a Leopold’s maneuver to assess fetal position and station.

ANS: a Feedback a. Correct. Dysuria, frequency, and urgency with urination are signs and symptoms of a urinary tract infection, necessitating further assessment and testing. b. These are abnormal urinary symptoms in the third trimester. c. Pregnant women need to increase their fluid intake during pregnancy, and dysuria and urgency are abnormal. d. Assessment of fetal position and station is not an appropriate response to reported signs and symptoms of a urinary tract infection.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 7. At the end of her 32-week prenatal visit, a woman reports discomfort with intercourse and tells you shyly that she wants to maintain a sexual relationship with her partner. The best response is to: a. Reassure woman/couple of normalcy of responseb. Suggest alternative positions for sexual intercourse and alternative sexual activity to sexual intercoursec. Recommend cessation of intercourse until after delivery due to advanced gestationd. Suggest woman discuss this with her care provider at her next appointment ANS: b Feedback a. Although this is a normal response, providing reassurance is not enough. Further intervention is indicated. b. Although shy to discuss this, she wants to maintain a sexual relationship with her partner.

Suggesting alternative positions for sexual intercourse and alternative sexual activity to sexual intercourse provides the woman with information to maintain sexual relations. c. She wants to maintain a sexual relationship with her partner, and there are no contraindications to intercourse during a healthy pregnancy. d. The patient is seeking out information and to defer her to her care provider at her next appointment is inappropriate. Additionally, she may not be comfortable discussing this with anyone else.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Complication | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 8. The clinic nurse talks to a 30-year-old woman at 34 weeks’ gestation who complains of having difficulty sleeping. Jayne has noticed that getting back to sleep after she has been up at night is difficult. The nurse’s best response is: a. ―This is abnormal; it is important that you describe this problem to the doctor.‖ b. ―This is normal, and many women have this same problem during pregnancy; try napping for several hours each morning and afternoon.‖

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c. ―This is abnormal; tell the doctor about this problem because diagnostic testing may be necessary.‖

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d. ―This is normal in pregnancy, particularly during the third trimester when you also feel fetal movement at night; try napping once a day.‖ ANS: d Feedback a. This sleep pattern is a normal finding. b. Sleeping for several hours in the morning and afternoon would contribute to further sleep disturbances at night. c. This sleep pattern is a normal finding. d. Pregnancy sleep patterns are characterized by reduced sleep efficiency, fewer hours of night sleep, frequent awakenings, and difficulty going to sleep. Nurses can advise patients that afternoon napping may help alleviate the fatigue associated with the sleep alterations.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 9. A 26-year-old woman at 29 weeks’ gestation experienced epigastric pain following the consumption of a large meal of fried fish and onion rings. The pain resolved a few hours later.

The most likely diagnosis for this symptom is: a. Cholelithiasis b. Influenza c. Urinary tract infection d. Indigestion ANS: a Feedback a. The progesterone-induced prolonged emptying time of bile from the gallbladder, combined with elevated blood cholesterol levels, may predispose the pregnant woman to gallstone formation (cholelithiasis). Pain in the epigastric region following ingestion of a high-fat meal constitutes the major symptom of these conditions. The pain is self-limiting and usually resolves within 2 hours. b. The symptoms described are not associated with influenza. c. The symptoms described are not associated with urinary tract infection. d. Prolonged emptying time of bile from the gallbladder, combined with elevated blood cholesterol levels, make cholelithiasis a more probable diagnosis than indigestion.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 10. The clinic nurse reviews the complete blood count results for a 30-year-old woman who is now 33 weeks’ gestation. Tamara’s hemoglobin value is 11.2 g/dL, and her hematocrit is 38%.

The clinic nurse interprets these findings as: a. Normal adult values b. Normal pregnancy values for the third trimester

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c. Increased adult values d. Increased values for 33 weeks’ gestation

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ANS: b Feedback a. The values are low normal for adults but represent normal findings for pregnant women. b. During pregnancy the woman’s hematocrit values may appear low due to the increase in total plasma volume (on average, 50%). Because the plasma volume is greater than the increase in erythrocytes (30%), the hematocrit decreases by about 7%. This alteration is termed ―physiologic anemia of pregnancy,‖ or ―pseudo-anemia.‖ The hemodilution effect is most apparent at 32 to 34 weeks. The mean acceptable hemoglobin level in pregnancy is 11 to 12 g/dL of blood. c. The values are not increased; they are low normal for adults but represent normal findings for pregnant women. d. The values are not increased; they are low normal for adults but represent normal findings for pregnant women.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 11. The clinic nurse is aware that the pregnant woman’s blood volume increases by: a. 20% to 25% b. 30% to 35% c. 40% to 45% d. 50% to 55% ANS: c Feedback a. An increase in maternal blood volume begins during the first trimester and peaks at term. The increase approaches 40% to 45%, not 20% to 25%. b. An increase in maternal blood volume begins during the first trimester and peaks at term. The increase approaches 40% to 45, not 30% to 35%. c. An increase in maternal blood volume begins during the first trimester and peaks at term. The increase approaches 40% to 45% and is primarily due to an increase in plasma and erythrocyte volume. Additional erythrocytes, needed because of the extra oxygen requirements of the maternal and placental tissue, ensure an adequate supply of oxygen to the fetus. The elevation in erythrocyte volume remains constant during pregnancy. d. An increase in maternal blood volume begins during the first trimester and peaks at term. The increase approaches 40% to 45%, not as high as 50% to 55%.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 12. The clinic nurse uses Leopold maneuvers to determine the fetal lie, presentation, and position. The nurse’s hands are placed on the maternal abdomen to gently palpate the fundal region of the uterus. This action is best described as the:

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a. First maneuver b. Second maneuver

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c. Third maneuver d. Fourth maneuver ANS: a Feedback a. Leopold maneuvers are a four-part clinical assessment method used to determine the lie, presentation, and position of the fetus. The first maneuver determines which fetal body part (e.g., head or buttocks) occupies the uterine fundus. The examiner faces the patient’s head and places the hands on the abdomen, using the palmar surface of the hands to gently palpate the fundal region of the uterus. The buttocks feel soft, broad, and poorly defined and move with the trunk.

The fetal head feels firm and round and moves independently of the trunk. b. Leopold maneuvers are a four-part clinical assessment method used to determine the lie, presentation, and position of the fetus. The first maneuver is described in this scenario. c. Leopold maneuvers are a four-part clinical assessment method used to determine the lie, presentation, and position of the fetus. The first maneuver is described in this scenario. d. Leopold maneuvers are a four-part clinical assessment method used to determine the lie, presentation, and position of the fetus. The first maneuver is described in this scenario.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 13. The clinic nurse talks with Kathy about her possible pregnancy. Kathy has experienced amenorrhea for 2 months, nausea during the day with vomiting every other morning, and breast tenderness. These symptoms are best described as: a. Positive signs of pregnancy b. Presumptive signs of pregnancy c. Probable signs of pregnancy d. Possible signs of pregnancy ANS: b Feedback a. Positive signs include fetal heartbeat, visualization of the fetus, and fetal movements palpated by the examiner. b. Presumptive signs of pregnancy include amenorrhea, nausea and vomiting, frequent urination, breast tenderness, perception of fetal movement, skin changes, and fatigue. Probable signs of pregnancy include abdominal enlargement, Piskacek sign, Hegar sign, Goodell sign, Braxton Hicks sign, positive pregnancy test, and ballottement. Positive signs include fetal heartbeat, visualization of the fetus, and fetal movements palpated by the examiner. c. Probable signs of pregnancy include abdominal enlargement, Piskacek sign, Hegar sign, Goodell sign, Braxton Hicks sign, positive pregnancy test, and ballottement. d. Possible signs of pregnancy may vary widely.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:

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Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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14. Lina is an 18-year-old woman at 20 weeks’ gestation. This is her first pregnancy. Lina is complaining of fatigue and listlessness. Her vital signs are within a normal range: BP = 118/60, pulse = 70, and respiratory rate 16 breaths per minute. Lina’s fundal height is at the umbilicus, and she states that she is beginning to feel fetal movements. Her weight gain is 25 pounds over the prepregnant weight (110 lb), and her height is 5 feet 4 inches. The perinatal nurse’s best approach to care at this visit is to: a. Ask Lina to keep a 3-day food diary to bring in to her next visit in 1 week. b. Explain to Lina that weight gain is not a concern in pregnancy, and she should not worry. c. Teach Lina about the expected normal weight gain during pregnancy (approximately 20 pounds by 20 weeks’ gestation). d. Explain to Lina the possible concerns related to excessive weight gain in pregnancy, including the risk of gestational diabetes.

ANS: a Feedback a. Nutrition and weight management play an essential role in the development of a healthy pregnancy. Not only does the patient need to have an understanding of the essential nutritional elements, she must also be able to assess and modify her diet for the developing fetus and her own nutritional maintenance. To facilitate this process, it is the nurse’s responsibility to provide education and counseling concerning dietary intake, weight management, and potentially harmful nutritional practices. To facilitate this process, it is the nurse’s responsibility to gather more information on the woman’s dietary practices through a food diary. b. Nutrition and weight management play an essential role in the development of a healthy pregnancy. To facilitate this process, it is the nurse’s responsibility to provide education and counseling concerning dietary intake, weight management, and potentially harmful nutritional practices. c. Nutrition and weight management play an essential role in the development of a healthy pregnancy. Not only does the patient need to have an understanding of the essential nutritional elements, she must also be able to assess and modify her diet for the developing fetus and her own nutritional maintenance. To facilitate this process, it is the nurse’s responsibility to provide education and counseling concerning dietary intake, weight management, and potentially harmful nutritional practices, not just inform the patient of expected normal weight gain. d. Nutrition and weight management play an essential role in the development of a healthy pregnancy. Not only does the patient need to have an understanding of the essential nutritional elements, she must also be able to assess and modify her diet for the developing fetus and her own nutritional maintenance. To facilitate this process, it is the nurse’s responsibility to provide education and counseling concerning dietary intake, weight management, and potentially harmful nutritional practices.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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15. A woman presents to a prenatal clinic appointment at 10 weeks’ gestation, in the first trimester of pregnancy. Which of the following symptoms would be considered a normal finding

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at this point in pregnancy? a. Occipital headache b. Urinary frequency c. Diarrhea d. Leg cramps ANS: b Feedback a. Headaches may be benign or, especially if noted after 20 weeks’ gestation, may be a symptom of pregnancy-induced hypertension (PIH). b. Urinary frequency is a common complaint of women during their first trimester. c. Diarrhea is rarely seen in pregnancy. Constipation is a common complaint. d. Leg cramps are commonly seen during the second and third trimesters.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 16. The nurse is providing prenatal teaching to a group of diverse pregnant women. One woman, who indicates she smokes two to three cigarettes a day, asks about its impact on her pregnancy.

The nurse explains that the most significant risk to the fetus is: a. Respiratory distress at birth b. Severe neonatal anemia c. Low neonatal birth weight d. Neonatal hyperbilirubinemia ANS: C Feedback a. Respiratory distress is not the most significant risk to the fetus unless the fetus is also premature. b. Severe neonatal anemia is not associated with pregnancies complicated by cigarette smoking. c. Low neonatal birth weight is the most common complication seen in pregnancies complicated by cigarette smoking. d. Neonatal hyperbilirubinemia is not associated with pregnancies complicated by cigarette smoking.

KEY: Integrated Process: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Application | Content Area: Antepartum Care; Growth and Development | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 17. While performing Leopold’s maneuvers on a woman in early labor, the nurse palpates a flat area in the fundal region, a hard round mass on the left side, a soft round mass on the right side, and small parts just above the symphysis. The nurse concludes which of the following? a. The fetal position is right occiput posterior.

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b. The fetal attitude is flexed.

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c. The fetal presentation is scapular. d. The fetal lie is vertical.

ANS: c Feedback a. This is a shoulder presentation. b. It is not possible to determine whether the attitude is flexed or not when doing Leopold’s maneuvers. c. This is a shoulder presentation. d. The lie is transverse or horizontal.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 18. A nurse is reviewing diet with a pregnant woman in her second trimester. Which of the following foods should the nurse advise the patient to avoid consuming during her pregnancy? a. Brie cheese b. Bartlett pears c. Sweet potatoes d. Grilled lamb ANS: a Feedback a. Soft cheese may harbor Listeria. The patient should avoid consuming uncooked soft cheese. b. A pear is an excellent food for a pregnant woman to consume. c. Sweet potatoes are an excellent food for a pregnant woman to consume. d. Grilled lamb is an excellent food for a pregnant woman to consume, although it should be well cooked.

KEY: Integrated Process: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate 19. The nurse is working in a prenatal clinic caring for a patient at 14 weeks’ gestation, G2 P1001. Which of the following findings should the nurse highlight for the nurse midwife? a. Body mass index of 23 b. Blood pressure of 100/60 c. Hematocrit of 29% d. Pulse rate of 76 bpm ANS: c Feedback

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a. A body mass index of 23 is normal. b. A blood pressure of 100/60 is normal.

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c. A hematocrit of 29% indicates that the patient is anemic. The nurse should highlight the finding for the nurse-midwife. d. A pulse rate of 76 bpm is a normal rate.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Laboratory Values | Client Need: Health Promotion and Maintenance: Antepartum Care; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Easy 20. A gravida, G4 P1203, fetal heart rate 150s, is 14 weeks pregnant, fundal height 1 cm above the symphysis. She denies experiencing quickening. Which of the following nursing conclusions made by the nurse is correct? a. The woman is experiencing a normal pregnancy. b. The woman may be having difficulty accepting this pregnancy. c. The woman must see a nutritionist as soon as possible. d. The woman will likely miscarry the conceptus.

ANS: a Feedback a. The patient is experiencing a normal pregnancy. b. Quickening is not felt until 16 to 20 weeks’ gestation. c. There is no apparent need for a nutritionist to see this patient. d. There is no indication in the scenario that this patient is at high risk for a miscarriage.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 21. A patient at 37 weeks’ gestation is being seen in the prenatal clinic. Where would the nurse expect the fundal height to be palpated? a. At the xiphoid process b. At a point between the umbilicus and the xiphoid c. At the umbilicus d. At a level directly above the symphysis pubis ANS: a Feedback a. At 36 weeks’ gestation, the fundus should be felt at the xiphoid process. b. At 36 weeks’ gestation, the fundus should be felt at the xiphoid process. c. At 20 weeks’ gestation, the fundus should be felt at the umbilicus. d. At 12 weeks’ gestation, the fundus should be felt directly above the symphysis pubis.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty

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Level: Easy

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22. A nurse is performing an assessment on a pregnant woman during a prenatal visit. Which of the following findings would lead the nurse to report to the obstetrician that the patient may be experiencing intrauterine growth restriction (IUGR)? a. Leopold’s maneuvers: Hard round object in the fundus, flat object on left of uterus, small parts on right of uterus, soft round object above the symphysis b. Weight gain: 6-pound increase over 4-week period c. Fundal height measurement: 22 cm at 26 weeks’ gestation d. Alpha-fetoprotein assessment: level is one-half normal, accompanied by complaints of severe nausea and vomiting ANS: c Feedback a. This baby is in the breech position. This is not a sign of IUGR. b. This weight gain is slightly above normal. This is not a sign of IUGR. c. The fundal height at 26 weeks should be approximately 26 cm. The fundal height, therefore, is below expected. This patient may be experiencing intrauterine growth restriction. d. A low AFP level is seen in patients whose babies have spina bifida and other central nervous system defects.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 23. A pregnant woman informs the nurse that her last normal menstrual period was on July 6, 2007. Using Naegele’s rule, which of the following would the nurse determine to be the patient’s estimated date of delivery (EDC)? a. January 9, 2008 b. April 13, 2008 c. April 20, 2008 d. September 6, 2008 ANS: b Feedback a. The EDC is calculated as April 13, 2008. b. The EDC is calculated as April 13, 2008. Naegele’s rule: subtract 3 months and add 7 days to the first day of the last normal menstrual period. c. The EDC is calculated as April 13, 2008. d. The EDC is calculated as April 13, 2008.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

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24. Which of the following findings, seen in pregnant women in the third trimester, would the nurse consider to be within normal limits?

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a. Diplopia b. Epistaxis c. Bradycardia d. Oliguria ANS: b Feedback a. Diplopia is sometimes seen in patients with pregnancy-induced hypertension (PIH). b. Epistaxis is commonly seen in pregnant patients. The bleeding is related to the increased vascularity of the mucous membranes. Unless the blood loss is significant, it is a normal finding. c. Bradycardia is often seen immediately after delivery but not during the third trimester. d. Oliguria is seen in patients with PIH. KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 25. A primigravida patient is 39 weeks pregnant. Which of the following symptoms would the nurse expect the patient to exhibit? a. Nausea b. Dysuria c. Urinary frequency d. Intermittent diarrhea ANS: c Feedback a. Nausea is usually not seen in the third trimester. b. Dysuria is not a normal finding at any time during a pregnancy. The possibility of a urinary traction infection (UTI) should be considered. c. Urinary frequency recurs at the end of the third trimester. As the uterus enlarges, it again compresses the bladder causing urinary frequency. d. Diarrhea is not a normal finding at any time during a pregnancy.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 26. The nurse has taken a health history on four multigravida patients at their first prenatal visits.

It is high priority that the patient whose first child was diagnosed with which of the following diseases receives nutrition counseling? a. Development dysplasia of the hip b. Achondroplastic dwarfism c. Spina bifida d. Muscular dystrophy

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ANS: c Feedback

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a. The etiology of developmental dysplasia of the hip is unrelated to the mother’s nutritional status. b. Achondroplasia is an inherited defect. Its etiology is unrelated to the mother’s nutritional status. c. The incidence of spina bifida is much higher in women with poor folic acid intakes. It is a priority that this patient receives nutrition counseling. d. Most forms of muscular dystrophy are inherited. Their etiologies are unrelated to the mother’s nutritional status.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Collaboration with Interdisciplinary Team; Management of Care: Referrals | Client Need: Health Promotion and Maintenance; Safe and Effective Care Environment: Management of Care | Difficulty Level: Moderate 27. A nurse working in a prenatal clinic is caring for a woman who asks advice on foods that are high in vitamin C because ―I hate oranges.‖ The nurse states that 1 cup of which of the following raw foods will meet the patient’s daily vitamin C needs? a. Strawberries b. Asparagus c. Iceberg lettuce d. Cucumber ANS: a Feedback a. Strawberries are an excellent source of vitamin C. b. Although asparagus has some vitamin C, it is not an excellent source. c. Iceberg lettuce is a poor source of vitamin C. d. Cucumber is a poor source of vitamin C. KEY: Integrated Process: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Knowledge | Content Area: Health and Wellness | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 28. The nurse notes each of the following findings in a woman at 10 weeks’ gestation. Which of the findings would enable the nurse to tell the woman that she is probably pregnant? a. Fetal heart rate via Doppler b. Positive pregnancy test c. Positive ultrasound assessment d. Absence of menstrual period ANS: b Feedback a. A fetal heart rate is a positive sign of pregnancy. b. A positive pregnancy test is a probable sign of pregnancy. It is not a positive sign because the

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hormone tested for—human chorionic gonadatropin (hCG)—may be being produced by, for example, a hydatidiform mole.

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c. A positive ultrasound is a positive sign of pregnancy. d. Amenorrhea is a presumptive sign of pregnancy.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Comprehension | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 29. A nurse who is discussing serving sizes of foods with a new prenatal patient would state that which of the following is equal to 1 (one) serving from the dairy food group? a.. 1 cup low-fat milk b. ½ cup vanilla yogurt c. ½ cup cottage cheese d.. 1 ounce cream cheese ANS: a Feedback a. 1 cup of any milk (e.g., whole milk, skim milk, buttermilk, chocolate milk) is equal to 1 serving size from the dairy group. b. 1 cup of yogurt is equal to 1 serving size from the dairy group. c. 1 ½ cup of cottage cheese is equal to 1 serving size from the dairy group. d. Cream cheese is not included in the dairy group. It is a fat product.

KEY: Integrated Process: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Comprehension | Content Area: Antepartum Care; Basic Care and Comfort: Nutrition | Client Need: Health Promotion and Maintenance; Physiological Integrity: Basic Care and Comfort | Difficulty Level: Easy 30. The nurse who is assessing a G2 P1 palpates the fundal height at the location noted on the picture below.

The nurse concludes that the fetus is equal to which of the following gestational ages? a. 12 weeks b. 20 weeks c. 28 weeks d. 36 weeks ANS: b Feedback a. At 12 weeks’ gestation, the fundus should be felt at the level of the symphysis pubis. b. The fundus at the level of the umbilicus indicates 20 weeks’ gestation. In this question, the fact that this patient is a multigravida is not relevant. Uterine growth should be consistent for both primigravidas and multigravidas. c. At 28 weeks’ gestation, the fundus should be felt 8 cm above the level of the umbilicus. d. At 36 weeks’ gestation, the fundus should be felt at the xiphoid process.

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KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 31. A patient at 28 weeks’ gestation was last seen in the prenatal clinic at 24 weeks’ gestation.

Which of the following changes should the nurse bring to the attention of the Certified Nurse Midwife? a. Weight change from 128 pounds to 132 pounds b. Pulse change from 88 bpm to 92 bpm c. Blood pressure change from 110/70 to 140/90 d. Respiratory change from 16 rpm to 20 rpm ANS: c Feedback a. A weight change of approximately 4 pounds in 4 weeks is normal in the second and third trimesters of pregnancy. b. This pulse rate change is within normal limits. c. A blood pressure elevation to 140/90 is a sign of mild preeclampsia. d. This respiratory rate change is within normal limits.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential— Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Easy 32. The clinic nurse includes screening for domestic violence in the first prenatal visit for all patients. An appropriate question would be: a. This is something that we ask everyone. Do you feel safe in your current living environment and relationships? b. This is something we ask everyone. Do you have any abuse in your life right now? c. Is your partner threatening or harming you in any way right now? d. I need to ask you, do you feel safe from abuse right now?

ANS: a Feedback a. Intimate partner violence is a difficult subject to discuss, and the nurse may fear insulting or psychologically hurting the patient more. A nonthreatening approach is to ask patients directly whether they feel safe going home and whether they have been hurt physically, emotionally, or sexually by a past or present partner. b. Intimate partner violence is a difficult subject to discuss, and the nurse may fear insulting or psychologically hurting the patient more. A nonthreatening approach is to ask patients directly whether they feel safe going home rather than asking if they have any abuse, as women may define abuse differently than care providers. c. Intimate partner violence is a difficult subject to discuss, and the nurse may fear insulting or

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psychologically hurting the patient more. A nonthreatening approach is to ask patients directly whether they feel safe going home and whether they have been hurt physically, emotionally, or

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sexually by a past or present partner. d. Intimate partner violence is a difficult subject to discuss, and the nurse may fear insulting or psychologically hurting the patient more. A nonthreatening approach is to ask patients directly whether they feel safe going home rather than asking if they have any abuse, as women may define abuse differently than care providers.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate Multiple Response 33. An 18-year-old woman at 23 weeks’ gestation tells the nurse that she has fainted two times.

The nurse teaches about the warning signs that often precede syncope so that she can sit or lie down to prevent personal injury. Warning signs include (select all that apply): a. Sweating b. Nausea c. Chills d. Yawning ANS: a, b, d Sweating is a warning sign that often precedes syncope. Syncope (a trandient loss of consciousness and postural tone with spontaneous recovery) during pregnancy is frequently attributed to orthostatic hypotension or inferior vena cava compression by the gravid uterus.

Nausea and yawning are warning signs that often precede syncope. Lightheadedness, sweating, nausea, yawning, and feelings of warmth are warning signs that often precede syncope. Chills are not a warning sign that often precede syncope.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 34. The perinatal nurse teaches the student nurse about the physiological changes in pregnancy that most often contribute to the increased incidence of urinary tract infections. These changes include (select all that apply): a. Relaxation of the smooth muscle of the urinary sphincter b. Relaxation of the smooth muscle of the bladder c. Inadequate emptying of the bladder d. Increased incidence of bacteriuria ANS: a, b, c, d Ascension of bacteria into the bladder can cause asymptomatic bacteriuria (ASB), or urinary tract infections (UTIs). These infections occur more frequently in pregnancy due to relaxation of the smooth muscle of the bladder and urinary sphincter and inadequate emptying of the bladder,

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changes that allow bacterial ascent into the bladder.

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KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 35. The clinic nurse discusses normal bladder function in pregnancy with a 22-year-old pregnant woman who is now in her 29th gestational week. The nurse explains that at this time in pregnancy, it is normal to experience (select all that apply): a. Urinary frequency b. Urinary urgency c. Nocturia d. Incontinence ANS: a, b, c During pregnancy, the bladder, a pelvic organ, is compressed by the weight of the growing uterus. The added pressure, along with progesterone-induced relaxation of the urethra and sphincter musculature, leads to urinary urgency, frequency, and nocturia. Incontinence of urine is not a normal change during pregnancy.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 36. A 32-year-old woman now at 32 weeks’ gestation is complaining of right-sided sharp abdominal pain. The patient is examined by the clinic nurse and given information about abdominal discomfort in pregnancy. She is also instructed to seek immediate attention if she (select all that apply): a. Has heartburn b. Has chills or a fever c. Feels decreased fetal movements d. Has increased abdominal pain ANS: b, c, d Heartburn is a common discomfort throughout pregnancy. Because the appendix is pushed upward and posterior by the gravid uterus, the typical location of pain is not a reliable indicator for a ruptured appendix during pregnancy. The pain should gradually subside, but if it persists or is accompanied by fever, a change in bowel habits, or decreased fetal movement, the patient should promptly contact her medical provider.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 37. The clinic nurse talks with Suzy, a pregnant woman at 9 weeks’ gestation who has just learned of her pregnancy. Suzy’s nausea and vomiting are most likely caused by (select all that apply):

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a. Increased levels of estrogen b. Increased levels of progesterone

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c. An altered carbohydrate metabolism d. Increased levels of human chorionic gonadotropin ANS: c, d Nausea and vomiting during the first trimester most likely are related to rising levels of human chorionic gonadotropin (hCG) and altered carbohydrate metabolism. Changes in taste and smell, due to alterations in the oral and nasal mucosa, can further aggravate the gastrointestinal discomfort.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 38. The clinic nurse encourages all pregnant women to increase their water intake to at least 8 to 10 glasses per day in order to (select all that apply): a. Decrease the risk of constipation b. Decrease the risk of bile stasis c. Decrease their feelings of fatigue d. Decrease the risk of urinary tract infections ANS: a, b, c, d Patients should be encouraged to drink at least 8 to 10 glasses of water each day and empty their bladders at least every 2 to 3 hours and immediately after intercourse. These measures will help prevent stasis of urine and the bacterial contamination that leads to infection, as well as constipation. Some women experience symptoms of fatigue that can be alleviated by remaining adequately hydrated.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 39. The perinatal nurse examines the thyroid gland as part of the physical examination of Savannah, a pregnant woman who is now at 16 weeks’ gestation. The perinatal nurse informs Savannah that during pregnancy (select all that apply): a. Increased size of the thyroid gland is normal b. Increased function of the thyroid gland is normal c. Decreased function of the thyroid gland is normal d. The thyroid gland will return to its normal size and function during the postpartal period ANS: a, b, d The thyroid gland changes in size and activity during pregnancy. Enlargement is caused by increased circulation from the progesterone-induced effects on the vessel walls, and by estrogeninduced hyperplasia of the glandular tissue. The thyroid gland increases not decreases in size and activity during pregnancy. The thyroid gland returns to normal size and activity postpartum.

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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40. The clinic nurse describes the respiratory system changes common to pregnancy to the new nurse. These changes include (select all that apply): a. An increased tidal volume b. A decreased airway resistance c. An increased chest circumference d. An increased airway resistance ANS: a, b, c During pregnancy, a number of changes occur to meet the woman’s increased oxygen requirements. The tidal volume (amount of air breathed in each minute) increases 30% to 40%.

The enlarging uterus creates an upward pressure that elevates the diaphragm and increases the subcostal angle. The chest circumference may increase by as much as 6 centimeters, and airway resistance decreases. Although the ―up and down‖ capacity of diaphragmatic movement is reduced, lateral movement of the chest and intercostal muscles accommodates for this loss of movement and keeps pulmonary functions stable. There is no increase in airway resistance during pregnancy.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 41. The clinic nurse teaches the new nurse about pregnancy-induced blood clotting changes. The nurse explains that a pregnant woman is at risk for venous thrombosis due to (select all that apply): a. Increased fibrinogen volume b. Increased blood factor V c. Increased blood factor X d. Venous stasis ANS: a, c, d Although the platelet cell count does not change significantly during pregnancy, fibrinogen volume has been shown to increase by as much as 50%. This alteration leads to an increase in the sedimentation rate. Blood factors VII, VIII, IX, and X are also increased, and this change causes hypercoagulability. The hypercoagulability state, coupled with venous stasis (poor blood return from the lower extremities) places the pregnant woman at an increased risk for venous thrombosis, embolism, and, when complications are present, disseminated intravascular coagulation (DIC). Blood factor V does not increase.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 42. The clinic nurse describes possible interventions for the pregnant woman who is experiencing pain and numbness in her wrists. The nurse suggests (select all that apply): a. Elevating the arms and wrists at night b. Reassessment during the postpartum period

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c. The use of ―cock splints‖ to prevent wrist flexion d. Massaging the hands and wrists with alcohol

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ANS: a, b, c Edema from vascular permeability can lead to a collection of fluid in the wrist that puts pressure on the median nerve lying beneath the carpal ligament, leading to carpal tunnel syndrome.

Elevation of the hands at night may help to reduce the edema. Occasionally, a woman may need to wear a ―cock splint‖ to prevent the wrist from flexing. Reassessment in the postpartum period is indicated because although carpal tunnel syndrome usually subsides after the pregnancy has ended, some women may require surgical treatment if symptoms persist. Massaging the hands and wrists with alcohol does not improve pain and numbness.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 43. The clinic nurse advocates for smoking cessation during pregnancy. Potential harmful effects of prenatal tobacco use include (select all that apply): a. Preterm birth b. Gestational hypertension c. Gestational diabetes d. Low birth weight ANS: a, d Nurses can help to improve the fetal environment by educating women about the dangers of direct and passive smoking during pregnancy. Effects of tobacco use during pregnancy are well documented and predispose to premature rupture of the membranes, preterm labor, placental abruption, placenta previa, and infants who are low birth weight or small for gestational age (SGA). Gestational hypertension and diabetes are not associated with smoking during pregnancy.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 44. Asking the pregnant woman about her use of recreational drugs is an essential component of the prenatal history. Harmful fetal effects that may occur from recreational drugs include (select all that apply): a. Miscarriage/spontaneous abortion b. Low birth weight c. Macrosomia d. Post-term labor/birth ANS: a, b Illegal or recreational drug use can have a number of detrimental effects on maternal and fetal health, including spontaneous abortion, low birth weight, placental abruption, and preterm labor.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment |

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Difficulty Level: Moderate

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45. The clinic nurse schedules Tracy for her first prenatal appointment with the certified nursemidwife (CNM) in the clinic. Tracy has appropriate questions for her potential health-care provider that include (select all that apply): a. Complementary and alternative methods used during labor and birth b. An opportunity to meet other providers in the practice c. Beliefs and practices concerning an episiotomy and an epidural anesthetic d. Whether the nurse-midwife will be continually available for support during labor ANS: a, b, c A woman’s journey through the pregnancy experience can have long-term effects on her selfperception and self-concept. Therefore, it is especially important that the patient choose a care provider and group with whom she can openly relate and who shares the same philosophical views on the management of pregnancy. At the first prenatal visit, it is not common to explore whether the nurse-midwife will be continually available for support during labor.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 46. The clinic nurse explains to Margaret, a newly diagnosed pregnant woman at 10 weeks’ gestation, that her rubella titer indicates that she is not immune. Margaret should be advised to (select all that apply): a. Avoid contact with all children b. Be retested in 3 months c. Receive the rubella vaccine postpartum d. Report signs or symptoms of fever, runny nose, and generalized red rash to the health-care provider ANS: c, d Testing for rubella (German measles) is not necessary as titers are reliable indicators of immunity. Rubella (German measles) is one of the most commonly recognized viral infections known to cause congenital problems. If a woman contracts rubella during the first 12 weeks of pregnancy, the fetus has a 90% chance of being adversely affected. A maternity patient who is not immune to rubella should be offered the rubella immunization following childbirth, ideally prior to hospital discharge. The patient should report signs or symptoms of rubella during pregnancy to her health-care provider. It is not realistic for a woman to avoid contact with all children.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 47. An overweight or obese pre-pregnancy weight increases the risk for which poor maternal outcomes? (Select all that apply.) a. Preeclampsia

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b. Hemorrhage

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c. Difficult delivery d. Vaginal infections ANS: a, b, c Being overweight or obese can substantially increase perinatal risk; however, no data support an increase in vaginal infections for the obese pregnant population.

KEY: Integrated Process: Knowledge | Cognitive Level: Complication | Content Area: Maternity | Client Need: Health Promotion and Maintenance: Antepartum Care | Difficulty Level: Moderate 48. Presumptive signs of pregnancy include (select all that apply): a. Nausea b. Fatigue c. Ballottement d. Amenorrhea ANS: a, b, d Nausea and vomiting, fatigue, and amenorrhea are all common during pregnancy and are the presumptive signs of pregnancy. Ballottement is a probably sign, noted during a vaginal exam.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 49. Physiologic changes that occur in the renal system during pregnancy predispose the pregnant woman to urinary tract infections (UTIs). Symptoms of a UTI include (select all that apply): a. Dysuria b. Hematuria c. Urgency d. Delayed urination ANS: a, b, c Urinary tract infection (UTI) symptoms include dysuria, hematuria, and urgency.

KEY: Integrated Process: Knowledge | Cognitive Level: Complication | Content Area: Maternity | Client Need: Physiologic Adaptation | Difficulty Level: Moderate 50. Urinary tract infection (UTI) prevention measures during pregnancy include counseling the pregnant woman to (select all that apply): a. Delay urination until bladder is full b. Limit hydration c. Wipe from front to back d. Urinate after intercourse ANS: a, c, d

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Anticipatory guidance for urinary tract infection prevention includes delaying urination, wipe front to back, and maintaining adequate hydration.

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 51. Interventions for low back pain during pregnancy should include (select all that apply): a. Utilizing proper body mechanics b. Applying ice or heat to affected area c. Avoiding pelvic rock and pelvic tilt d. Using additional pillows for support during sleep ANS: a, b, d Interventions for back pain during pregnancy include utilizing proper body mechanics, applying heat or ice to the area, using additional pillows during sleep, and not avoiding pelvic rock/tilt, but encouraging pelvic rock/tilt.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Intrapartum care | Client Need: Health Promotion and Maintenance: Intrapartum Care | Difficulty Level: Moderate 52. Jorgina is a 24-year-old pregnant woman at 26 weeks’ gestation. This is Jorgina’s third pregnancy, and her obstetrical history includes one full-term birth, one preterm birth, and two living children. Today Jorgina arrives at the clinic with complaints of fatigue, insomnia, and backache. She reports that she is a nurse on an oncology unit and is worried about continuing with working her 12-hour shifts. The perinatal nurse identifies concerns in Jorgina’s history and work environment including (select all that apply): a. Risk of preterm birth b. Presence of chemotherapeutic agents c. Requirement for heavy lifting d. History of diabetes ANS: a, b, c Women who are currently experiencing pregnancy complications and those who have a history of pregnancy complications (such as history of preterm birth) or other preexisting health disorders may be required to reduce their hours or stop working. The potential for maternal exposure to toxic substances such as chemotherapeutic agents, lead, and ionizing radiation (found in laboratories and health-care facilities); heavy lifting; and use of heavy machinery and other hazardous equipment should prompt reassignment to a different work area. If reassignment is not possible, Jorgina may need to stop working until the pregnancy has been completed. In this scenario there is no history of diabetes.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 53. The clinic nurse is assessing the complete blood count results for Kim-Ly, a 23-year-old

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pregnant woman. Kim-Ly’s hemoglobin is 9.8 g/dL. This laboratory finding places Kim-Ly’s pregnancy at risk for (select all that apply):

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a. Preterm birth b. Placental abruption c. Intrauterine growth restriction d. Thrombocytopenia ANS: a, c True anemia, or iron-deficiency anemia, occurs when the hemoglobin level drops below 10 g/dL. The blood’s decreased oxygen-carrying capacity causes a reduction in oxygen transport to the developing fetus. Decreased fetal oxygen transport has been associated with intrauterine growth restriction (IUGR) and preterm birth. There is not a risk factor for abruption or thrombocytopenia.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 54. Teera is a 22-year-old woman who is experiencing her third pregnancy. Her obstetrical history includes one first-trimester elective abortion and one first-trimester spontaneous abortion.

Teera is a semi-vegetarian who drinks milk and eats yogurt and fish as part of her daily intake.

The perinatal nurse discusses Teera’s diet with her as she may be deficient in (select all that apply): a. Iron b. Magnesium c. Zinc d. Vitamin B12 ANS: a, c Semi-vegetarian diets include fish, poultry, eggs, and dairy products but no beef or pork and have adequate intake of magnesium. Pregnant women who adhere to this diet may consume inadequate amounts of iron and zinc. Because strict vegetarians (vegans) consume only plant products, their diets are deficient in vitamin B12, found only in foods of animal origin.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 55. During the initial antenatal visit, the clinic nurse asks questions about the woman’s nutritional intake. Specific questions should include information pertaining to (select all that apply): a. Preferred foods b. The presence of cravings c. Use of herbal supplements d. Aversions to certain foods and odors ANS: a, b, c, d

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The nurse should obtain a nutritional history on all pregnant patients and patients of childbearing age to gain specific information related to the pregnancy, including foods that are preferred while

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pregnant (which may provide information about cultural and environmental dietary factors), special diets (which will assist the nurse in planning for education or interventions for risk factors associated with dietary practices), cravings or aversions to specific foods, and use of herbal supplements.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 56. The perinatal nurse talks to the prenatal class attendees about guidelines for exercise in pregnancy. Recommended guidelines include (select all that apply): a. Stopping if the woman is tired b. Bouncing and slowly arching the back c. Increasing fluid intake throughout the physical activity d. Maintaining the ability to walk and talk during exercise ANS: a, c, d Women should adhere to some basic safety guidelines when formulating their exercise program, including monitoring the breathing rate and ensuring that the ability to walk and talk comfortably is maintained during physical activity, stopping exercise when the woman becomes tired, and maintaining adequate fluid intake. Pregnant women should avoid exercises that can cause any degree of trauma to the abdomen or those that include rigorous bouncing, arching of the back, or bending beyond a 45-degree angle.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate Short Answer 57. Lesions at the gum line that bleed easily ANS: Epulis gravidarum Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 58. Anterior convexity of the lumbar spine ANS: Lumbar lordosis Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 59. Increased saliva production

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ANS: Ptyalism Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 60. Reflux of the stomach contents into the esophagus ANS: Pyrosis Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 61. Severe itching due to stasis of bile in the liver ANS: Pruritis gravidarum Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 62. Nosebleeds ANS: Epistaxis Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy True/False 63. The clinic nurse speaks with the student nurse prior to the physical examination of a pregnant woman who is 32 weeks’ gestation. The clinic nurse explains that the heart sounds heard in pregnancy are usually S1 and S3 with a possible murmur related to increased cardiac output.

ANS: True Exaggerated first and third heart sounds and systolic murmurs are common findings during pregnancy. The murmurs are usually asymptomatic and require no treatment.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 64. Cecilia, a pregnant woman at 30 weeks’ gestation, has her vital signs assessed during a routine prenatal visit. Cecilia’s blood pressure has remained at 110/70 for the last few visits, and

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her pulse rate has increased from 70 to 80 beats per minute. These findings would be considered normal at this time in pregnancy.

ANS: True During the first trimester, blood pressure normally remains the same as prepregnancy levels but then gradually decreases up to around 20 weeks’ of gestation. After 20 weeks, the vascular volume expands and the blood pressure increases to reach prepregnant levels by term.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 65. The clinic nurse knows that every time a woman of childbearing age comes in to the office for a health maintenance visit, she should be counseled about the benefits of daily folic acid supplementation.

ANS: True Because of the strong connection between folic acid deficiency and the subsequent development of neural tube defects, all women of childbearing age should take a folic acid supplement of at least 400 mcg/day.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 66. The perinatal nurse recommends strengthening exercises during pregnancy, as this can improve posture and increase energy levels.

ANS: True Muscle strengthening benefits the woman as she copes with the physical changes of pregnancy, which include weight gain and postural changes. Muscle strengthening exercises also help to decrease the risk of ligament and joint injury.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 67. The perinatal nurse explains to the new nurse that ptyalism is a condition more acute than the normal nausea and vomiting of pregnancy and is often associated with dehydration, hypokalemia, and weight loss.

ANS: False Hyperemesis gravidarum is a pregnancy-related condition characterized by persistent, continuous, severe nausea and vomiting, often accompanied by dry retching. Hyperemesis gravidarum results in weight loss and fluid and electrolyte imbalance. Ptyalism is an excessive

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production of saliva.

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate Fill-in-the-Blank 68. The clinic nurse explains to the new nurse that during pregnancy, the maternal metabolism is altered to support the pregnancy by the hormones and , which are produced by the anterior gland.

ANS: thyrotropin; adrenotropin; pituitary Maternal metabolism is altered to support the pregnancy by thyrotropin and adrenotropin. These hormones, produced by the anterior pituitary gland, exert their effects on the thyroid and adrenal glands. Thyrotropin causes an increased basal metabolism, and adrenotropin alters adrenal gland function to increase fluid retention by the kidneys.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 69. During the prenatal class, the perinatal nurse describes factors that may initiate the process of labor. One of these factors is the production of , which are found in the uterine and are released from the at term as it softens and dilates.

ANS: prostaglandins; decidua or lining; cervix Prostaglandins are lipid substances found in high concentrations in the female reproductive tract and in the uterine decidua during pregnancy. Their exact function in pregnancy is unknown, although they may maintain a reduced placental vascular resistance. A decrease in prostaglandin levels may contribute to hypertension and preeclampsia. At term, an increased release of prostaglandins from the cervix as it softens and dilates may contribute to the onset of labor.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 70. The perinatal nurse describes common complaints of pregnancy to the prenatal class attendees. Nasal , medically termed ― of pregnancy,‖ is caused by increased levels of estrogen and progesterone.

ANS: stuffiness; rhinitis Nasal stuffiness and congestion (rhinitis of pregnancy) are common complaints during pregnancy. The nurse should educate the patient about these normal changes and offer reassurance. Increasing oral fluid intake helps to keep the mucus thin and easier to mobilize.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

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71. The clinic nurse promotes a diet rich in vitamin during the third trimester to prevent the possibility of rupture of the membranes.

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ANS: C; premature Low levels of vitamin C may predispose women to premature rupture of membranes. As the cellular availability of vitamin C decreases, the rate of degradation of cervical collagen increases.

With decreased collagen, the cervix more easily ripens, prompting effacement and dilatation.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 72. The clinic nurse monitors the blood pressure and assesses a woman’s urine at each prenatal visit to assess for signs or symptoms of . A previous history or the presence of a are also risk factors.

ANS: preeclampsia; new partner A previous history of preeclampsia increases the woman’s likelihood of a recurrence during subsequent pregnancies. If a woman did not experience preeclampsia with previous pregnancies but has a new partner for her current pregnancy, her risk of developing preeclampsia is similar to that of a woman who is pregnant for the first time. Although preeclampsia is a systemic disorder that occurs only during pregnancy, it is generally recognized by two classic symptoms: elevated blood pressure and proteinuria.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 73. The clinic nurse is aware of the importance of chlamydia screening during pregnancy.

Chlamydia transmission to the infant at may result in .

ANS: birth; ophthalmia neonatorum Chlamydia trachomatis is a bacteria that causes infection that is prevalent in sexually active populations, especially those in the under-25 age group. Complications of chlamydia infections include salpingitis, pelvic inflammatory disease, infertility, ectopic pregnancy, premature rupture of the membranes, and preterm birth. Transmission to the neonate may occur during birth and results in ophthalmia neonatorum and chlamydial neonatal pneumonia.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 74. The prenatal nurse describes the need for and screening at the first antenatal visit. If the pregnant woman is not immune, she will be counseled to avoid contact with young children who have a rash and could be infectious.

ANS: rubella; varicella

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Some of the routine maternal laboratory tests screen for childhood diseases that are known to cause congenital anomalies or other pregnancy complications if contracted during early pregnancy. When contracted during the first trimester, rubella causes a number of fetal

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deformities. Varicella (chickenpox) is another common childhood disease that may cause problems in the developing embryo and fetus. Therefore, all pregnant women are screened for rubella and varicella.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 75. The prenatal nurse cautions a pregnant woman about Caesar salad consumption during pregnancy or any source of or milk.

ANS: raw eggs; unpasteurized A word of caution should be provided by health-care providers to pregnant women with regard to microbial food-borne illness. Raw, or unpasteurized, milk as well as partially cooked eggs and foods containing raw or partially cooked eggs should be avoided.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 76. The clinic nurse describes to the student nurse that is excessive saliva production in pregnancy. This condition is most likely caused by increased levels.

ANS: ptyalism; hormone Ptyalism, or excessive salivation, can be quite distressing for the pregnant woman who must frequently wipe her mouth or spit into a cup. Although the cause of ptyalism is unknown, it is most likely related to increased hormone levels.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 77. The clinic nurse talks with the newly diagnosed pregnant woman about the nausea that the woman is experiencing in this pregnancy. The clinic nurse suggests eating meals more often, remaining after eating, and the using techniques.

ANS: smaller; upright; relaxation Nausea is often one of the first symptoms of pregnancy experienced. Nurses can suggest strategies to help offset the nausea, such as the avoidance of ―trigger foods‖ (foods that cause nausea from sight or smell) and tight clothing that constricts the abdomen. The use of relaxation techniques (i.e., slow, deep breathing, mental imagery) can also help to decrease nausea. Other techniques that are often helpful include consuming plain, dry crackers or sucking on peppermint candy before arising; adhering to small, frequent meals; and remaining in an upright position after eating.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:

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Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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78. The clinic nurse understands that the physiological changes of pregnancy include vascular relaxation from the effects of and impaired venous circulation from pressure exerted by the enlarged uterus, predisposing the pregnant woman to .

ANS: progesterone; varicose veins Progesterone results in vascular relaxation which combined with impaired venous return increases the incidence of varicose veins in pregnant women.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 79. The perinatal nurse knows that a common .

, which is the eating of nonnutritive substances, is

ANS: pica; eating disorder Pica, the consumption of nonnutritive substances or food, is a common eating disorder that can affect pregnancy. Substances that are most often ingested include clay, dirt, cornstarch, and ice.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy Matching The clinic nurse understands the meaning of the following terms related to pregnancy care.

Match these terms with the definitions listed below: Advocacy Lordosis Amenorrhea Ballottement Striae gravidarum Preterm birth 80. Passive movement of the unengaged fetus ANS: Ballottement Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 81. Verbalizing someone else’s wishes if he or she is unable to do so ANS: Advocacy Refer To: Chapter 2

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 82. Absence of menses ANS: Amenorrhea Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 83. Curvature of the spine ANS: Lordosis Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 84. Stretch marks ANS: Striae gravidarum Refer To: Glossary KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy The perinatal nurse talks to the prenatal class attendees about guidelines for exercise in pregnancy. Recommended guidelines include (select all that apply):Select one or more: a. Stopping if the woman is tired b. Bouncing and slowly arching the back c. Increasing fluid intake throughout the physical activity d. Maintaining the ability to walk and talk during exercise A, C D A 26-year-old woman at 29 weeks' gestation experienced epigastric pain following the consumption of a large meal of fried fish and onion rings. The painresolved a few hours later. The most likely diagnosis for this symptom is: Select one: a. Cholelithiasis b. Influenza

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c. Urinary tract infection d. Indigestion A The clinic nurse includes screening for domestic violence in the first prenatal visitfor all patients. An appropriate question would be: Select one: a. This is something that we ask everyone. Do you feel safe in your current living environment and relationships? b. This is something we ask everyone. Do you have any abuse in your life rightnow? c. Is your partner threatening or harming you in any way right now? d. I need to ask you, do you feel safe from abuse right now?

A Cecilia, a pregnant woman at 30 weeks' gestation, has her vital signs assessed during a routine prenatal visit. Cecilia's blood pressure has remained at 110/70for the last few visits, and her pulse rate has increased from 70 to 80 beats perminute. These findings would be considered normal at this time in pregnancy.Select one: True False True The clinic nurse explains to Margaret, a newly diagnosed pregnant woman at 10weeks' gestation, that her rubella titer indicates that she is not immune.

Margaret should be advised to (select all that apply): Select one or more: a. Avoid contact with all children b. Be retested in 3 months c. Receive the rubella vaccine postpartum d. Report signs or symptoms of fever, runny nose, and generalized red rash to thehealthcare provider C, D Which of the following findings, seen in pregnant women in the third trimester,would the nurse consider to be within normal limits?

Select one:

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a. Diplopia B. Epistaxis c. Bradycardia d. Oliguria B Interventions for low back pain during pregnancy should include (select all thatapply): Select one or more: a. Utilizing proper body mechanics b. Applying ice or heat to affected area c. Avoiding pelvic rock and pelvic tilt d. Using additional pillows for support during sleep A, B, D Interventions for back pain during pregnancy include utilizing proper body mechanics, applying heat or ice to the area, using additional pillows during sleep, and not avoiding pelvic rock/tilt, but encouraging pelvic rock/tilt.

The clinic nurse is assessing the complete blood count results for Kim-Ly, a 23-year-old pregnant woman. Kim-Ly's hemoglobin is 9.8 g/dL. This laboratory finding places Kim-Ly's pregnancy at risk for (select all that apply): Select one or more: a. Preterm birth b. Placental abruption c. Intrauterine growth restriction d. Thrombocytopenia A, C At the end of her 32-week prenatal visit, a woman reports discomfort with intercourse and tells you shyly that she wants to maintain a sexual relationshipwith her partner. The best response is to: Select one: a. Reassure woman/couple of normalcy of response b. Suggest alternative positions for sexual intercourse and alternative sexualactivity to sexual intercourse c. Recommend cessation of intercourse until after delivery due to advancedgestation d. Suggest woman discuss this with her care provider at her next appointment B

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The clinic nurse encourages all pregnant women to increase their water intake toat least 8 to 10 glasses per day in order to (select all that apply): Select one or more: a. Decrease the risk of constipation b. Decrease the risk of bile stasis c. Decrease their feelings of fatigue d. Decrease the risk of urinary tract infections A,C,D The clinic nurse discusses normal bladder function in pregnancy with a 22 year old pregnant woman who is now in her 29th gestational week. The nurse explainsthat at this time in pregnancy, it is normal to experience (select all that apply): Select one or more: a. Urinary frequency b. Urinary urgency c. Nocturia d. Incontinence A,B,C During the initial antenatal visit, the clinic nurse asks questions about thewoman's nutritional intake. Specific questions should include informationpertaining to (select all that apply): Select one or more: a. Preferred foods b. The presence of cravings c. Use of herbal supplements d. Aversions to certain foods and odors A,B,C,D The nurse should obtain a nutritional history on all pregnant patients and patients of childbearing age to gain specific information related to the pregnancy, including foods that are preferred while pregnant (which may provide information about cultural and environmental dietary factors), special diets (which will assist the nurse in planning for education or interventions for risk factors associated with dietary practices), cravings or aversions to specific foods, and use of herbal supplements.

Presumptive signs of pregnancy include (select all that apply):Select one or more: a. Nausea b. Fatigue

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c. Ballottement d. Amenorrhea A,B,D The clinic nurse uses Leopold maneuvers to determine the fetal lie, presentation,and position. The nurse's hands are placed on the maternal abdomen to gently palpate the fundal region of the uterus. This action is best described as the: Select one: a. First maneuver b. Second maneuver c. Third maneuver d. Fourth maneuver A The nurse is working in a prenatal clinic caring for a patient at 14 weeks' gestation, G2 P1001. Which of the following findings should the nurse highlightfor the nurse midwife?

Select one: a. Body mass index of 23 b. Blood pressure of 100/60 c. Hematocrit of 29% d. Pulse rate of 76 bpm C The perinatal nurse teaches the student nurse about the physiological changes in pregnancy that most often contribute to the increased incidence of urinary tractinfections.

These changes include (select all that apply): Select one or more: a. Relaxation of the smooth muscle of the urinary sphincter b. Relaxation of the smooth muscle of the bladder c. Inadequate emptying of the bladder d. Increased incidence of bacteriuria A,B, C, D Asking the pregnant woman about her use of recreational drugs is an essential component of the prenatal history. Harmful fetal effects that may occur from recreational drugs include (select all that apply): Select one or more:

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a. Miscarriage/spontaneous abortion b. Low birth weight c. Macrosomia d. Postterm labor/birth A,B A nurse is reviewing diet with a pregnant woman in her second trimester. Whichof the following foods should the nurse advise the patient to avoid consuming during her pregnancy?

Select one: a. Brie cheese b. Bartlett pears c. Sweet potatoes d. Grilled lamb A The nurse who is assessing a G2 P1 palpates the fundal height at the location noted on the picture below. The nurse concludes that the fetus is equal to whichof the following gestational ages?

Select one: a. 12 weeks b. 20 weeks c. 28 weeks d. 36 weeks B A nurse working in a prenatal clinic is caring for a woman who asks advice on foods that are high in vitamin C because "I hate oranges." The nurse states that1 cup of which of the following raw foods will meet the patient's daily vitamin Cneeds?

Select one: a. Strawberries b. Asparagus c. Iceberg lettuce d. Cucumber A

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The perinatal nurse explains to the new nurse that ptyalism is a condition moreacute than the normal nausea and vomiting of pregnancy and is often associatedwith dehydration, hypokalemia, and weight loss.

Select one: True False False The nurse has taken a health history on four multigravida patients at their first prenatal visits. It is high priority that the patient whose first child was diagnosedwith which of the following diseases receives nutrition counseling?

Select one: a. Development dysplasia of the hip b. Achondroplastic dwarfism c. Spina bifida d. Muscular dystrophy C The perinatal nurse recommends strengthening exercises during pregnancy, asthis can improve posture and increase energy levels.

Select one: True False True A gravida, G4 P1203, fetal heart rate 150s, is 14 weeks pregnant, fundal height 1cm above the symphysis. She denies experiencing quickening. Which of the following nursing conclusions made by the nurse is correct?

Select one: a. The woman is experiencing a normal pregnancy. b. The woman may be having difficulty accepting this pregnancy. c. The woman must see a nutritionist as soon as possible. d. The woman will likely miscarry the conceptus. .

A The clinic nurse describes the respiratory system changes common to pregnancyto the new nurse. These changes include (select all that apply): Select one or more:

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a. An increased tidal volume b. A decreased airway resistance c. An increased chest circumference d. An increased airway resistance A,B The clinic nurse talks with Kathy about her possible pregnancy. Kathy has experienced amenorrhea for 2 months, nausea during the day with vomiting every other morning, and breast tenderness. These symptoms are best describedas: Select one: a. Positive signs of pregnancy b. Presumptive signs of pregnancy c. Probable signs of pregnancy d. Possible signs of pregnancy B Teera is a 22-year-old woman who is experiencing her third pregnancy. Her obstetrical history includes one first-trimester elective abortion and one first- trimester spontaneous abortion. Teera is a semi-vegetarian who drinks milk andeats yogurt and fish as part of her daily intake. The perinatal nurse discusses Teera's diet with her as she may be deficient in (select all that apply): Select one or more: a. Iron b. Magnesium c. Zinc d. Vitamin B12 A A woman presents to a prenatal clinic appointment at 10 weeks' gestation, in thefirst trimester of pregnancy. Which of the following symptoms would be considered a normal finding at this point in pregnancy?

Select one: a. Occipital headache b. Urinary frequency c. Diarrhea d. Leg cramps B

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Lina is an 18-year-old woman at 20 weeks' gestation. This is her first pregnancy.Lina is complaining of fatigue and listlessness. Her vital signs are within a normal range: BP = 118/60, pulse = 70, and respiratory rate 16 breaths per minute. Lina's fundal height is at the umbilicus, and she states that she is beginning to feel fetal movements. Her weight gain is 25 pounds over the prepregnant weight (110 lb), and her height is 5 feet 4 inches. The perinatal nurse's best approach to care at this visit is to: Select one: a. Ask Lina to keep a 3-day food diary to bring in to her next visit in 1 week. b. Explain to Lina that weight gain is not a concern in pregnancy, and she shouldnot worry. c. Teach Lina about the expected normal weight gain during pregnancy (approximately 20 pounds by 20 weeks' gestation). d. Explain to Lina the possible concerns related to excessive weight gain in pregnancy, including the risk of gestational diabetes.

A The clinic nurse describes possible interventions for the pregnant woman who is experiencing pain and numbness in her wrists. The nurse suggests (select all thatapply): Select one or more: a. Elevating the arms and wrists at night b. Reassessment during the postpartum period c. The use of "cock splints" to prevent wrist flexion A,B,C A nurse who is discussing serving sizes of foods with a new prenatal patient would state that which of the following is equal to 1 (one) serving from the dairyfood group?

Select one: a. 1 cup low-fat milk b. cup vanilla yogurt c. cup cottage cheese d. 1 ounce cream cheese A The clinic nurse is aware that the pregnant woman's blood volume increases by:Select one: a. 20% to 25%

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b. 30% to 35% c. 40% to 45% d. 50% to 55% C The clinic nurse understands the meaning of the following terms related topregnancy care.

Match these terms with the definitions listed below: Passive movement of the unengaged fetus: BallotementCurvature of the spine: Lordosis Verbalizing someone else's wishes if he or she is unable to do so: AdvocacyAbsence of menses: Amenorrhea Stretch marks: Striae gravidarum Lordosis Advocacy Amenorrhea gravidarum An overweight or obese pre-pregnancy weight increases the risk for which poormaternal outcomes? (Select all that apply.) a. Preeclampsia b. Hemorrhage c. Difficult delivery d. Vaginal infections A,B Being overweight or obese can substantially increase perinatal risk; however, no data support an increase in vaginal infections for the obese pregnant population.

The clinic nurse reviews the complete blood count results for a 30-year-old woman who is now 33 weeks' gestation. Tamara's hemoglobin value is 11.2 g/dL,and her hematocrit is 38%. The clinic nurse interprets these findings as: a. Normal adult values b. Normal pregnancy values for the third trimester c. Increased adult values d. Increased values for 33 weeks' gestation B The nurse is providing prenatal teaching to a group of diverse pregnant women.One woman, who indicates she smokes two to three cigarettes a day, asks about

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its impact on her pregnancy. The nurse explains that the most significant risk tothe fetus is: Select one: a. Respiratory distress at birth b. Severe neonatal anemia c. Low neonatal birth weight d. Neonatal hyperbilirubinemia C A nurse is performing an assessment on a pregnant woman during a prenatal visit. Which of the following findings would lead the nurse to report to the obstetrician that the patient may be experiencing intrauterine growth restriction(IUGR)?

Select one: a. Leopold's maneuvers: Hard round object in the fundus, flat object on left ofuterus, small parts on right of uterus, soft round object above the symphysis b. Weight gain: 6-pound increase over 4-week period c. Fundal height measurement: 22 cm at 26 weeks' gestation d. Alpha-fetoprotein assessment: level is one-half normal, accompanied by complaints of severe nausea and vomiting C Which of the following would be a priority for the nurse when caring for apregnant woman who has recently emigrated from another country?

Select one: a. Help her develop a realistic, detailed birth plan. b. Identify her support system. c. Teach her about expected emotional changes of pregnancy. d. Refer her to a doula for labor support.

B When providing a psychosocial assessment on a pregnant woman at 21 weeks'gestation, the nurse would expect to observe which of the following signs?

Select one: a. Ambivalence b. Depression c. Anxiety d. Happiness

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C The correct answer is: Anxiety The maternal tasks of pregnancy include acceptance of pregnancy and generally happy feelings during this time. Adaptation to pregnancy in the second trimester, more specifically, includes anxiety regarding body changes, and the presence of fears and phobias. Feelings of anxiety in addition to changes in body image include loss of old life, changing relationships with friends and family, changes in sexual activity and "tuning in" to the fetus in terms of movement, etc.

Jenny, a 21-year-old single woman, comes for her first prenatal appointment at 31 weeks' gestation with her first pregnancy. The clinic nurse's most appropriatestatement is: Select one: a. "Jenny, it is late in your pregnancy to be having your first appointment, but itis nice to meet you and I will try to help you get caught up in your care." b. "Jenny, have you had care in another clinic? I can't believe this is your first appointment!" c. "Jenny, by the date of your last menstrual period, you are 31 weeks and now that you are finally here, we need you to come monthly for the next two visits andthen weekly." d. "Jenny, by your information, you are 31 weeks' gestation in this pregnancy. Doyou have questions for me before I begin your prenatal history and information sharing?"

D Strategies for culturally responsive care include (select all that apply):Select one or more: a. Practicing ethnocentrism b. Applying stereotyping c. Examining one's own biases d. Learning another language C,D The perinatal nurse screens all pregnant women early in pregnancy for maternalattachment risk factors, which include (select all that apply): Select one or more: a. Adolescence b. Low educational level c. History of depression d. A strong support system for the pregnancy A,B,C

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Sally is in her third trimester and has begun to sing and talk to the fetus. Sally isprobably exhibiting signs of: Select one: a. Mental illness b. Delusions c. Attachment d. Crisis C The clinic nurse encourages paternal attachment during pregnancy by includingthe father in (select all that apply): Select one or more: a. Prenatal visits b. Ultrasound appointments c. Prenatal class information d. History taking and obtaining prenatal screening information A,B,C The clinic nurse meets with Rebecca, a 30-year-old woman who is experiencingher first pregnancy. Rebecca's quadruple marker screen result is positive at 17 weeks' gestation.

The nurse explains that Rebecca may need a referral to: Select one: a. A genetics counselor/specialist for further diagnostic testing b. An obstetrician c. A gynecologist d. A social worker A Your pregnant patient is in her first trimester and is scheduled for an abdominal ultrasound. When explaining the rationale for early pregnancy ultrasound, the best response is: Select one: a. "The test will help to determine the baby's position." b. "The test will help to determine how many weeks you are pregnant." c. "The test will help to determine if your baby is growing appropriately." d. "The test will help to determine if you have a boy or girl."

B

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Your patient is 34 weeks pregnant and during a regular prenatal visit tells you she does not understand how to do "kick counts." The best response by the nursewould be to explain: Select one: a. "Here is an information sheet on how to do kick counts." b. "It is not important to do kick counts because you have a low-risk pregnancy." c. "Fetal kick counts are not a reliable indicator of fetal well-being in the third trimester." d. "Fetal movements are an indicator of fetal well-being. You should count twicea day, and you should feel 10 fetal movements within 2 hours."

D Maternal assessment of fetal movement by counting fetal movements in a period time can identify potentially hypoxic fetuses. Fetal activity is diminished in the compromised fetus. The pregnant woman is instructed to palpate her abdomen and track fetal movements daily for 1-2 hours. Ten distinct fetal movements within 2 hours is considered normal. Once movement is achieved, counts can be discontinued for the day.

A 37-year-old woman who is 17 weeks pregnant has had an amniocentesis. Beforedischarge, the nurse teaches the woman to call her doctor if she experiences which of the following side effects?

Select one: a. Pain at the puncture site b. Macular rash on the abdomen c. Decrease in urinary output d. Cramping of the uterus D Your pregnant patient is having maternal alpha-fetoprotein (AFP) screening. Shedoes not understand how a test on her blood can indicate a birth defect in the fetus. The best reply by the nurse is: Select one: a. "We have done this test for a long time." b. "If babies have a neural tube defect, alpha-fetoprotein leaks out of the fetus and is absorbed into your blood, causing your level to rise. This serum blood testdetects that rise." c. "Neural tube defects are a genetic anomaly, and we examine the amount ofalphafetoprotein in your DNA." d. "If babies have a neural tube defect, this results in a decrease in your level ofalphafetoprotein."

B

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Which statement best exemplifies adaptation to pregnancy in relation to theadolescent?

Select one: a. Adolescents adapt to motherhood in a similar way to other childbearingwomen. b. Social support has very little effect on adolescent adaptation to pregnancy. c. The pregnant adolescent faces the challenge of multiple developmental tasks. d. Pregnant adolescents of all ages can be capable and active participants inhealthcare decisions.

C What is the most common expected emotional reaction of a woman to the newsthat she is pregnant?

Select one: a. Jealousy b. Acceptance c. Ambivalence d. Depression B The clinic nurse visits with Wayne, a 32-year-old man whose partner is pregnantfor the first time and is at 12 weeks. Wayne describes nausea and vomiting, fatigue, and weight gain. His symptoms are best described as: a. Influenza b. Couvade syndrome c. Acid reflux d. Cholelithiasis B Your patient is a 37-year-old pregnant woman who is 5 weeks pregnant and is considering genetic testing. During your discussion, the woman asks the nurse what the advantages of chorionic villus sampling (CVS) are over amniocentesis.The best response is: a. "You will need anesthesia for amniocentesis, but not for CVS." b. "CVS is a faster procedure." c. "CVS provides more detailed information than amniocentesis." d. "CVS can be done earlier in your pregnancy, and the results are availablemore quickly."

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D An example of a cultural prescriptive belief during pregnancy is:Select one: a. Remain active during pregnancy b. Coldness in any form should be avoided c. Do not have your picture taken d. Avoid sexual intercourse during the third trimester A Feedback: The belief that the patient should remain active during pregnancy is the only example of a cultural prescriptive belief. All of the other answers are examples of cultural restrictive beliefs.

Which of the following information regarding sexual activity would the nursegive a pregnant woman who is 35 weeks' gestation?

Select one: a. Sexual activity should be avoided from now until 6 weeks postpartum. b. Sexual desire may be affected by nausea and fatigue. c. Sexual desire may be increased due to increased pelvic congestion. d. Sexual activity may require different positions to accommodate the woman'scomfort.

D Jane's husband Brian has begun to put on weight. What is this a possible sign of?Select one: a. Culturalism syndrome b. Couvade syndrome c. Moratorium phase d. Attachment B A laboratory report indicates the L/S ratio (lecithin/sphingomyelin) results froman amniocentesis of a gravid patient with preeclampsia are 2:1. The nurse interprets the result as which of the following?

Select one: a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia.

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A he nurse is interviewing a pregnant client who states she plans to drink chamomile tea to ensure an effective labor. The nurse knows that this is anexample of: Select one: a. Cultural prescription b. Cultural taboo c. Cultural restriction d. Cultural demonstration A The primary complications of amniocentesis are: Select one: a. Damage to fetal organs b. Puncture of umbilical cord c. Maternal pain d. Infection D A first-time father is experiencing couvade syndrome. He is likely to exhibitwhich of the following symptoms or behaviors?

Select one: a. Urinary frequency b. Hypotension c. Bradycardia d. Prostatic hypertrophy A Taboos are cultural restrictions that: Select one: a. Have serious supernatural consequences b. Have serious clinical consequences c. Have superstitious consequences d. Are functional and neutral practices A Taboos are believed to have serious supernatural consequences. Taboos are not known to have clinical or superstitious consequences and are not functional or neutral practices.

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Identify the hallmark of placenta previa that differentiates it from abruptioplacenta.

Select one: a. Sudden onset of painless vaginal bleeding b. Board-like abdomen with severe pain c. Sudden onset of bright red vaginal bleeding d. Severe vaginal pain with bright red bleeding A For the patient with which of the following medical problems should the nursequestion a physician's order for beta agonist tocolytics?

Select one: a. Type 1 diabetes mellitus b. Cerebral palsy c. Myelomeningocele d. Positive group B streptococci culture A The perinatal nurse explains to the student nurse that the most frequent fetalrisk associated with the use of forceps is cord compression. select one: True False False A woman who is admitted to labor and delivery at 30 weeks' gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for thenurse to assess each hour?

Select one: a. temperature b. pulse c. respiratory rate d. blood pressure C A woman who is 36 weeks pregnant presents to the labor and delivery unit with ahistory of congestive heart disease. Which of the following findings should the

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nurse report to the primary health-care practitioner?Select one: a. Presence of cholasma b. Presence of severe heartburn c. 10-pound weight gain in a month d. Patellar reflexes +1 c Some of the normal cardiac changes during pregnancy can exacerbate cardiac disease including increase in total blood volume, increase in cardiac output, increased heart rate, and slight enlargement of the heart. Usual signs of deteriorating cardiac function include fluid retention which leads to weight gain above that expected of normal pregnancy. Chloasma, heartburn, and patellar reflexes are not related to cardiac disease.

You are caring for a patient who was admitted to labor and delivery at 32 weeks'gestation and diagnosed with preterm labor. She is currently on magnesium sulfate, 2 gm per hour.

Upon your initial assessment you note that she has a respiratory rate of 8 with absent deep tendon reflexes. What will be your first nursing intervention?

Select one: a. Elevate head of the bed b. Notify the provider c. Discontinue magnesium sulfate and notify the provider d. Draw a serum magnesium level c Initial nursing intervention needs to be discontinuing magnesium sulfate because the patient is exhibiting signs of magnesium toxicity with absent deep tendon reflexes and decreased respiratory rate.

A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor.

Which of the following common medication effects would thenurse expect to see in the mother?

Select one: a. Serum potassium level increases b. Diarrhea c. Urticaria d. Tachycardia D Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension?

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Select one: a. Proteinuria of 2.0 g in a 24-hour urine collection period b. Total platelet count of 40,000 mm c. AST <41 units/L; ALT < 30 units/L d. Low serum creatinine B In hypertensive disorders of pregnancy, evaluation of lab values includes findings of elevated serum creatinine, low platelet count, and and elevated liver enzymes Your antepartal patient is 38 weeks' gestation, has a history of thrombosis, andhas been on strict bed rest for the last 12 hours. She is now experiencing shortness of breath and you suspect pulmonary embolism (PE). What are the risk factors that may contribute to PE? Select one: a. Physiologic changes in pregnancy result in venous stasis, vasodilation, and compression of the inferior vena cava and pelvic veins, which increases the tendency to form blood clots. b. Physiologic changes in pregnancy result in vasoconstriction, which increasesthe tendency to form blood clots. c. Physiologic changes in pregnancy result in anemia, which increases thetendency to form blood clots. d. Physiologic changes in pregnancy result in decreased perfusion to the lungs,which increases the tendency to form blood clots.

A The patient's shortness of breath, bed rest, and history of thrombosis indicate possible pulmonary embolism. Her pregnant state also increases the potential for thrombosis resulting from increased levels of coagulation factors and decreased fibrinolysis, venous dilation, and obstruction of the venous system by the gravid uterus. Thromboembolitic diseases occurring most frequently in pregnancy include deep vein thrombosis and pulmonary embolism.

A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes.Identify the priority nursing assessment to ensure client safety.

Select one: a. Assess uterine contractions continuously. b. Assess fetal heart rate continuously. c. Assess urinary output. d. Assess respiratory rate.

D Magnesium sulfate is a central nervous system depressant and has been proven to help reduce seizure activity without documentation of long-term adverse effects to the woman and fetus.

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Care of the woman on Magnesium sulfate includes assessment of vital signs every 5-15 minutes during loading dose and then every 30-60 minutes until stabilization. Assess deep tendon reflexes (DTRs) every 2 hours; decreasing DTRs may be a sign of impending respiratory depression.

Respiratory depression, <14 breaths/minute, is the primary complication of Magnesium sulfate use.

The nurse is caring for a woman at 28 weeks' gestation with a history of pretermdelivery.

Which of the following laboratory data should the nurse carefully assessin relation to this diagnosis?

Select one: a. Human relaxin levels b. Amniotic fluid levels c. Alpha-fetoprotein levels d. Fetal fibronectin levels D Fetal fibronectin (fFN) is a biochemical marker used in the assessment of preterm labor. A negative fFN (<50 ng/mL) has a high negative predictive value that the woman will not deliver in 7-14 days.

The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 weeks' gestation. The nurse ispreparing to administer the second dose of beta-methasone prescribed by the physician. Marilyn asks: "What is this injection for again?" The nurse's best response is: Select one: a. "This is to help your baby's lungs to mature." b. "This is to prepare your body to begin the labor process." c. "This is to help stabilize your blood pressure." d. "This is to help your baby grow and develop in preparation for birth."

A Betamethasone is a corticosteroid given by injection to pregnant women at 24-34 weeks' gestation with signs of preterm labor or at risk to deliver preterm. Betamethasone stimulates the production of more mature surfactant in the fetal lungs to prevent respiratory distress syndrome in premature infants.

The nurse working in a prenatal clinic is providing care to three primigravidapatients.

Which of the patient findings would the nurse highlight for the provider?

Select one: a. 15 weeks, denies feeling fetal movement b. 20 weeks, fundal height at the umbilicus

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c. 25 weeks, complains of excess salivation d. 30 weeks, states that her vision is blurry D Visual disturbances may be an indication of preeclampsia. The other responses are normal findings for the various stages of pregnancy.

Kerry, a 30 year old G3 TPAL 0110 woman presents to the labor unit triage withcomplaints of lower abdominal cramping and urinary frequency at 30 weeks' gestation. Appropriate nursing actions include (select all that apply): Select one or more: a. Fetal and uterine monitoring for well being and contractions b. Obtain urine for analysis and dipstick c. Assess Kerry's temperature, blood pressure, and pulse d. Start an IV A,B,C A woman at 32 weeks' gestation is diagnosed with severe preeclampsia with HELLP (Hemolysis, elevated Liver enzymes, Low Platelets) syndrome. The nursewill identify which of the following as a positive patient care outcome?

Select one: a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of polycythemia C With HELLP, hemolysis is a result of red blood cell destruction as the cells travel through constricted vessels.

Elevated liver enzymes result from decreased blood flow and damage to the liver. Low platelets (thrombocytopenia) result from aggregation at the site of damaged vascular endothelium causing platelet consumption. Medical management includes replacement of platelets; a resolution of thrombocytopenia would indicate successful treatment.

The single most important risk factor for preterm birth is:Select one: a. Uterine and cervical anomalies b. Infection c. Increased BMI d. Prior preterm birth

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D The single most important factor is prior preterm birth with a reoccurrence rate of up to 40%.

Women with gestational diabetes (GDM) do not need to be monitored for type2diabetes after the birth.

Select one: True False False Metabolic changes during pregnancy Select one: a. lower b. increase c. maintain d. alter

glucose tolerance.

A Metabolic changes during pregnancy lower glucose tolerance.

Which of the following statements is most appropriate for the nurse to say to apatient with a complete or total placenta previa?

Select one: a. "During the second stage of labor you will need to bear down." b. "You should ambulate in the halls at least twice each day." c. "Your provider will likely induce your labor with oxytocin." d. "Please promptly report any vaginal bleeding or if you feel any lower back discomfort.

D A labor nurse is caring for a patient, 39 weeks' gestation, who has been diagnosedwith placenta previa. Which of the following physician orders should the nurse question?

Select one: a. Type and crossmatch her blood. b. Sterile vaginal exam c. Administer an oral stool softener to reduce straining. d. Assess her complete blood count.

B A sterile vaginal exam is contraindicated in all pregnant women with extensive vaginal bleeding until the source of bleeding is identified. Due to the possibility of massive hemorrhage, ensure

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adequate IV access is established and blood/blood products are readily available. Straining at stool is also contraindicated as this can cause cervical dilation and increased risk of hemorrhage; stool softeners are often given to prevent straining.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks' gestationin her first pregnancy. She is worried about having her baby "too soon," and sheis experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: Select one: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks contractions D Which of the following signs or symptoms would the nurse expect to see in awoman with concealed abruptio placentae?

Select one: a. Abrupt onset of uterine pain b. Normal vital signs c. Normal fetal heart rate (FHR) pattern d. Mild uterine tenderness A Concealed abruptio placenta occurs when more than 1/2 of the placenta separates prematurely.

Total blood loss can be >1500 ml with moderate to severe dark vaginal bleeding and abrupt onset of uterine pain described as tearing, knifelike, and continuous. The uterus may be described as hard or board-like. Significant maternal tachycardia with severe orthostatic hypotension and significant tachypnea are also seen. Fetal heart patterns show compromise and death can occur.

The perinatal nurse describes for the new nurse the various risks associated withprolonged premature preterm rupture of membranes (PPROM). These risks include (select all that apply): Select one or more: a. Chorioamnionitis b. Fetal/neonatal sepsis c. Operative birth d. Cord compression

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A,B,C,D Feedback; Even though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of maternal infection such as chorioamnionitis, fetal/neonatal sepsis, increased rates of cesarean/operative birth, and cord compression causing fetal hypoxia or asphyxia.

The perinatal nurse knows that the laboring diabetic patient's blood glucose levelshould be maintained at 70-110 mg/dL. Select one: True False true The nurse is caring for two laboring women. Which of the patients should bemonitored most carefully for signs of placental abruption?

Select one: a. The patient with placenta previa b. The patient whose vagina is colonized with group B streptococci c. The patient who is hepatitis B surface antigen positive d. The patient with eclampsia D The perinatal nurse knows that tocolytic agents are most often used to (select allthat apply): Select one or more: a. Prevent maternal infection b. Suppress uterine contractions c. Prolong pregnancy to facilitate administration of antenatal corticosteroids d. Allow for transport of the woman to a tertiary care facility prior to delivery B,C,D During pregnancy, poorly controlled asthma can place the fetus at risk for:Select one: a. Hyperglycemia b. Hypoxia c. Hypoglycemia d. Macrosomia B

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Marked hemodynamic changes in pregnancy can impact the pregnant woman with cardiac disease. Signs and symptoms of deteriorating cardiac status include(select all that apply): Select one or more: a. Orthopnea b. Nocturnal dyspnea c. Palpitations d. Irritation A B C The correct answer is: Orthopnea, Nocturnal dyspnea, Palpitations Signs and symptoms of deteriorating cardiac status with cardiac disease include orthopnea, nocturnal dyspnea, and palpitations, but do not include irritation.

A type 1 diabetic patient has repeatedly experienced elevated serum glucoselevels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see?

Select one: a. Postpartum hemorrhage b. Neonatal hyperglycemia c. Postpartum oliguria d. Neonatal macrosomia D The perinatal nurse knows that the term to describe a woman at 26 weeks'gestation with a history of hypertension prior to pregnancy and who now presents with a new onset proteinuria (by dipstick) is: Select one: a. Preeclampsia and eclampsia syndrome b. Chronic hypertension c. Gestational hypertension d. Preeclampsia superimposed on chronic hypertension D A 34-weeks' gestation multigravida, G3 P1 is admitted to the labor suite with contractions, fever, and low back pain. The woman has several medical problems. Which of the following of her comorbidities is most consistent with theclinical picture?

Select one: a. Kyphosis b. Urinary tract infection

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c. Congestive heart failure d. Cerebral palsy B Risk factors for preterm labor include infection, especially genitourinary and periodontal. The other comorbidities listed are not generally associated with preterm labor risk.

A woman at 10 weeks' gestation is diagnosed with gestational trophoblastic disease (hydatiform mole). The nurse is aware that this condition puts the womanat an increased risk for choriocarcinoma. Medical management the nurse would expect to see include: Select one: a. Immediate evacuation of hydatiform mole by aspiration/suction D&C b. Platelet transfusions c. Blood draw for hCG analysis d. Amniocentesis A A hydatiform mole is a benign proliferating growth with formation of vascular transparent vesicles in grape-like clusters without a viable fetus. Due to the use of Ultrasound, this condition is diagnosed early in pregnancy. The mole must be immediately evacuated and hCG levels are drawn at the time of diagnosis and as follow-up for at least 6 months to detect trophoblastic neoplasia.

The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour.Information provided about preterm labor and birth prevention includes (select all that apply) Select one or more: a. Encouraging regular, ongoing prenatal care b. Reporting symptoms of urinary frequency, abdominal cramping, and low backpain to the health-care provider c. Coming to the labor triage unit if back pain or cramping persist or becomeregular contractions d. Stay at home on bedrest with restricted fluid intake until contractions are 5minutes apart A,B,C Ms. M is 38 weeks' gestation and is a G1 P0. At 10 pm Ms. M has just been informed by the nurse that she is 3 to 4 cm dilated, cervix is 100% effaced, and contractions are every 4 to 5 minutes. When the nurse tells her the findings from

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the sterile vaginal exam (SVE), Ms. M states that she had been contracting sinceearly that morning and she becomes extremely frustrated stating "I should havehad this baby by now." Knowing that this is the latent phase of labor for this primiparous woman, what is the best response by the nurse?

Select one: a. Tell her she probably has many hours of labor ahead of her and not to worry. b. Provide emotional support, verbal encouragement, teach and reinforce relaxation techniques. c. Discuss various analgesic options d. Tell Ms. M that the provider will be contacted immediately about the slowprogress of labor B Discuss labor progress in latent phase of labor especially with first babies. Women in the latent phase of labor may be frustrated with lack of progress or slow progress of labor and desire companionship and encouragement. The other responses are inappropriate. The nurse should first encourage breathing and relaxation methods as well as provide reassurance, and then contact the provider.

Question 2 You are caring for a woman in the 4th stage of labor and birth. Fundal massagereveals a firm, well-contracted uterus but you note unusual swelling of the perineum. This might indicate formation of a hematoma.

Select one: True False True During the 4th stage of labor and birth, the nurse closely monitors the perineum for unusual swelling which may indicate internal bleeding and hematoma formation.

The mechanisms of labor include engagement, descent, flexion, internal rotation,extension, external rotation, and expulsion. These mechanisms are also referredto as: Select one:

a. Stages of labor b. The cardinal movements of labor c. First stage of labor d. Fetal lie B The cardinal movements of labor allow passage of the fetus through the birth canal. These

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include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.

The labor patient you are caring for is ambulating in the hall. Her vaginal exam1 hour ago indicated she was 4 cm dilated/70% effaced/-1 station. She tells you she has fluid running down her leg. Your priority nursing intervention is to: Select one: a. Assess the color, odor, and amount of fluid. b. Assist your patient to the bathroom. c. Assess the fetal heart rate (FHR). d. Call the care provider. c When rupture of membranes (ROM) is suspected, the first nursing action is to assess the fetal heart rate (FHR) as there is an increase risk of umbilical cord prolapse with ROM especially if the fetal head is not well engaged.

When caring for a primiparous woman being evaluated for admission for labor, akey distinction between true versus false labor is: Select one: a. True labor contractions result in rupture of membranes, and with false labor,the membranes remain intact. b. True labor contractions result in increasing anxiety and discomfort, and falselabor does not. c. True labor contractions are accompanied by loss of the mucus plug and bloodyshow, and with false labor there is no vaginal discharge. d. True labor contractions bring about changes in cervical effacement and dilation, and with false labor there are irregular contractions with little or nocervical changes. d Question 6 Ms. P has delivered her first baby 30 minutes ago and the placenta delivered 15minutes ago. She is attempting to breastfeed her newborn daughter for the firsttime. Which action by the nurse would NOT be appropriate?

Select one: a. The nurse is checking the BP every 15 minutes b. The nurse is massaging the fundus vigorously c. The nurse is auscultating the infant's heart and lungs while on the mother'schest

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d. The nurse is leaving the patient unattended for 30 minutes to bond with hernewborn d During the fourth stage of labor the mothers should not be left unattended as maternal bleeding needs to be closely monitored.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks' gestationin her first pregnancy. She is worried about having her baby "too soon," and sheis experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: Select one: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks contractions D Braxton-Hicks contractions are irregular and do not result in cervical change; also referred to as "false labor." Regular contractions causing cervical change are true indicators of labor. True labor (regular contractions with cervical change including effacement and dilation) at 34+ weeks would be preterm.

It would be most important for a nurse caring for a mother and the infant in thefourth stage of labor to do which of the following?

Select one or more: a. Assess and massage the fundus every 15 minutes or more often if needed tomaintain tightly contracted uterus b. Massage the uterus continuously c. Administer oxytocin per protocol or provider order d. Assess the patient for a distended bladder A,C,D The fourth stage of labor immediately follows the delivery of the placenta. The nurse should be assessing the fundus every 15 minutes for position, tone, and location. The provider may order oxytocin at this stage, and the nurse should assist the woman to the bathroom if she has a distended bladder which could interfere with the contraction of the uterus.

Feedback The correct answer is: Assess and massage the fundus every 15 minutes or more often if needed to maintain tightly contracted uterus, Administer oxytocin per protocol or provider order, Assess the patient for a distended bladder

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A woman is considered in active labor when the following characteristics haveoccurred: Select one: a. Cervical dilation progresses from 4 to 7 cm with effacement of 40%-80%, contractions becoming more intense, occurring every 2 to 5 minutes with duration of 45-60 seconds. b. Cervical dilation progresses to 4 cm with effacement, contractions becomemore intense, occurring every 1-2 minutes with duration of 50-90 seconds. c. Cervical dilation progresses to 8 cm with full effacement of 100%, contractionsbecome more intense, occurring every 1 to 2 minutes with duration of 45 to 60 seconds. d. Cervical dilation progresses to 10 cm with effacement of 90%, contractionsbecome more intense, occurring every 2 to 5 minutes with duration of 45 to 60seconds.

A Active phase of labor indicates cervical dilation of 4-7 centimeters, increasing effacement, contractions every 3-5 minutes, moderate/strong in intensity, and lasting 30-45 seconds.

You are in the process of admitting a multiparous woman to labor and deliveryfrom the triage area. One hour ago her vaginal exam was 7 cm dilated/70% effaced/0 station. While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to:Select one: a. Reassure the patient and rapidly complete the admission. b. Assist your patient to the bathroom to have a bowel movement. c. Assess the fetal heart rate and uterine contractions. d. Perform a vaginal exam as delivery may be imminent.

D Feedback The correct answer is: Perform a vaginal exam as delivery may be imminent.

Mutiparous women can move from active labor to transition within 1-2 hours; an urge to have a bowel movement may indicate the fetal head has descended rapidly and delivery is imminent.

Performing a sterile vaginal exam (SVE) will assess how quickly delivery might be anticipated and allow appropriate preparations to be made.

You are caring for a woman in active labor who is 6 cm dilated with a normalfetal heart rate (FHR) pattern and regular strong uterine contractions (UCs). Thefetal heart rate (FHR) and UCs during active labor should be assessed:

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Select one: a. Continuously b. Every 10 minutes c. Every 15-30 minutes d. Every 60 minutes C During the active phase of labor, FHR and UCs should be assessed every 1530 minutes or by hospital protocol Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client'sblood glucose levels?

Select one: a. Nifedipine b. Betamethasone c. Magnesium sulfate d. Indomethacin B Betamethasone will raise blood sugar and may require temporary insulin coverage to maintain euglycemia in diabetic women Mrs. H is telling you she feels the urge to push. This is most likely caused by whatreflex?

Select one: a. Low fetal station triggering the Ferguson reflex b. A fetal position of occiput posterior (OP) c. The second stage of labor d. Transition phase A Once the cervix is fully dilated, the vertex (head) is low in the pelvis, and the woman feels the urge to push, she will involuntarily bear down. This is activated by the presenting part as it descends and stretches the pelvic floor muscles and triggers the Ferguson reflex.

In caring for a primiparous woman in labor, one of the factors to evaluate isuterine activity. This is referred to as the of labor.

Select one: a. Passenger

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b. Passage c. Powers d. Psyche C Powers refer to the involuntary uterine contractions (UCs) of labor the the voluntary pushing or bearing down that combine to propel and deliver the fetus and placenta.

The Apgar score consists of a rapid assessment of five physiological signs that indicate the physiological status of the newborn at 1 and 5 minutes of life. Apgarscores include rapid assessment of: Select one: a. Apical pulse strength, respiratory rate, muscle flexion, reflex irritability, andcolor b. Heart rate, clarity of lungs, muscle tone, reflexes, and color c. Apical pulse strength, respiratory rate, muscle tone, reflex irritability, andcolor of extremities d. Heart rate, respiratory effort, muscle tone, reflex irritability, and color D The Apgar score consists of 5 physiological signs: heart rate based on auscultation, respiratory rate based on observed movement of the chest, muscle tone based on degree of flexion and movement of extremities, reflex irritability based on response to tactile stimulation, and color based on observation. Each sign is given a score of 0, 1, or 2 with a maximum score of 10 A woman you are caring for in labor requests an epidural for pain relief. Included in your preparation for epidural placement is a baseline set of vitalsigns. The most common complication of epidural placement is: Select one: a. Maternal hypotension Up to 40% of women may experience hypotension. Loss of consciousness and respiratory distress may occur with incorrect placement of the epidural or injection of medication intravascularly.

A low-risk patient calls the labor unit and says "I need to come in to be checkedright now, there were pink streaks on the toilet paper when I went to the bathroom. I think I'm bleeding." What response should the nurse say first?

Select one: a. "How much blood is there?" b. "You sound concerned, what other labor symptoms do you have?

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c. "Don't worry that sounds like a mucus plug." d. "Does it burn when you urinate?"

B The correct answer is: "You sound concerned, what other labor symptoms do you have?

The nurse is using reflection to acknowledge the woman's concerns and asks for further assessment. The woman's fear must first be acknowledged and then other questions or comments can be made.

You are in the process of admitting a multiparous woman to labor and deliveryfrom the triage area. One hour ago her vaginal exam was 7 cm dilated/70% effaced/0 station. While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to:Select one: a. Reassure the patient and rapidly complete the admission. b. Assist your patient to the bathroom to have a bowel movement. c. Assess the fetal heart rate and uterine contractions. d. Perform a vaginal exam as delivery may be imminent.

D Mutiparous women can move from active labor to transition within 1-2 hours; an urge to have a bowel movement may indicate the fetal head has descended rapidly and delivery is imminent.

Performing a sterile vaginal exam (SVE) will assess how quickly delivery might be anticipated and allow appropriate preparations to be made.

The provision of support during labor has demonstrated that women experiencea decrease in anxiety and a feeling of being in more control. In clinical situations,this has resulted in: Select one: a. A decrease in interventions b. Increased epidural rates c. Earlier admission to the hospital d. Improved gestational age A The nurse knows that a FHR monitor printout indicates a Category III abnormalfetal heart rate pattern when: Select one: a. Baseline variability is minimal or absent with decelerations. b. FHR mirrors the uterine contractions. c. Occasional periodic accelerations occur. d. Baseline variability is 6 to 25 bpm with decelerations

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A Which statement correctly describes the nurse's responsibility related toelectronic fetal monitoring (EFM)?

Select one: a. Teach the woman and her family about the monitoring equipment and discussany questions they have. b. Report abnormal findings to the care provider before initiating correctiveactions. c. Inform the support person that the nurse will be responsible for all comfortmeasures when the electronic equipment is in place. d. Document the frequency, duration, and intensity of contractions measured bythe external device.

A Nurses are expected to independently assess, interpret, and intervene related to interpretations of electronic fetal monitoring (EFM). Nurses are expected to provide information and explanations to patients and their families in order to relieve anxiety and answer questions. Nurses are expected to share information with obstetric providers to insure clear communication. EFM is a means to information regarding fetal response to labor but does not take the place of nursing and support person interactions. Remember that external devices cannot measure uterine intensity/pressure during a contraction but can provide information on frequency and duration.

The nurse uses the external electronic fetal heart monitor to evaluate fetal status.The fetal heart tracing shows accelerations. Accelerations in the fetal heart are: Select one: a. Associated with fetal well-being and adequate oxygenation b. An indication of potential fetal intolerance to labor c. Never associated with the uterine contraction pattern d. A reason to notify the care provider A The presence of accelerations is predictive of adequate central fetal oxygenation and reflects the absence of fetal acidemia. Accelerations identify a well-oxygenated fetus and require no intervention.

The perinatal nurse providing care to a laboring woman recognizes a Category IIfetal heart rate tracing. The most appropriate initial action for uterine resuscitation is to: Select one: a. Assist the laboring woman to change her position b. Decrease the intravenous solution

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c. Request that the physician/certified nurse-midwife come to the hospital STAT d. Document the fetal heart rate and variability a Category II tracings are indeterminate and call for increased vigilance. The initial step in intrauterine resuscitation is a change in maternal position. If no improvement is seen in the FHR tracing, other resuscitation measures are indicated such as IV fluid bolus and the use of oxygen.

Following resuscitation, document all findings and interventions. Keep obstetric providers aware of nursing actions and results.

Which of the following is not true regarding the use of Amnioinfusion as aresuscitative technique?

Select one: a. Amnioinfusion has been shown to dilute thick meconium-stained amnioticfluid. b. Amnioinfusion has been shown to resolve variable decelerations due to oligohydramnios. c. Amnioinfusion is the first line of defense against meconium aspiration syndrome (MAS). d. Amnioinfusion consists of normal saline or lactated Ringer's infused into theuterus.

C Amnioinfusion has been used to resolve variable decelerations by relieving umbilical cord compression due to oligohydramnios. Normal saline or lactated Ringer's solution is infused into the uterus by gravity or pump. Amnioinfusion dilutes thick meconium-stained amniotic fluid but does not appear to reduce the risk of moderate or severe meconium aspiration syndrome (MAS).

As the tocodynamometer (Toco) is placed on the laboring patient's abdomen, thenurse explains that this monitoring device provides information on which of thefollowing?

Select one: a. Fetal heart rate b. Frequency of contractions c. Intensity of contractions d. Progress of labor B Uterine contractions are measured via a tocodynamometer (Toco) which is an external uterine monitor. The Toco measures the frequency and duration of uterine contractions but cannot measure uterine pressure/intensity. Uterine pressure/intensity can be estimated by palpation during contractions or through the use of an internal monitor such as an intrauterine pressure catheter (IUPC).

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Documentation related to vacuum delivery includes which of the following:Select one or more: a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position A,B,C The correct answer is: Fetal heart rate, Timing and number of applications, Position and station of fetal head Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuum deliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

A nurse is preparing to monitor a patient who is to receive an amnioinfusion.Which of the following actions should the nurse make at this time?

Select one: a. Attach the patient to an electronic blood pressure cuff. b. Assist in insertion of an intrauterine pressure catheter (IUPC). c. Attach the patient to an oxygen saturation monitor. d. Perform an amniotic fluid Nitrazine test.

B CorrectAmnioinfusion involves the introduction of room-temperature saline through the cervix into the uterus via intrauterine pressure catheter (IUPC). The main purpose for amnioinfusion is to correct cord compression associated with too little amniotic fluid (oligohydramnios). Prior to amnioinfusion an IUPC must be inserted.

Documentation related to vacuum delivery includes which of the following:Select one or more: a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position A,B,C Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuum deliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

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The perinatal nurse is providing care to Carol, a 28-year-old multiparous womanin labor.

Upon arrival to the birthing suite, Carol was 7 cm dilated and experiencing contractions every 1 to 2 minutes which she describes as "strong." Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states that she is feeling somerectal pressure. Carol is most likely experiencing: Select one: a. Hypertonic contractions b. Hypotonic contractions c. Precipitous labor d. Uterine hyperstimulation C Precipitous labor that lasts fewer than 3 hours from onset to birth. Precipitous labor is more likely to be seen in woman who have previously given birth or have a previous history of rapid labors. As the fetal head descends, the woman may feel rectal pressure indicating delivery is imminent.

A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor.The following assessments were made on admission: Bishop score of 4, fetal heartrate 140s with moderate variability and no decelerations, TPR 98.6°F, 88, 20, BP120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrantthe removal of the Cervidil (dinoprostone)?

Select one: a. Bishop score of 5 b. Fetal heart of 152 bpm c. Respiratory rate of 24 rpm d. More than 5 contractions in 10 minutes D Cervidil should be removed in the presence of tachysystole or Category II/III FHR patterns.

Contraindications for induction of labor include: Select one or more: a. Abnormal fetal position b. Post-term pregnancy c. Pregnancy-induced hypertension d. Placental abnormalities A,D Contraindications for induction of labor include abnormal fetal position because of the risk of

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fetal injury and placental abnormalities because of the risk of hemorrhage. Pregnancy-induced hypertension and post-term pregnancy are two of the common indications for induction of labor.

If the umbilical cord prolapses during labor, the nurse should immediately:Select one: a. Type and cross-match blood for an emergency transfusion. b. Await provider order for preparation for an emergency cesarean section. c. Attempt to reposition the cord above the presenting part. d. Performing vaginal exam and lifting the presenting part off of the cord torelieve pressure on the cord.

D Prolapse of the umbilical cord is when the cord lies below the presenting part of the fetus. The cord becomes trapped against the presenting part and circulation is occluded; FHR will usually show bradycardia or prolonged decel. An emergency cesarean birth is typically performed.

Occlusion of the cord may be partially relieved by lifting the presenting part off the cord with a vaginal exam. The examiner's hand remains in the vagina, lifting the presenting part off the cord until delivery by cesarean. There is no attempt to push the cord above the presenting part. Type and screen of blood is generally done on admission for all laboring women; type and cross-match can readily be accomplished using the blood sample already in the lab.

During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2 minutes with duration of 60 seconds, of moderate strength to palpation. Based onthis assessment, the nurse should take which action?

Select one: a. Increase oxytocin infusion rate per provider's protocol. b. Stop oxytocin infusion immediately. c. Maintain present oxytocin infusion rate and continue to assess. d. Decrease oxytocin infusion rate by 2 mU/min and report to provider.

C The goal of oxytocin use in labor is to establish uterine contraction patterns that promote cervical dilation of about 1 cm/hr once in active labor. The lowest possible dose should be used to achieve labor progress. Generally, the labor pattern should be 3 UCs in 10 minutes, lasting 40-60 seconds with an intensity of 25-75 mm/HG with IUPC and resting tone <20 mm HG with 1 minute between each UC. The labor pattern described above is appropriate and no increase or decrease in oxytocin infusion rate is indicated.

The perinatal nurse notes a rapid decrease in the fetal heart rate that does notrecover immediately following an amniotomy. The most likely cause of this obstetrical emergency is: Select one: a. Prolapsed umbilical cord

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b. Vasa previa c. Oligohydramnios d. Placental abruption A Amniotomy is the artificial rupture of membranes (AROM) to induce or augment labor. This is a common procedure seen in obstetrics. Risks associated with amniotomy include umbilical cord prolapse when the presenting part is not engaged. Vasa previa or rupture of fetal vessels unsupported by the placenta is a very rare situation and usually results in rapid fetal exsanguination in the presence of bloody fluid seen following AROM. A 25 year-old woman gave birth to her second child 6 hours ago. She informs thenurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: Select one: a. Explain that this is normal for second-time moms b. Assess the location and firmness of the fundus c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.

B : Frequent assessment of uterine tone and placement allows for the identification of potential complications such as uterine atony (decreased uterine muscle tone) that may lead to postpartum hemorrhage.

Which of the following is not true regarding current research on the appropriateuse of maternal oxygen?

Select one: a.Maternal oxygen therapy can be appropriately administered via nasal cannula. b. Maternal oxygen therapy is beneficial in improving fetal oxygen status duringlabor and in resolving nonCategory 1 FHR patterns including fetal tachycardia and late decelerations. c. Fetal hemoglobin has a higher affinity for oxygen than adult hemoglobin; fetal hematocrit is higher than adult hematocrit. d. Maternal oxygen therapy should be utilized for 1530 minutes based on fetalresponse.

A Providing maternal oxygen has been shown to improve fetal oxygen status and resolve nonCategory 1 Fetal Heart Rate (FHR) patterns.

Maternal oxygen is best provided at 10L via nonrebreather facemask.

Maternal oxygen can improve FHR variability, decrease fetal tachycardia, and reduce/eliminate late decelerations. The benefits of maternal oxygenation on the fetus have been shown to continue for as much as 30 minutes after discontinuation. Evidence is inconsistent as to how long

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maternal oxygen therapy should last. This article recommends maternal oxygen therapy be used for 1530 minutes but there is a need for more research.

Early decelerations are probably caused by: Select one: a. Decreased maternal-fetal exchange b. Umbilical cord occlusion c. Momentary increase in intracranial pressure due to head compression d. Compression of umbilical cord C Early decelerations are visually apparent, usually symmetrical, with a gradual decrease and return of FHR associated with a uterine contraction (UC). Early decels usually mirror the UC and are generally associated with fetal head compression resulting in a transient increase in intracranial pressure. Early decels are considered benign and require no intervention but should be documented in the nurse's charting.

Tachysystole, previously referred to as hyperstimulation, is defined as:Select one or more: a. Contractions lasting 2 minutes or longer b. Five or more contractions in 10 minutes over a 30 minute window c. Contractions occurring within 1 minute of each other d. Uterine resting tone below 20 mm/Hg A, B, C Contractions lasting more than 2 minutes, five or more contractions in 10 minutes, and contractions occurring within 1 minute of each other describe the criteria for tachysystole. Uterine resting tone below 20 mm/Hg reflects normal uterine resting tone.

The perinatal nurse is providing care to Carol, a 28 year old multiparous womanin labor.

Upon arrival to the birthing suite, Carol was 7 cm dilated and experiencing contractions every 1 to 2 minutes which she describes as "strong." Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states that she is feeling somerectal pressure. Carol is most likely experiencing: Select one: a. Hypertonic contractions b. Hypotonic contractions c. Precipitous labor d. Uterine hyperstimulation

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C Precipitous labor that lasts fewer than 3 hours from onset to birth. Precipitous labor is more likely to be seen in woman who have previously given birth or have a previous history of rapid labors. As the fetal head descends, the woman may feel rectal pressure indicating delivery is imminent.

Your patient is a 28 year old gravida 2 para 1 in active labor. She has been in labor for 12 hours. Upon further assessment, the nurse determines that she is experiencing a hypotonic labor pattern. Possible maternal and fetal implicationsfrom hypotonic uterine dysfunction are: Select one: a. Intrauterine infection and maternal exhaustion with fetal distress usually occurring in the latent phase of labor. b. Intrauterine infection and maternal exhaustion with fetal distress usually occurring in the active phase of labor. c. Intrauterine infection and postpartum hemorrhage with fetal distress early inlabor. d. Intrauterine infection, ruptured uterus and fetal death.

B The correct answer is: Intrauterine infection and maternal exhaustion with fetal distress usually occurring in the active phase of labor.

With hypotonic uterine dysfunction, normal progress is seen in the latent phase of labor but during the active phase, the UCs become weaker and less effective. The woman is at risk for exhaustion and infection related to the prolonged labor. The fetus is at risk for fetal intolerance of labor and asphyxia During the postpartum assessment, the perinatal nurse notes that a patient whohas just experienced a forceps assisted birth now has a large quantity of bright red bleeding. Her uterine fundus is firm. The nurse's most appropriate action isto notify the physician/certified nurse midwife and anticipate the need for: Select one: a. Vaginal assessment and possible repair of vaginal and/or cervical lacerations b. An oxytocin infusion c. Further information for the woman/family about forceps d. Bladder assessment and catheterization A The correct answer is: Vaginal assessment and possible repair of vaginal and/or cervical lacerations Risks as a result of forceps delivery include vaginal/cervical lacerations, extension of episiotomy, hemorrhage related to uterine atony or rupture, perineal hematoma, bladder injury, and perineal wound infection.

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Maternal hypotension is most often the result of supine position.Select one: True False True ago. The Bishop score is now 3. Which of the following actions by the nurse isappropriate?

Select one: a. Perform Nitrazine analysis of the amniotic fluid. b. Report the lack of progress to the obstetrician. c. Place the woman on her left side. d. Ask the provider for an order for oxytocin.

B Prepidil is indicated for cervical ripening, the process of physical softening and opening of the cervix. Cervical status is the most important predictor of successful induction of labor. Cervical status is assessed before induction of labor using the Bishop score. A score of 6 or more is considered favorable for successful induction of labor.

A pregnant woman who has a history of cesarean births is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situations shouldthe nurse advise the patient that her request may be declined?

Select one: a. Previous uterine surgery b. Flexed fetal attitude c. Previous low flap uterine incision d. Positive vaginal candidiasis A Which of the following is considered to be a "reassuring" or Category 1 FetalHeart Rate (FHR) pattern?

Select one: a. Baseline rate of 100-150; minimal variability; presence of accelerations; occasional decelerations b. Baseline rate of 110-160; moderate variability; presence of accelerations;absence of decelerations c. Baseline rate of 150-200; moderate variability; occasional accelerations;variable decelerations d. Baseline rate of 120; absent variability; presence of accelerations; early decelerations present

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B : A "reassuring" or Category 1 FHR pattern is defined as: baseline rate of 110-160 beats per minute (bpm); moderate variability; presence of accelerations; absence of decelerations.

A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor.The following assessments were made on admission: Bishop score of 4, fetal heartrate 140s with moderate variability and no decelerations, TPR 98.6°F, 88, 20, BP120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrantthe removal of the Cervidil (dinoprostone)?

Select one: a. Bishop score of 5 b. Fetal heart of 152 bpm c. Respiratory rate of 24 rpm d. More than 5 contractions in 10 minutes D Cervidil should be removed in the presence of tachysystole or Category II/III FHR patterns.

The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks gestationin her first pregnancy. She is worried about having her baby "too soon," and sheis experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: A) Preterm labor B) Term labor C) Back labor D) Braxton-Hicks contractions D) Braxton-Hicks contractions The perinatal nurse knows that the term to describe a woman at 26 weeks gestation with a history of elevated blood pressure who presents with a urineshowing 2+ protein (by dipstick) is: A) Preeclampsia B) Chronic hypertension C) Gestational hypertension D) Chronic hypertension with superimposed preeclampsia D) Chronic hypertension with superimposed preeclampsia

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The perinatal nurse describes risk factors for placenta previa to the studentnurse. Placenta previa risk factors include: Select all answers that apply.

A) Cocaine use B) Tobacco use C) Previous caesarean birth D) Previous use of medroxyprogesterone (Depo-Provera) A) Cocaine use B) Tobacco use C) Previous caesarean birth Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks gestation. An appropriate nursing action would be to: Select all answers that apply.

A) Assess the fetal heart rate B) Obtain urine for culture and sensitivity C) Assess Kerry's blood pressure and pulse D) Palpate Kerry's abdomen for contractions A Assess the fetal heart rate B Obtain urine for culture and sensitivity D Palpate Kerry's abdomen for contractions The perinatal nurse knows that tocolytic agents are most often used to:Select all answers that apply.

A) Prevent maternal infection B) Prolong pregnancy to 40 weeks gestation C) Prolong pregnancy to facilitate administration of antenatal corticosteroids D) Allow for transport of the woman to a tertiary care facility C Prolong pregnancy to facilitate administration of antenatal corticosteroids D Allow for transport of the woman to a tertiary care facility The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour.Information provided about preterm labor and birth prevention includes:

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Select all answers that apply.

A) Encouraging regular, ongoing prenatal care B) Reporting symptoms of urinary frequency and burning to the health careprovider C) Coming to the labor triage unit if back pain or cramping persist or becomeregular D) Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5 minutes A Encouraging regular, ongoing prenatal care B Reporting symptoms of urinary frequency and burning to the health care provider C Coming to the labor triage unit if back pain or cramping persist or become regular The perinatal nurse describes for the new nurse the various risks associated withprolonged premature preterm rupture of membranes. These risks include: Select all answers that apply.

A) Chorioamnionitis B) Abruptio placentae C) Operative birth D) Cord prolapse A Chorioamnionitis B Abruptio placentae D Cord prolapse A condition where the the placenta attaches to the lower uterine segment of theuterus Placenta previa A pregnancy that ends before 20 weeks gestation Miscarriage Specks or spots in the vision where the patient cannot see; "blind spots" Scotoma

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A disease characterized by an abnormal placental development that results in theproduction of fluid-filled grapelike clusters and a vast proliferation of trophoblastic tissue Hydatiform mole/Gestational trophoblastic disease No expulsion of the products of conception, but bleeding and dilation of thecervix such that a pregnancy is unlikely Inevitable abortion Placement of suture to mechanically close a weak cervix Cervical Cerclage The perinatal nurse observes the placental inspection by the health care providerafter birth. This examination may help to determine whether an abruption has occurred prior to or during labor.

A) True B) False A) True The perinatal nurse knows that the survival rate for infants born at or greaterthan 28 to 29 gestational weeks is greater than 90%.

A) True B) False B) False The perinatal nurse knows that the survival rate for infants born at or greaterthan 28 to 29 gestational weeks is greater than 90%.

A) True B) False A) True The perinatal nurse knows that an early pregnancy loss occurs before weeks, and a late pregnancy loss is one that occurs between 12 and weeks.

2, 20

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Mary, a G3 TPAL 0020 woman at 20 weeks gestation, has had a transvaginal ultrasound. Mary has been informed that she has cervical incompetence. The perinatal nurse explains that this diagnosis means that her cervix has without contractions. dilated, regular The perinatal nurse knows that nausea and vomiting are common in pregnancyand usually resolve by weeks gestation. The severe form of this condition is .

6, hyperemesis gravidarum The perinatal nurse explains to the student nurse who is assessing the abdomen of a 32week pregnant woman with placenta previa that it would not be unusualto find the fetus in a or position. breech, transverse The perinatal nurse knows that a hemorrhage is limited to the uterus, and a hemorrhage moves blood toward and through the cervix. concealed, revealed The perinatal nurse encourages Colleen, who has just been discharged from thehospital for intravenous therapy for severe nausea and vomiting, to ensure thatshe often, eats frequent meals and avoids odors. rests, small, cooking A patient is receiving magnesium sulfate for severe preeclampsia. The nurse mustnotify the attending physician immediately of which of the following findings?

A) Patellar and biceps reflexes of +4 B) Urinary output of 50 mL/hr C) Respiratory rate of 10 rpm D) Serum magnesium level of 5 mg/dL C) Respiratory rate of 10 rpm A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor.

Which of the following common medication effects would thenurse expect to see in the mother?

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A) Serum potassium level increases B) Diarrhea C) Urticaria D) Complaints of nervousness D) Complaints of nervousness Which of the following signs or symptoms would the nurse expect to see in awoman with concealed abruptio placentae?

A) Increasing abdominal girth measurements B) Profuse vaginal bleeding C) Bradycardia with an aortic thrill D) Hypothermia with chills A) Increasing abdominal girth measurements A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likelycontributed to these findings?

A) Pyelonephritis B) Pregnancy-induced hypertension C) Gestational diabetes D) Abruptio placentae C) Gestational diabetes For the patient with which of the following medical problems should the nursequestion a physician's order for beta agonist tocolytics?

A) Type 1 diabetes mellitus B) Cerebral palsy C) Myelomeningocele D) Positive group B streptococci culture A) Type 1 diabetes mellitus The nurse is caring for two laboring women. Which of the patients should bemonitored most carefully for signs of placental abruption?

A) The patient with placenta previa B) The patient whose vagina is colonized with group B streptococci C) The patient who is hepatitis B surface antigen positive D) The patient with eclampsia

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D) The patient with eclampsia The nurse is caring for a woman at 28 weeks gestation with a history of preterm delivery.

Which of the following laboratory data should the nurse carefully assessin relation to this diagnosis?

A) Human relaxin levels B) Amniotic fluid levels C) Alpha-fetoprotein levels D) Fetal fibronectin levels D) Fetal fibronectin levels Which of the following statements is most appropriate for the nurse to say to apatient with a complete placenta previa?

A) "During the second stage of labor you will need to bear down."

B) "You should ambulate in the halls at least twice each day."

C) "The doctor will likely induce your labor with oxytocin."

D) "Please promptly report if you experience any bleeding or feel any back discomfort."

D) "Please promptly report if you experience any bleeding or feel any back discomfort."

A woman at 32 weeks gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positivepatient care outcome?

A) Rise in serum creatinine B) Drop in serum protein C) Resolution of thrombocytopenia D) Resolution of polycythemia C) Resolution of thrombocytopenia A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following?

A) High leukocyte count B) Explosive diarrhea C) Fractured pelvis D) Low platelet count D) Low platelet count

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A woman at 10 weeks gestation is diagnosed with gestational trophoblasticdisease (hydatiform mole). Which of the following findings would the nurseexpect to see?

A) Platelet count of 550,000/ mm3 B) Dark brown vaginal bleeding C) White blood cell count 17,000/ mm3 D) Macular papular rash B) Dark brown vaginal bleeding After an education class, the nurse overhears an adolescent woman discussingsafe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed?

A) "I could get an STI even if I just have oral sex."

B) "Girls over 16 are less likely to get STDs than younger girls."

C) "The best way to prevent an STI is to use a diaphragm."

D) "Girls get human immunodeficiency virus (HIV) easier than boys do."

C) "The best way to prevent an STI is to use a diaphragm."

A woman who is admitted to labor and delivery at 30 weeks gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for thenurse to assess each hour?

A) Temperature B) Pulse C) Respiratory rate D) Blood pressure C) Respiratory rate A 34-week gestation multigravida, G3 P1 is admitted to the labor suite. She is contracting q 7 minutes ⋅ 40 seconds. The woman has several medical problems.Which of the following of her comorbidities is most consistent with the clinical picture?

A) Kyphosis B) Urinary tract infection C) Congestive heart failure D) Cerebral palsy B) Urinary tract infection

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A primiparous woman has been admitted at 35 weeks gestation and diagnosed with HELLP syndrome. Which of the following laboratory changes is consistentwith this diagnosis?

A) Hematocrit dropped to 28%.

B) Platelets increased to 300,000 cells/mm3.

C) Red blood cells increased to 5.1 million cells/mm3.

D) Sodium dropped to 132 mEq/dL. Hematocrit dropped to 28%.

A labor nurse is caring for a patient, 39 weeks gestation, who has been diagnosedwith placenta previa. Which of the following physician orders should the nurse question?

A) Type and cross match her blood.

B) Insert an internal fetal monitor electrode.

C) Administer an oral stool softener.

D) Assess her complete blood count.

B) Insert an internal fetal monitor electrode.

A type 1 diabetic patient has repeatedly experienced elevated serum glucoselevels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see?

A) Postpartum hemorrhage B) Neonatal hyperglycemia C) Postpartum oliguria D) Neonatal macrosomia D) Neonatal macrosomia According to agency policy, the perinatal nurse provides the followingintrapartal nursing care for the patient with preeclampsia: A) Take the patient's blood pressure every 6 hours B) Encourage the patient to rest on her back C) Notify the physician of a urine output greater than 30 mL/hr D) Administer magnesium sulfate according to agency policy D) Administer magnesium sulfate according to agency policy The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 weeks gestation. The nurse ispreparing to administer the second dose of β-methasone prescribed by the

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physician. Marilyn asks: "What is this injection for again?" The nurse's bestresponse is: A) "This is to help your baby's lungs to mature."

B) "This is to prepare your body to begin the labor process."

C) "This is to help stabilize your blood pressure."

D) "This is to help your baby grow and develop in preparation for birth."

A) "This is to help your baby's lungs to mature."

A patient with hypertension who is receiving intravenous magnesium sulfate therapy has requested an epidural anesthetic. The perinatal nurse should firstreview the patient's complete blood count results for evidence of a decreased platelet count.

A) True B) False A) True The perinatal nurse knows that the laboring diabetic patient's blood glucose levelshould always be less than 120 mg/dL. A) True B) False A) True A woman who is 36 weeks pregnant presents to the labor and delivery unit with ahistory of congestive heart disease. Which of the following findings should the nurse report to the primary health care practitioner?

A) Presence of chloasma B) Presence of severe heartburn C) 10-pound weight gain in a month D) Patellar reflexes +1 C) 10-pound weight gain in a month A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes.Identify the priority nursing assessment to insure client safety.

A) Assess uterine contractions continuously.

B) Assess fetal heart rate continuously.

C) Assess urinary output.

D) Assess respiratory rate.

D) Assess respiratory rate.

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A pregnant client with a history of multiple sexual partners is at highest risk forwhich of the following complications: A) Premature rupture of membranes B) Gestational diabetes C) Ectopic pregnancy D) Pregnancy-induced hypertension C) Ectopic pregnancy Identify the hallmark of placenta previa that differentiates it from abruptioplacenta.

A) Sudden onset of painless vaginal bleeding B) Board-like abdomen with severe pain C) Sudden onset of bright red vaginal bleeding D) Severe vaginal pain with bright red bleeding Sudden onset of painless vaginal bleeding Which of the following assessments would indicate instability in the clienthospitalized for placenta previa?

A) BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPM B) FHR moderate variability without accelerations C) Dark brown vaginal discharge when voiding D) Oral temperature of 99.9°F BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPM During pregnancy, poorly controlled asthma can place the fetus at risk for: A) Hyperglycemia B) IUGR C) Hypoglycemia D) Macrosomia B) IUGR Which of the following nursing diagnoses is of highest priority for a client with an ectopic pregnancy who has developed disseminated intravascular coagulation(DIC)?

A) Risk for deficient fluid volume B) Risk for family process interrupted C) Risk for disturbed identity D) High risk for injury

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A) Risk for deficient fluid volume Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension?

A) Total urine protein of 200 mg/dL B) Total platelet count of 40,000 mm C) Uric acid level of 8.0 mg/dL D) Blood urea nitrogen 24 mg/dL B) Total platelet count of 40,000 mm Immediately postpartum, the insulin needs in diabetic women increasedramatically.

A) True B) False B) False Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client'sblood glucose levels?

A) Nifedipine B) Betamethasone C) Magnesium sulfate D) Indomethacin B) Betamethasone While educating the client with class II cardiac disease, at 28 weeks gestation, thenurse instructs the client to notify the physician if she experiences which of the following conditions?

A) Emotional stress at work B) Increased dyspnea while resting C) Mild pedal and ankle edema D) Weight gain of 1 pound in 1 week B) Increased dyspnea while resting Birth prior to 37 completed weeks of pregnancy is . preterm birth

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The nurse working in a prenatal clinic is providing care to three primigravidapatients.

Which of the patient findings would the nurse highlight for the physician?

A) 15 weeks, denies feeling fetal movement B) 20 weeks, fundal height at the umbilicus C) 25 weeks, complains of excess salivation D) 30 weeks, states that her vision is blurry D) 30 weeks, states that her vision is blurry Metabolic changes during pregnancy Select one: a. lower b. increase

c. maintain d. alter LOWER

glucose tolerance.

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Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

Chapter 5: Psycho-Social-Cultural Aspects of the AntepartumPeriod Multiple Choice 1. Sally is in her third trimester and has begun to sing and talk to the fetus. Sally is probably exhibiting signs of: a. Mental illnessb. Delusionsc. Attachmentd. Crisis ANS: c Feedback a. This is normal maternal–fetal adaptation.b. Delusions are not real, and the fetus is real.c. Correct, because talk ing to the fetus is a sign of positive maternal adaptation. All other answers indicate pathology.d. Interacting with the fetus in utero represents normal development of attachment to the fetus.KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate2. What is the most common expected emotional reaction of a woman to the news that she is pregnant? a.

Jealousyb. Acceptancec. Ambivalenced. Depression

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ANS: cFeedback a. Others in the family may be jealous of the fetus, but that is not a common maternal response.b. Acceptance of the pregnancy typically occurs later in the pregnancy.c. Ambivalence is a normal expected reaction to the news of pregnancy, whether or not the pregnancy is planned or wanted.d. This would represent an abnormal emotional response to pregnancy.

KEY: Integrated Process: Teaching and Learning | Nursing Process: Analysis | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy 3. Which of the following information regarding sexual activity would the nurse give a pregnant woman who is 35 week s’ gestation? a. Sexual activity should be avoided from now until 6 week s postpartum.b. Sexual desire may be affected by nausea and fatigue. c. Sexual desire may be increased due to increased pelvic congestion.d. Sexual activity may require different positions to accommodate the woman’s comfort.

ANS: d Feedback a. There are no contraindications to sexual activity during this time for a normally progressing pregnancy.b. Nausea and fatigue affect sexual desire during the first trimester, not the third.c. Increased sexual desire r/t increased pelvic congestion is a characteristic of the second trimester, not the third.d. Correct. An enlarging abdomen creates feelings of awk wardness and bulk iness and may require couples to modify intercourse positions for the pregnant woman’s comfort.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 4. Which statement best exemplifies adaptation to pregnancy in relation to the adolescent? a. Adolescents adapt to motherhood in a similar way to other childbearing women.b.

Social support has very little effect on adolescent adaptation to pregnancy. c. The pregnant adolescent faces the challenge of multiple developmental task s.d. Pregnant adolescents of all ages can be capable and active participants in health-care decisions.

ANS: c Feedback a. Adolescents must cope with the conflicting developmental task s of

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pregnancy and adolescence at the same time.b. Social support has been associated with a more positive adaptation to mothering for adolescents.c. Correct. Pregnant adolescents face conflicting and multiple developmental task s of pregnancy and adolescence at the same time.d. By late adolescence (ages 17 to 20) this can occur, but early adolescents are oriented toward the present and are self-centered, and often pregnancy at this age is a result of abuse or coercion.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult 5. Jane’s husband Brian has begun to put on weight. What is this a possible sign of? a. Culturalism syndromeb. Couvade syndromec. Moratorium phased. Attachment ANS: bFeedback a. This is not related to culture.b. Correct. Couvade syndrome has symptoms that mimic changes of pregnancy.c. Moratorium phase represents one of the phases of the father’s responses to pregnancy.d. Attachment is reflected in behaviors.

KEY: Integrated Process: Caring | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy 6. Cathy is pregnant for the second time. Her son, Steven, has just turned 2 years old. She ask s you what she should do to help him get ready for the expected birth. What is the nurse’s most appropriate response? a. Steven will probably not understand any explanations about the arrival of the new baby, so Cathy should do nothing.b. If Steven’s sleeping arrangements need to be changed, it should be done well in advance of the birth.c. Steven should come to the next prenatal visit and listen to the fetal heartbeat to encourage sibling attachment. d. Steven should be encouraged to plan an elaborate welcome for the newborn.

ANS: bFeedback a. This applies to very young children under the age of 2.b. Children still sleeping in a crib should be moved to a bed at least 2 months before the baby is due, as this age group is particularly sensitive to disruptions of the physical environment.c. This is not appropriate for a 2-year-old but may be appropriate for older age groups.d. This is not appropriate for a 2-year-old but may be appropriate for older age groups.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content

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Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult

7. The nurse is interviewing a pregnant client who states she plans to drink chamomile tea to ensure an effective labor. The nurse k nows that this is an example of: a. Cultural prescriptionb. Cultural tabooc. Cultural restrictiond. Cultural demonstration

ANS: aFeedback a. Correct. Cultural prescription is an expected behavior of the pregnant woman during the childbearing period.b. Taboos are cultural restrictions believed to have serious supernatural consequences. Drink ing chamomile tea would not be in this category.c. Restrictions are activities during the childbearing period which are limited for the pregnant woman. Drink ing chamomile tea would not be in this category.d.

Demonstration is not a term that is used in relation to cultural behaviors.KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Basic Care and Comfort | Difficulty Level: Easy 8. Which of the following would be a priority for the nurse when caring for a pregnant woman who has recently emigrated from another country? a. Help her develop a realistic, detailed birth plan.b. Identify her support system.c. Teach her about expected emotional changes of pregnancy.d. Refer her to a doula for labor support.

ANS: bFeedback a. A detailed birth plan may not be culturally appropriate and is not first priority.b. Correct, because lack of social support has been correlated with an increased risk of pregnancy complications and difficult adaptation to pregnancy. Pregnant women who are recent immigrants face many challenges in obtaining needed social support, and the nurse should first identify her support system to plan further interventions and referrals.c. There may be cultural variations in emotional changes of pregnancy.d. The nurse should first identify her support system before planning further interventions and referrals.KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate 9. A pregnant client at 20 week s’ gestation comes to the clinic for her prenatal visit.

Which of the following client statements would indicate a need for further assessment? a. ―I hate it when the baby moves.‖b. ―I’ve started calling my mom every day.‖c. ―My partner and I can’t stop talk ing about the baby.‖d. ―I still don’t k now much time I’m

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going to tak e off work after the baby comes.‖

ANS: aFeedback a. Experiencing quick ening as unpleasant may be a sign of maladaptation to pregnancy and needs further assessment by the nurse.b. This is an expected finding in maternal adaptation and development of the maternal role.c. This is an expected finding in maternal adaptation and development of the maternal role.d. At 20week s’ gestation, the client still has plenty of time to process this decision.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate 10. A pregnant client ask s the nurse why she should attend childbirth classes. The nurse’s response would be based on which of the following information? a. Attending childbirth class is a good way to mak e new friends.b. Childbirth classes will help new families develop sk ills to meet the challenges of childbirth and parenting.c.

Attending childbirth classes will help a pregnant woman have a shorter labor.d.

Childbirth classes will help a pregnant woman decrease her chance of having a cesarean delivery.

ANS: bFeedback a. There may be a beneficial effect of childbirth classes, but this is not the primary goal of childbirth education.b. Correct. These are the stated goals of childbirth education (ICEA, Lamaze).c. Evidence remains inconclusive regarding link ing attendance at childbirth classes with a decreased incidence of cesarean section and shorterlabors.d.

Evidence remains inconclusive regarding link ing attendance at childbirth classeswith a decreased incidence of cesarean section and shorter labors.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy 11. A woman presents for prenatal care at 6 week s’ gestation by LMP. Which of the following findings would the nurse expect to see? a. Multiple pillow orthopneab. Maternal ambivalencec. Fundus at the umbilicusd. Pedal and ank le edema ANS: bFeedback a. Orthopnea is a common complaint of women during the third trimester.b. Ambivalence is a common feeling of women during the first trimester.c. The

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fundus should be at the umbilicus at 20 week s’ gestation.d. Dependent edema is a common complaint of women during the third trimester.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 12. A first-time father is experiencing couvade syndrome. He is lik ely to exhibit which of the following symptoms or behaviors? a. Urinary frequencyb. Hypotensionc. Bradycardiad. Prostatic hypertrophy ANS: aFeedback a. Urinary frequency is a common symptom of couvade.b. The father’s blood pressure is not usually affected.c. The father’s heart rate is not usually affected.d.

Prostatic changes are not related to couvade.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Family Dynamics | Client Need: Psychosocial Integrity | Difficulty Level: Moderate 13. When providing a psychosocial assessment on a pregnant woman at 21 week s’ gestation, the nurse would expect to observe which of the following signs? a. Ambivalenceb. Depressionc. Anxietyd. Happiness ANS: dFeedback a. Ambivalence is often seen during the first trimester.b. The nurse would not expect to see depression at any time during the pregnancy.c. The patient may express some anxiety near the time of delivery.d. The nurse would expect the patient to exhibit signs of happiness at this time.

KEY: Integrated Process: Communication and Documentation; Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 14. An example of a cultural prescriptive belief during pregnancy is: a. Remain active during pregnancyb. Coldness in any form should be avoidedc. Do not

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have your picture tak end. Avoid sexual intercourse during the third trimester ANS: aThe belief that the patient should remain active during pregnancy is the only example of a cultural prescriptive belief. All of the other answers are examples of cultural restrictive beliefs.

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Cultural Respect | Difficulty Level: Easy 15. Taboos are cultural restrictions that :a. Have serious supernatural consequencesb. Have serious clinical consequencesc. Have superstitious consequencesd. Are functional and neutral practices ANS: aTaboos are believed to have serious supernatural consequences. Taboos are not k nown to have clinical or superstitious consequences and are not functional or neutral practices.

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Cultural Competence | Client Need: Cultural Respect | Difficulty Level: Moderate 16. Jenny, a 21-year-old single woman, comes for her first prenatal appointment at 31 week s’ gestation with her first pregnancy. The clinic nurse’s most appropriate statement is: a. ―Jenny, it is late in your pregnancy to be having your first appointment, but it is nice to meet you and I will try to help you get caught up in your care.‖b. ―Jenny, have you had care in another clinic? I can’t believe this is your first appointment!‖c. ―Jenny, by the date of your last menstrual period, you are 31 week s and now that you are finally here, we need you to come monthly for the next two visits and then week ly.‖d. ―Jenny, by your information, you are 31 week s’ gestation in this pregnancy. Do you have questions for me before I begin your prenatal history and information sharing?‖ ANS: dFeedback a. The initial interview time with the patient should be used to build a positive, nonthreatening relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care that is woman centered.b. The initial interview time with the patient should be used to build a positive, nonthreatening relationship and to gain her confidence by respecting her choices and advocating for continued prenatal

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care and not mak ing assumptions about prior care. The prenatal nurse’s objective is to provide a user-friendly service that is efficient, effective, caring, and patient centered.c.

The initial interview time with the patient should be used to build a positive, nonthreatening, and nonjudgmental relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care.d. The initial interview time with the patient should be used to build a positive, nonthreatening relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care. The prenatal nurse’s objective is to provide a user-friendly service that is efficient, effective, caring, and patient centered.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 17. The clinic nurse visits with Wayne, a 32-year-old man whose partner is pregnant for the first time and is at 12 week s. Wayne describes nausea and vomiting, fatigue, and weight gain. His symptoms are best described as: a. Influenzab. Couvade syndromec. Acid refluxd. Cholelithiasis ANS: bFeedback a. This cluster of symptoms is indicative of couvade syndrome, the experience of maternal signs and symptoms of pregnancy.b. In preparation for parenthood, the male partner moves through a series of developmental task s. During the first trimester, the father begins to deal with the reality of the pregnancy and may worry about financial strain and his ability to be a good father. Feelings of confusion and guilt often surface with the recognition that he is not as excited about the pregnancy as his partner, and couvade syndrome, the experience of maternal signs and symptoms, may develop.c. This cluster of symptoms is indicative of couvade syndrome, the experience of maternal signs and symptoms of pregnancy.d. This cluster of symptoms is indicative of couvade syndrome, the experience of maternal signs and symptoms of pregnancy.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate Multiple Response 18. The clinic nurse encourages paternal attachment during pregnancy by including the

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father in (select all that apply):

a. Prenatal visitsb. Ultrasound appointmentsc. Prenatal class informationd. History tak ing and obtaining prenatal screening information ANS: b, c, dPregnancy is psychologically stressful for men; some enjoy the role of nurturer, but others feel alienated and begin to stray from the relationship. The nurse can be instrumental in promoting early paternal attachment. Involvement of the father during examinations and tests and prenatal classes, along with thorough explanations of the need for them, can minimize the father’s feelings of being left out. A history and prenatal screening should be conducted at the first prenatal visit with the woman alone to ensure confidentiality and an open discussion of any problems or concerns she may have. The history should include information about the current pregnancy; the obstetric and gynecologic history; and a cultural assessment, and a medical, nutritional, social, and family (including the father’s) medical history.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 19. The perinatal nurse screens all pregnant women early in pregnancy for maternal attachment risk factors, which include (select all that apply): a. Adolescenceb. Low educational levelc. History of depressiond. A strong support system for the pregnancy ANS: a, b, cMaternal attachment to the fetus is an important area to assess and can be useful in identifying families at risk for maladaptive behaviors. The nurse should assess for indicators such as unintended pregnancy, domestic violence, difficulties in the partner relationship, sexually transmitted infections, limited financial resources, substance use, adolescence, poor social support systems, low educational level, the presence of mental conditions, or adolescence that might interfere with the patient’s ability to bond with and care for the infant. A strong support system can facilitate the patient’s ability to bond with and care for the infant.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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20. Strategies for culturally responsive care include (select all that apply): a. Practicing ethnocentrismb. Applying stereotypingc. Examining one’s own biasesd.

Learning another language ANS: c, dThe only actions among the choices that are culturally responsive are examining one’s own biases and learning another language. Ethnocentrism and stereotyping are not culturally responsive actions.

KEY: Integrated Process: Safe and Effective Care Environment | Cognitive Level: Application | Content Area: Cultural Competence | Client Need: Cultural Respect | Difficulty Level: Moderate Fill-in-the-Blank

21. The clinic nurse talk s with Beck y, a 16-year-old woman who is now 28 week s’ gestation. Today’s visit is only the second prenatal appointment that Beck y has k ept. The nurse wonders if Beck y’s failure to come for routine prenatal check s is, in part, related to an adolescent’s orientation to the , rather than to the .

ANS: present; futureThe adolescent may not seek prenatal care unless pressured by authority figures or peers to do so. By nature, adolescents are not future oriented. Hence, the pregnant adolescent may not be able to readily accept the reality of the unborn child.

KEY: Integrated Process: Teaching/Learning | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 22. According to Rubin, the mother-to-be needs to accept the pregnancy and incorporate it into her own reality and . This process is k nown as ― .‖ ANS: self-concept; binding inThe mother-to-be needs to accept the pregnancy and incorporate it into her own reality and self-concept. This process is k nown as ―bindingin.‖ Acceptance of the child is critical to a successful adjustment to the pregnancy.

Acceptance must come from the expectant woman as well as from others.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

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23. The clinic nurse ask s pregnant women about their acceptance and planning for this pregnancy as a component of domestic violence screening. The nurse is aware that a(n) pregnancy the risk for domestic violence.

ANS: unplanned; increasesIntimate partner violence (IPV) may occur for the first time during pregnancy, or the nurse may identify evidence during the physical examination that is suspicious of ongoing physical abuse. Acceptance of pregnancy may be delayed if it was unplanned or unwanted. As a women’s advocate, nurses have a duty to be observant, to actively listen, and to use communication sk ills to gain clarification and understanding.

Chapter 6:

Antepartal Tests

Multiple Choice 1. Your pregnant patient is in her first trimester and is scheduled for an abdominal ultrasound. When explaining the rationale for early pregnancy ultrasound, the best response is: a. ―The test will help to determine the baby’s position.‖b. ―The test will help to determine how many week s you are pregnant.‖c. ―The test will help to determine if your baby is growing appropriately.‖d. ―The test will help to determine if you have a boy or girl.‖ ANS: bFeedback a. Fetal position during pregnancy changes, and position in the first trimester is not indicative of position later in pregnancy.b. Fetal growth and size are fairly consistent during the first trimester and are a reliable indicator of the week s of gestation. c. Fetal growth is best assessed later in pregnancy.d. The primary rationale for ultrasounds is not to determine gender.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 2. Your pregnant patient is having maternal alpha-fetoprotein (AFP) screening. She does not understand how a test on her blood can indicate a birth defect in the fetus. The best

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reply by the nurse is:

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a. ―We have done this test for a long time.‖b. ―If babies have a neural tube defect, alphafetoprotein leak s out of the fetus and is absorbed into your blood, causing your level to rise. This serum blood test detects that rise.‖c. ―Neural tube defects are a genetic anomaly, and we examine the amount of alpha-fetoprotein in your DNA.‖d. ―If babies have a neural tube defect, this results in a decrease in your level of alpha-fetoprotein.‖ ANS: bFeedback a. This response does not explain AFP screening.b. When a neural tube defect is present, AFP is absorbed in the maternal circulation, resulting in a rise in the maternal AFP level.c. AFP testing is not related to DNA.d. Fetal neural tube defects result in an increase in maternal AFP.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 3. The primary complications of amniocentesis are: a. Damage to fetal organsb. Puncture of umbilical cordc. Maternal paind. Infection ANS: dFeedback a. Amniocentesis is done under ultrasound guidance, and damage to fetal organs is very rare.b. Amniocentesis is done under ultrasound guidance, and damage to the umbilical cord is very rare.c. Amniocentesis is done under local anesthesia, and maternal pain is generally minimal.d. Amniocentesis involves insertion of a needle into the amniotic sac, and infection is the primary complication.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 4. Your patient is 34 week s pregnant and during a regular prenatal visit tells you she does not understand how to do ―k ick counts.‖ The best response by the nurse would be to explain: a. ―Here is an information sheet on how to do k ick counts.‖b. ―It is not important to do k ick counts because you have a low-risk pregnancy.‖c. ―Fetal k ick counts are not a reliable indicator of fetal well-being in the third trimester.‖d. ―Fetal movements are an indicator of fetal well-being. You should count twice a day, and you should feel 10 fetal movements in 2 hours.‖ ANS: dFeedback a. Providing written information may not be enough, and the patient

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may need a verbal explanation.b. Kick counts are indicated for all pregnancies.c. Kickcounts are a reliable indicator of fetal well-being after 32 to 34 week s’ gestation.d. This response provides the patient with information on how to do k ick counts and the rationale for doing k ick counts and criteria for normal fetal movement.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 5. Your patient is a 37-year-old pregnant woman who is 5 week s pregnant and is considering genetic testing. During your discussion, the woman ask s the nurse what the advantages of chorionic villus sampling (CVS) are over amniocentesis. The best response is: a. ―You will need anesthesia for amniocentesis, but not for CVS.‖b. ―CVS is a faster procedure.‖c. ―CVS provides more detailed information than amniocentesis.‖d. ―CVS can be done earlier in your pregnancy, and the results are available more quick ly.‖ ANS: dFeedback a. Anesthesia is not done for either procedure.b. The length of time for either procedure is similar.c. Both amniocentesis and CVS provide the same information. d. CVS can be done earlier in gestation.KEY: Integrated Process: Teaching and Learning | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 6. The clinic nurse meets with Rebecca, a 30-year-old woman who is experiencing her first pregnancy. Rebecca’s quadruple mark er screen result is positive at 17 week s’ gestation. The nurse explains that Rebecca needs a referral to: a. A genetics counselor/specialistb. An obstetricianc. A gynecologistd. A social work er

ANS: aFeedback a. All women should be offered screening with maternal serum mark ers.

The Triple Mark er screen and the Quadruple Mark er screen test for the presence of alphafetoprotein (AFP), estradiol, human chorionic gonadotropin (hCG), and other mark ers.

These tests screen for potential neural tube defects, Down syndrome, and Trisomy 18. If the screen is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed.b. If genetic screening is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic

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villus sampling (CVS) or amniocentesis, should be performed.c. If genetic screening is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed. d. If genetic screening is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 7. A 37-year-old woman who is 17 week s pregnant has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences which of the following side effects? a. Pain at the puncture siteb. Macular rash on the abdomenc. Decrease in urinary outputd.

Cramping of the uterus ANS: dFeedback a. It is normal for the patient to experience pain at the puncture site.b. A rash is not an expected complication.c. Oliguria is not an expected complication.d. The woman should report any uterine cramping. Although rare, amniocentesis could stimulate preterm labor.KEY: Integrated Process: Nursing Process: Implementation; Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate 8. A laboratory report indicates the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid patient with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby’s lung fields are mature.b. The mother is high risk for hemorrhage.c. The baby’s k idneys are functioning poorly.d. The mother is high risk for eclampsia.

ANS: aFeedback a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature.b.

L/S ratios are unrelated to maternal blood loss.c. L/S ratios are unrelated to fetal renal function.d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

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Chapter 7: High-Risk Antepartum Nursing Care Multiple Choice 1.

A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes.

Identify the priority nursing assessment to ensure client safety.

A.

Assess uterine contractions continuously

B.

Assess fetal heart rate continuously.

C.

Assess urinary output.

D.

Assess respiratory rate.

ANS: d Feedback a. Monitoring contractions does not indicate magnesium toxicity.b.

Magnesium sulfate will decrease fetal variability and not provide an accurate assessment of magnesium toxicity.c. Urinary output does not correlate to decreased deep tendon reflexes.d. Correct. Respiratory effort and deep tendon reflexes (DTRs) are involuntary, and a decrease in DTRs could indicate the risk of magnesium sulfate toxicity and the riskfor daecsrrespiratory effort.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate 2. A pregnant client with a history of multiple sexual partners is at highest risk for which of the following complications: a.

Premature rupture of membranes

b.

Gestational diabetes

c.

Ectopic pregnancy

d.

Pregnancy-induced hypertension

ANS: c Feedback a. Multiple partners do not increase a woman’s risk of premature rupture of membranes.b. Genetics and client diet and weight are contributing factors to

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gestational diabetes.c. Correct. A history of multiple sexual partners places the client at a higher risk of having contracted a sexually transmitted disease that could have ascended the uterus to the fallopian tubes and caused fallopian tube block age, placing the client at high risk for an ectopic pregnancy.d. Multiple sexual partners are not a risk factor for pregnancy-induced hypertension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 3. Identify the hallmark of placenta previa that differentiates it from abruptio placenta. a.

Sudden onset of painless vaginal bleeding

b.

Board-lik e abdomen with severe pain

c.

Sudden onset of bright red vaginal bleeding

d.

Severe vaginal pain with bright red bleeding

ANS: a Feedback a. Correct. When the placenta attaches to the lower uterine segment near or over the cervical os, bleeding may occur without the onset of contractions or pain.b.

The hallmark for abruptio placenta is pain and a board-lik e abdomen.c. Bright red bleeding could be related to abruptio placenta, placenta previa, or other complications of pregnancy.d. Pain is not a hallmark of placenta previa.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 4. Which of the following assessments would indicate instability in the client hospitalized for placenta previa? a.

BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPM

b.

FHR moderate variability without accelerations

c.

Dark brown vaginal discharge when voiding

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d.

Oral temperature of 99.9°F

ANS: a Feedback a. A decrease in BP accompanied by bradycardia or tachycardia is an indication of hypovolemic shock .b. FHR with moderate variability can be absent of accelerations during fetal sleep cycles or after maternal sedation.c. Bright red vaginal bleeding is an indication of current bleeding.d. Oral temperature may fluctuate based on the client’s hydration status. It should be reassessed. Cause for concern is a temperature of 100.4°F or more.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 5. During pregnancy, poorly controlled asthma can place the fetus at risk for: a.

Hyperglycemia

b.

IUGR

c.

Hypoglycemia

d.

Macrosomia ANS: b Feedback a. Maternal asthma does not place the fetus at risk for hyperglycemia.b. Compromised pulmonary function can lead to decompensation and hypoxia that decrease oxygen flow to the fetus and can cause intrauterine growth restriction (IUGR).c. Asthma does not directly affect glycemic control.d. A fetus experiencing hypoxia would be small for gestational age, not large for gestational age.KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: AnalysisContent Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 6. Which of the following nursing diagnoses is of highest priority for a client with an ectopic pregnancy who has developed disseminated intravascular coagulation (DIC)? a. Risk for deficient fluid volumeb. Risk for family process interruptedc. Risk for disturbed identityd. High risk for injury

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ANS: a Feedback a. Correct. The client is at high risk for hypovolemia which is life threatening and tak es precedence over any psychosocial or less pressing diagnoses.b. This is a psychosocial diagnosis and is not life threatening.c. This is a psychosocial diagnosis and is not life threatening.d. The client is at risk for injury; however, the diagnosis of deficient fluid volume is more descriptive and has clearly defined goals and interventions.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult 7. Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension? a. Total urine protein of 200 mg/dLb. Total platelet count of 40,000 mm c. Uric acid level of 8 mg/dLd. Blood urea nitrogen 24 mg/dL ANS: b Feedback a. The client’s urine protein is elevated. A urine protein of ≥300 mg/dL in a 24-hour collection is considered concerning.b. Correct. A platelet count of £50,000 is a critical value and should be reported to the health-care provider immediately. This client is at increased risk of hemorrhage.c. The uric acid level is only slightly elevated.d.

The BUN is only slightly elevated.KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult 8. Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client’s blood glucose levels? a. Nifedipine b. Betamethasone c. Magnesium sulfate d. Indomethacin ANS: b Feedback a. Nifedipine does not affect maternal blood glucose levels.b. Betasympathomimetics may stimulate hyperglycemia which will require an increased need for insulin.c. Magnesium sulfate does not affect blood glucose levels.d. Indomethacin does not affect blood glucose levels.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Difficult

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9. While educating the client with class II cardiac disease, at 28 week s’ gestation, the nurse instructs the client to notify the physician if she experiences which of the following conditions? a. Emotional stress at work b. Increased dyspnea while restingc. Mild pedal and ank leedemad.

Weight gain of 1 pound in 1 week ANS: b Feedback a. Emotional stress increases cardiac work load; however, without symptoms of cardiac decompensation, this is not immediately concerning.b. Increasing dyspnea, at rest, can be a sign of cardiac decompensation leading to increased congestive heart failure.c. Mild edema during the third trimester is normal. However, increasing edema and pitting edema should be reported as they can be a sign of increasing CHF.d. A weight gain of 1 pound per week is expected during the third trimester.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

10. The nurse work ing in a prenatal clinic is providing care to three primigravida patients.

Which of the patient findings would the nurse highlight for the physician? a. 15 week s, denies feeling fetal movementb. 20 week s, fundal height at the umbilicusc.

25 week s, complains of excess salivationd. 30 week s, states that her vision is blurry ANS: d Feedback a. This finding is normal. Quick ening is usually felt between 16 and 20 week s’ gestation.b. This finding is normal. The fundal height at 20 week s’ gestation is usually at the level of the umbilicus.c. Excess salivation is a normal, albeit annoying, finding.d. Blurred vision is a sign of pregnancy-induced hypertension (PIH). This finding should be reported to the woman’s health-care practitioner.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 11. The perinatal nurse is assessing a woman in triage who is 34 + 3 week s’ gestation in her first pregnancy. She is worried about having her baby ―too soon,‖ and she is

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experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most lik ely diagnosis would be: a. Preterm laborb. Term laborc. Back labord. Braxton-Hick s contractions

ANS: d Feedback a. Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the end of the 36th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.b. Term labor occurs after 37 week s’ gestation.c. There is no indication in this scenario that this is back labor.d. Braxton-Hick s contractions are regular contractions occurring after the third month of pregnancy. They may be mistak en for regular labor, but unlik e true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 12. The perinatal nurse k nows that the term to describe a woman at 26 week s’ gestation with a history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick ) is: a. Preeclampsiab. Chronic hypertensionc. Gestational hypertensiond. Chronic hypertension with superimposed preeclampsia ANS: d Feedback a. Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, and renal and central nervous systems.b.

Chronic hypertension is hypertension that is present and observable prior to pregnancy or hypertension that is diagnosed before the 20th week of gestation.c. Gestational hypertension is a nonspecific term used to describe the woman who has a blood pressure elevation detected for the first time during pregnancy, without proteinuria.d. The following criteria are necessary to establish a diagnosis of superimposed preeclampsia: hypertension and no proteinuria early in pregnancy (prior to 20 week s’ gestation) and new-onset proteinuria, a sudden increase in protein—urinary excretion of 0.3 g protein or more in a 24-hour specimen, or two dipstick test results of 2+ (100 mg/dL), with the values recorded at least 4 hours apart, with no evidence of urinary tract infection; a

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sudden increase in blood pressure in a woman whose blood pressure has been well controlled; thrombocytopenia (platelet count lower than 100,000/mmC); and an increase in the liver enzymes alanine transaminase (ALT) or aspartate transaminase (AST) to abnormal levels.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 13. A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings? a. Patellar and biceps reflexes of +4b. Urinary output of 50 mL/hrc. Respiratory rate of 10 rpmd. Serum magnesium level of 5 mg/dL ANS: c Feedback a. The magnesium sulfate has been ordered because the patient has severe pregnancy-induced hypertension. Patellar and biceps reflexes of +4 are symptoms of the disease.b. The urinary output must be above 25 mL/hr.c. The drop in respiratory rate may indicate that the patient is suffering from magnesium toxicity. The nurse should report the finding to the physician.d. The therapeutic range of magnesium is 4 to 7 mg/dL. KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Adverse Effects/Contraindications; Antepartum Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Diagnostic Tests | Client Need: Health Promotion and Maintenance; Pharmacological and Parenteral Therapies; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 14. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother? a. Serum potassium level increasesb. Diarrheac. Urticariad. Complaints of nervousness

ANS: d Feedback a. The nurse would not expect to see a rise in the mother’s serum potassium levels.b. The beta agonists are not associated with diarrhea.c. The beta agonists are not associated with urticaria.d. Complaints of nervousness are commonly made by

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women receiving subcutaneous beta agonists.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications and Side Effects | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate 15. Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae? a. Increasing abdominal girth measurementsb. Profuse vaginal bleedingc. Bradycardia with an aortic thrilld. Hypothermia with chills ANS: a Feedback a. The nurse would expect to see increasing abdominal girth measurements.b. Profuse vaginal bleeding is rarely seen in placental abruption and is never seen when the abruption is concealed.c. With excessive blood loss, the nurse would expect to see tachycardia.d. The nurse would expect to see a stable temperature.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate 16. A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams.

Which of the following complications of pregnancy lik ely contributed to these findings? a. Pyelonephritisb. Pregnancy-induced hypertensionc. Gestational diabetesd. Abruptio placentae ANS: c Feedback a. Pyelonephritis does not lead to the development of hydramnios or macrosomia.b. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia.c. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies.d. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application |

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Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 17. For the patient with which of the following medical problems should the nurse question a physician’s order for beta agonist tocolytics? a. Type 1 diabetes mellitusb. Cerebral palsyc. Myelomeningoceled. Positive group B streptococci culture ANS: a Feedback a. Beta agonists often elevate serum glucose levels. The nurse should question the order.b. Beta agonists are not contraindicated for patients with cerebral palsy.c. Beta agonists are not contraindicated for patients with myelomeningocele.d. Beta agonists are not contraindicated for patients with group B streptococci.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of RiskPotential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 18. The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? a. The patient with placenta previab. The patient whose vagina is colonized with group B streptococcic. The patient who is hepatitis B surface antigen positived. The patient with eclampsia ANS: d Feedback a. Patients with placenta previa are not especially high risk for placental abruption.b. Patients colonized with group B streptococci are not especially high risk for placental abruption.c. Patients who are hepatitis B surface antigen positive are not especially high risk for placental abruption.d. Patients with eclampsia are high risk for placental abruption.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Complications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

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19. The nurse is caring for a woman at 28 week s’ gestation with a history of preterm delivery. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis? a. Human relaxin levelsb. Amniotic fluid levelsc. Alpha-fetoprotein levelsd. Fetal fibronectin levels ANS: d Feedback a. Relaxin levels are rarely assessed. In addition, they are unrelated to the incidence of preterm labor.b. Amniotic fluid levels are not directly related to the incidence of preterm labor.c. Alpha-fetoprotein levels are not related to the incidence of preterm labor.d. A rise in the fetal fibronectin levels in cervical secretions has been associated with preterm labor.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Laboratory Values | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of RisP k otential | Difficulty Level: Moderate 20. Which of the following statements is most appropriate for the nurse to say to a patient with a complete placenta previa? a. ―During the second stage of labor you will need to bear down.‖b. ―You should ambulate in the halls at least twice each day.‖c. ―The doctor will lik ely induce your labor with oxytocin.‖d. ―Please promptly report if you experience any bleeding or feel any back discomfort.‖ ANS: d Feedback a. This response is inappropriate. This patient will be delivered by cesarean section.b. This response is inappropriate. Patients with placenta previa are usually on bed rest.c. This response is inappropriate. This patient will be delivered by cesarean section.d. Labor often begins with back pain. Labor is contraindicated for a patient with complete placenta previa.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 21. A woman at 32 week s’ gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care

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outcome? a. Rise in serum creatinineb. Drop in serum proteinc. Resolution of thrombocytopeniad.

Resolution of polycythemia ANS: c Feedback a. A rise in serum creatinine indicates that the k idneys are not effectively excreting creatinine. It is a negative outcome.b. A drop in serum protein indicates that the k idneys are allowing protein to be excreted. This is a negative outcome. c. Resolution of thrombocytopenia is a positive sign. It indicates that the platelet count is returning to normal.d. Polycythemia is not related to HELLP syndrome. Rather one sees a drop in red cell and platelet counts with HELLP. A positive sign, therefore, would be a rise in the RBC count.

KEY: Integrated Process: Nursing Process: Evaluation | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Illness Management | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 22. A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? a. High leuk ocyte countb. Explosive diarrheac. Fractured pelvisd. Low platelet count

ANS: d Feedback a. High leuk ocyte count is not associated with severe pregnancyinduced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.b. Explosive diarrhea is not associated with severe PIH or HELLP syndrome.c. A fractured pelvis is not associated with severe PIH or HELLP syndrome.d.

Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Diagnostic Tests; Reduction of Risk Potential: Laboratory Data | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 23. A woman at 10 week s’ gestation is diagnosed with gestational trophoblastic disease (hydatiform mole). Which of the following findings would the nurse expect to see?

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a. Platelet count of 550,000/ mm3b. Dark brown vaginal bleedingc. White blood cell count 17,000/ mm3d. Macular papular rash ANS: b Feedback a. The nurse would not expect to see an elevated platelet count.b. The nurse would expect to see dark brown vaginal dischargec. The nurse would not expect to see an elevated white blood cell count.d. The nurse would not expect to see a rash.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 24. After an education class, the nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed? a. ―I could get an STI even if I just have oral sex.‖b. ―Girls over 16 are less lik ely to get STDs than younger girls.‖c. ―The best way to prevent an STI is to use a diaphragm.‖d. ―Girls get human immunodeficiency virus (HIV) easier than boys do.‖ ANS: c Feedback a. This statement is true. Organisms that cause sexually transmitted infections can invade the respiratory and gastrointestinal tracts.b. This statement is true.

Young women are especially high risk for becoming infected with sexually transmitted diseases.c. This statement is untrue. The young woman needs further teaching. Condoms protect against STDs and pregnancy. In addition, condoms can be k ept in readiness for whenever sex may occur spontaneously. Using condoms does not require the teen to plan to have sex. A diaphragm is not an effective infection-control method. Plus, it would require the teen to plan for intercourse.d. This statement is true. Young women are higher risk for becoming infected with HIV than are young men.

KEY: Integrated Process: Nursing Process: Evaluation; Teaching and Learning | Cognitive Level: Application | Content Area: Disease Prevention; High Risk Behaviors; Human Sexuality | Client Need: Health Promotion and Maintenance: High RiskBehaviors; Human Sexuality | Difficulty Level: Moderate 25. A woman who is admitted to labor and delivery at 30 week s’ gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback . Which of the following maternal vital signs is most important for the nurse to assess each

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hour? a. Temperatureb. Pulsec. Respiratory rated. Blood pressure ANS: c Feedback a. The temperature should be monitored, but it is not the most important vital sign.b. The pulse rate should be monitored, but it is not the most important vital sign.c. The respiratory rate is the most important vital sign. Respiratory depression is a sign of magnesium toxicity.d. The blood pressure should be monitored, but it is not the most important vital sign.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Intrapartum Care; Potential for Complications from Pharmacological Therapies: Adverse Effects/Contraindications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate 26. You are caring for a patient who was admitted to labor and delivery at 32 week s’ gestation and diagnosed with preterm labor. She is currently on magnesium sulfate, 2 gm per hour. Upon your initial assessment you note that she has a respiratory rate of 8 with absent deep tendon reflexes. What will be your first nursing intervention? a. Elevate head of the bedb. Notify the MDc. Discontinue magnesium sulfated. Draw a serum magnesium level ANS: c Initial nursing intervention needs to be discontinuing magnesium sulfate because the patient is exhibiting signs of magnesium toxicity with absent deep tendon reflexes and decreased respiratory rate.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application and Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Hard 27. A 34-week s’ gestation multigravida, G3 P1 is admitted to the labor suite. She is contracting every 7 minutes and 40 seconds. The woman has several medical problems.

Which of the following of her comorbidities is most consistent with the clinical picture? a. Kyphosisb. Urinary tract infectionc. Congestive heart failured. Cerebral palsy

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ANS: b Feedback a. Kyphosis is unrelated to preterm labor.b. Urinary tract infections often precipitate preterm labor.c. It is unlik ely that the congestive heart failure precipitated the preterm labor.d. Cerebral palsy is unrelated to preterm labor.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance: Antepartum Care; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 28. A primiparous woman has been admitted at 35 week s’ gestation and diagnosed with HELLP syndrome. Which of the following laboratory changes is consistent with this diagnosis? a. Hematocrit dropped to 28%.b. Platelets increased to 300,000 cells/mm3.c. Red blood cells increased to 5.1 million cells/mm3.d. Sodium dropped to 132 mEq/dL. ANS: a Feedback a. The nurse would expect to see a drop in the hematocrit: The H in HELLP stands for hemolysis.b. The nurse would expect to see low platelets.c. The nurse would expect to see hemolysis.d. The sodium is usually unaffected in HELLP syndrome.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Moderate 29. A labor nurse is caring for a patient, 39 week s’ gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? a. Type and cross-match her blood.b. Insert an internal fetal monitor electrode.c.

Administer an oral stool softener.d. Assess her complete blood count.

ANS: b Feedback a. It would be appropriate to type and cross-match the patient for a blood transfusion.b. This action is inappropriate. When a patient has a placenta previa, nothing should be inserted into the vagina.c. To prevent constipation, it is appropriate fora patient to tak e a stool softener.d. It is appropriate to monitor the patient for signs of anemia.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:

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Application | Content Area: Antepartum Care; Patient Advocacy; Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential; Safe and Effective Care Environment: Management of Care | Difficulty Level: Moderate 30. A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see? a. Postpartum hemorrhageb. Neonatal hyperglycemiac. Postpartum oliguriad. Neonatal macrosomia ANS: d Feedback a. The patient is not especially high risk for a postpartum hemorrhage.b.

The nurse would expect to see neonatal hypoglycemia, not hyperglycemia.c. The nurse would expect to see postpartum polyuria.d. The nurse would expect to see neonatal macrosomia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 31. According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia: a. Tak e the patient’s blood pressure every 6 hoursb. Encourage the patient to rest on her back c. Notify the physician of a urine output greater than 30 mL/hrd. Administer magnesium sulfate according to agency policy ANS: d Feedback a. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The blood pressure is tak en every 1 hour or more frequently according to physician orders or institutional protocol.b.

The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a side-lying position to enhance uterine perfusion.c. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria and the physician must be notified.d. The nurse is the manager of care for the woman with preeclampsia during

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the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 32. The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 week s’ gestation. The nurse is preparing to administer the second dose of beta-methasone prescribed by the physician.

Marilyn ask s: ―What is this injection for again?‖ The nurse’s best response is: a. ―This is to help your baby’s lungs to mature.‖b. ―This is to prepare your body to begin the labor process.‖c. ―This is to help stabilize your blood pressure.‖d. ―This is to help your baby grow and develop in preparation for birth.‖ ANS: a Feedback a. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 week s and childbirth can be delayed for 48 hours.b. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 week s and childbirth can be delayed for 48 hours.c.

Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 week s and childbirth can be delayed for 48 hours.d. Antenatal glucocorticoids such as betamethasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 week s and childbirth can be delayed for 48 hours.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 33. A woman who is 36 week s pregnant presents to the labor and delivery unit with a history of congestive heart disease. Which of the following findings should the nurse report to the primary health-care practitioner? a. Presence of chloasmab. Presence of severe heartburnc. 10-pound weight gain in a monthd. Patellar reflexes +1

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ANS: c Feedback a. Chloasma is a normal pregnancy finding.b. Heartburn is an expected finding during the third trimester.c. The weight gain may be due to fluid retention. Fluid retention may occur in patients with pregnancy-induced hypertension and in patients with congestive heart failure. The physician should be notified.d. Although slightly hyporeflexic, patellar reflexes of +1 are within normal limits.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of RiskPotential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 34. The single most important risk factor for preterm birth includes: a. Uterine and cervical anomaliesb. Infectionc. Increased BMId. Prior preterm birth ANS: dThe single most important factor is prior preterm birth with a reoccurrence rate of up to 40%.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 35. Your antepartal patient is 38 week s’ gestation, has a history of thrombosis, and has been on strict bed rest for the last 12 hours. She is now experiencing shortness of breath.

What about the patient may be a contributing factor for her shortness of breath? a. Physiologic changes in pregnancy result in vasodilation, which increases the tendency to form blood clots.b. Physiologic changes in pregnancy result in vasoconstriction, which increases the tendency to form blood clots.c. Physiologic changes in pregnancy result in anemia, which increases the tendency to form blood clots.d. Physiologic changes in pregnancy result in decreased perfusion to the lungs, which increases the tendency to form blood clots.

ANS: a The patient’s shortness of breath, bed rest, and history of thrombosis indicate possible pulmonary embolism. Her pregnant state also increases the potential for thrombosis resulting from increased levels of coagulation factors and decreased fibrinolysis, venous dilation, and obstruction of the venous system by the gravid uterus.

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Thromboembolitic diseases occurring most frequently in pregnancy include deep vein thrombosis and pulmonary embolism.

KEY: Integrated Process: Critical Think ing | Cognitive Level: Complication | Content Area: Physiologic Adaptation: Alteration in Body Systems | Client Need: Physiologic Adaptation | Difficulty Level: Hard 36. Metabolic changes during pregnancy

glucose tolerance.

a. lowerb. increasec. maintaind. alter ANS: a Metabolic changes during pregnancy lower glucose tolerance.

KEY: Integrated Process: Knowledge | Cognitive Level: Synthesis | Content Area: Maternity| Client Need: Physiologic Adaptation | Difficulty Level: Hard True/False 37. Immediately postpartum, the insulin needs in diabetic women increase dramatically.

ANS: False There is a significant decrease in the need for insulin immediately after delivery related to the loss of antagonistic placental hormones and suppression of the anterior pituitary growth hormone.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Easy 38. The perinatal nurse observes the placental inspection by the health-care provider after birth. This examination may help to determine whether an abruption has occurred prior to or during labor.

ANS: True Fifty percent of abruptions occur before labor and after the 30th week , 15% occur during labor, and 30% are identified only upon inspection of the placenta after delivery.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty

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Level: Moderate 39. It is critical for the perinatal nurse to learn, as part of the facility’s policies and procedures, to immediately perform a vaginal examination on a woman who presents with vaginal bleeding after 24 week s’ gestation.

ANS: False Placenta previa should be suspected in all patients who present with bleeding after 24 completed week s of gestation. Because of the risk of placental perforation, vaginal examinations are not performed.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 40. The perinatal nurse k nows that the survival rate for infants born at or greater than 28 to 29 gestational week s is greater than 90%.

ANS: True With appropriate medical care, neonatal survival dramatically improves as the gestational age increases, with over 50% of neonates surviving at 25 week s’ gestation, and over 90% surviving at 28 to 29 week s of gestation.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 41. A patient with hypertension who is receiving intravenous magnesium sulfate therapy has requested an epidural anesthetic. The perinatal nurse should first review the patient’s complete blood count results for evidence of a decreased platelet count.

ANS: True Baseline information, including complete blood count (CBC), clotting studies, serum electrolytes, and renal function tests, is used to alert the care providers to changes in the patient’s condition as additional laboratory tests are obtained.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Difficult 42. The perinatal nurse k nows that the laboring diabetic patient’s blood glucose level should always be less than 120 mg/dL.

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ANS: TrueBlood glucose levels are assessed every hour, and fluid/insulin adjustments are made as needed to maintain maternal blood glucose levels between 80 and 120 mg/dL. KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy Multiple Response 43. The perinatal nurse describes risk factors for placenta previa to the student nurse.

Placenta previa risk factors include (select all that apply): a. Cocaine useb. Tobacco usec. Previous caesarean birthd. Previous use of medroxyprogesterone (Depo-Provera) ANS: a, b, cFeedback a. Placenta previa may be associated with risk factors including smok ing, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years.b. Placenta previa may be associated with risk factors including smok ing, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years.c. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age.d.

Previous use of medroxyprogesterone (Depo-Provera) is not a risk factor for placenta previa.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 44. Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 week s’ gestation.

An appropriate nursing action would be to (select all that apply): a. Assess the fetal heart rateb. Obtain urine for culture and sensitivityc. Assess Kerry’s blood pressure and pulsed. Palpate Kerry’s abdomen for contractions ANS: a, b, dFeedback a. Women experiencing preterm labor may complain of back ache, pelvic aching, menstrual-lik e cramps, increased vaginal discharge, pelvic pressure,

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urinary frequency, and intestinal cramping with or without diarrhea. The patient’s abdomen should be palpated to assess for contractions, and the fetus’s heart rate should be monitored.b. Women experiencing preterm labor may complain of back ache, pelvic aching, menstrual-lik e cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency). The patient’s abdomen should be palpated to assess for contractions, and the fetus’s heart rate should be monitored.c.

Assessment of blood pressure and pulse is not an important nursing action in this scenario.d. Women experiencing preterm labor may complain of back ache, pelvic aching, menstrual-lik e cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient’s abdomen should be palpated to assess for contractions and the fetus’s heart rate should be monitored.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 45. The perinatal nurse k nows that tocolytic agents are most often used to (select all that apply): a. Prevent maternal infectionb. Prolong pregnancy to 40 week s’ gestationc. Prolong pregnancy to facilitate administration of antenatal corticosteroidsd. Allow for transport of the woman to a tertiary care facility ANS: c, dFeedback a. Tocolytics are not used to treat maternal infection.b. Tocolytics are generally only effective in delaying delivery for several days.c. Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of antenatal corticosteroids to accelerate fetal lung maturity.d. Delaying the birth provides time for maternal transport to a facility equipped with a neonatal intensive care unit.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 46. The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information

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provided about preterm labor and birth prevention includes (select all that apply): a. Encouraging regular, ongoing prenatal careb. Reporting symptoms of urinary frequency and burning to the health-care providerc. Coming to the labor triage unit if back pain or cramping persist or become regulard. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5 minutes ANS: a, b, cFeedback a. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur.b. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur.c. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider if symptoms of preterm labor occur.d.

Lying on the right side; drink ing fluids, not withholding fluids; and counting fetal movements if contractions occur every 5 minutes are recommended if a woman think sshe is contracting.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 47. The perinatal nurse describes for the new nurse the various risk s associated with prolonged premature preterm rupture of membranes. These risk s include (select all that apply): a. Chorioamnionitisb. Abruptio placentaec. Operative birthd. Cord prolapse ANS: a, b, dEven though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cord prolapse.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level:

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Moderate 48. Betamethasone is a steroid that is given to a pregnant woman with signs of preterm labor. The purpose of giving steroids is to (select all that apply): a. Stimulate the production of surfactant in the preterm infantb. Be given between 24 and 34 week s’ gestationc. Increase the severity of respiratory distressd. Accelerate fetal lung maturity ANS: a, b, dBetamethasone is a steroid that is given to pregnant women with signs of preterm labor between 24 and 34 week s’ gestation. It stimulates the production of surfactant in the preterm infant and accelerates fetal lung maturity.

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Pharmacological and Parenteral Therapies: Expected Effects/Outcomes | Client Need: Pharmacologic and Parenteral Therapies | Difficulty Level: Hard 49. Mark ed hemodynamic changes in pregnancy can impact the pregnant woman with cardiac disease. Signs and symptoms of deteriorating cardiac status include (select all that apply): a. Orthopneab. Nocturnal dyspneac. Palpitationsd. Irritation ANS: a, b, cSigns and symptoms of deteriorating cardiac status with cardiac disease include orthopnea, nocturnal dyspnea, and palpitations, but do not include irritation.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Synthesis | Content Area: Reduction of Risk Potential-Potential for Complications | Client Need: Physiologic Adaptation | Difficulty Level: Hard Short Answer 50. A condition where the placenta attaches to the lower uterine segment of the uterus ANS: Placenta previaRefer To: Maternity Nursing Terms and Definitions; Ref. 7 KEY: Integrated Process: Teaching/Learning | Cognitive Level: Knowledge | Content

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Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 51. A pregnancy that ends before 20 week s’ gestation ANS: MiscarriageRefer To: Maternity Nursing Terms and Definitions; Ref. 7 KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 52. Birth prior to 37 completed week s of pregnancy ANS: Preterm birthRefer To: Glossary; Perinatal Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 53. Speck s or spots in the vision where the patient cannot see; ―blind spots‖ ANS: ScotomaRefer To: Maternity Nursing Terms and Definitions; Ref. 7 KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 54. A disease characterized by an abnormal placental development that results in the production of fluid-filled grapelik e clusters and a vast proliferation of trophoblastic tissue ANS: Hydatidiform mole/Gestational trophoblastic diseaseRefer To: Perinatal Nursing Terms and Definitions; Ref. 7 KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

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55. No expulsion of the products of conception, but bleeding and dilation of the cervix such that a pregnancy is unlik ely ANS: Inevitable abortionRefer To: Maternity Nursing Terms and Definitions; Ref. 7 KEY: Integrated Processes: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 56. Placement of suture to mechanically close a weak cervix ANS: Cervical cerclageRefer To: Maternity Nursing Terms and Definitions; Ref. 7 KEY: Integrated Process: Teaching and Learning | | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy Fill-in-the-Blank

57. The perinatal nurse k nows that an early pregnancy loss occurs before week s, and a late pregnancy loss is one that occurs between 12 and

week s.

ANS: 12; 20Not all conceptions result in a live-born infant. Of all clinically recognized pregnancies, 10% to 20% are lost, and approximately 22% of pregnancies detected on the basis of hCG assays are lost before the appearance of any clinical signs or symptoms. By definition, an early pregnancy loss occurs before 12 week s of gestation; a late pregnancy loss is one that occurs between 12 and 20 week s.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 58. Mary, a G3 TPAL 0020 woman at 20 week s’ gestation, has had a transvaginal ultrasound. Mary has been informed that she has cervical incompetence. The perinatal nurse explains that this diagnosis means that her cervix has without contractions.

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ANS: dilated; regularPatients with cervical incompetence usually present with painless dilation and effacement of the cervix, often during the second trimester of pregnancy. The patient frequently gives a history of repeated second trimester losses with no apparent etiology. Incompetent cervix is estimated to cause approximately 15% of all second trimester losses.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 59. The perinatal nurse k nows that nausea and vomiting are common in pregnancy and usually resolve by week s’ gestation. The severe form of this condition is .

ANS: 16; hyperemesis gravidarumFeedback 1: Nausea and vomiting are a common condition of pregnancy which affect 70% to 85% of pregnant women and usually resolve by the 16th week of gestation.Feedback 2: Hyperemesis gravidarum represents the extreme end of the nausea/vomiting spectrum in terms of severity. Criteria for the diagnosis of hyperemesis gravidarum include persistent vomiting unrelated to other causes, a measure of acute starvation (usually large k etonuria), and some discrete weight loss, most often 5% of the prepregnancy weight.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 60. The perinatal nurse explains to the student nurse who is assessing the abdomen of a 32-week pregnant woman with placenta previa that it would not be unusual to find the fetus in a or position.

ANS: breech; transversePlacenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. This condition accounts for 20% of all antepartal hemorrhages. Leopold maneuvers often reveal the fetus to be in a breech or oblique position or transverse lie because of the abnormal location of the placenta.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

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61. The perinatal nurse k nows that a

hemorrhage is limited to the uterus, anda

hemorrhage moves blood toward and through the cervix.

ANS: concealed; revealedFeedback 1: A concealed hemorrhage occurs in 20% of cases and describes an abruption in which the bleeding is confined within the uterine cavity. The most common abruption is associated with a revealed or external hemorrhage, wherethe blood dissects downward toward the cervix.Feedback 2: The most common abruption is associated with a revealed or external hemorrhage, where the blood dissects downwardtoward the cervix.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | DifficultyLevel: Easy 62. The perinatal nurse encourages Colleen, who has just been discharged from the hospital for intravenous therapy for severe nausea and vomiting, to ensure that she often, eats frequent, meals and avoids odors.

ANS: rests; small; cook ingThe nurse should counsel the woman with nausea and vomiting to avoid foodsand sensory stimuli that provok e symptoms (i.e., some womenbecome nauseous when they smell certain foods being prepared) and also to eat small,

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Chapter 8: Intrapartum Assessment and Interventions Multiple Choice 1. In caring for a primiparous woman in labor, one of the factors to evaluate is uterine

activity. This isreferred to as the ANS: c

of labor.a. Passengerb. Passagec. Powersd. Psyche

Feedback a. The passenger refers to the fetus. b. The passage refers to the pelvis and birth canal. c. Powers refer to the contractions. d. Psyche refers to the response of a woman to labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Physiological Adaptation | Difficulty Level: Easy 2. The provision of support during labor has demonstrated that women experience a decrease in anxietyand a feeling of being in more control. In clinical situations, this has resulted in:a. A decrease in interventionsb. Increased epidural ratesc. Earlier admission to the hospitald.

Improved gestational age ANS: a Feedback a. Studies have shown that with a support person, be it a family member, friend, or professional

such as aDoula or nurse, the patient experiences a decrease in anxiety and has a feeling of being in more control. This, in turn, results in a decrease in interventions, a significantly lower level of pain, and an enhanced overall maternal satisfaction. b. There is decreased use of pain medication with continuous labor support. c. There is no evidence that continuous labor support results in earlier admission to the hospital. d. There is no evidence that continuous labor support results in improved gestational age for

the fetus. KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area:Maternity | Client Need: PSI, Psychosocial Integrity | Difficulty Level: Moderate 3. When caring for a primiparous woman being evaluated for admission for labor, a key distinction between true versus false labor is:a. True labor contractions result in rupture of membranes, and with falselabor, the membranes remain intact.b. True labor contractions result in increasing anxiety and discomfort,and false labor does not.c. True labor contractions are accompanied by loss of the mucus plug and bloody

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show, and with false labor there is no vaginal discharge. d. True labor contractions bring about changes incervical effacement and dilation, and with false labor there are irregular contractions with little or no cervical changes.

ANS: d Feedback a. Rupture of membranes can occur prior to labor or during labor. b. A womans response to labor may not be reflective of her status in labor but is

influenced byexpectations and emotional status. c. Loss of the mucus plug can occur prior to the onset of labor. d. True labor contractions bring about changes in cervical effacement and dilation, and with

false laborthere are irregular contractions with little or no cervical changes.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 4. The mechanism of labor known as cardinal movements of labor are the positional changes that

the fetusgoes through to best navigate the birth process. These cardinal movements are:a.

Engagement, Descent, Flexion, Extension, Internal rotation, External rotation, Expulsion b.

Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion c.

Engagement, Flexion, Internal rotation, Extension, External rotation, Descent, Expulsion d.

Engagement, Flexion, Internal rotation, Extension, External rotation, Flexion, Expulsion ANS: b Feedback a. The order of the cardinal movements is incorrect. b. Engagement occurs when the greatest diameter of the fetal head passes through the pelvic

inlet. Engagement can occur late in pregnancy or early in labor. Descent is the movement of the fetus through the birth canal during the first and second stages of labor. Flexion is when the chin of the fetus moves toward the fetal chest. Flexion occurs when the descending head meets resistance from maternal tissues. This movement results in the smallest fetal diameter to the maternal pelvic dimensions. It typically occursearly in labor. Internal rotation is the movement, the rotation of the fetal head, that aligns the long axis of the fetal head with the long axis of the maternal pelvis. It occurs mainly during the second stage of labor. Extension is the movement facilitated by resistance of the pelvic floor, causing the presenting part to pivot

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beneath the pubic symphysis and the head to be delivered. This occurs during the second stage of labor. External rotation is when the sagittal suture moves to a transverse diameter and the shoulders align in theanteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as the trunk navigates through the pelvis. Expulsion is the movement that occurs when the shoulders and remainder ofthe body are delivered. c. The order of the cardinal movements is incorrect. d. The order of the cardinal movements is incorrect.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area:Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 5. A woman is considered in active labor when:a. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to 80%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.b. Cervical dilation progresses to 3 cm with effacement of 30, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.c. Cervical dilation progresses to 8 cm with effacement of 80%, contractions become more intense, occurring every 2to 5 minutes with duration of 45 to 60 seconds.d. Cervical dilation progresses to 10 cm with effacement of90%, contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.

ANS: a Feedback a. Characteristics of this phase are the cervix dilates, on an average, 1.2 cm/hr for primiparous women and

1.5 cm/hr for multiparous women. Cervical dilation progresses from 4 to 7 cm with effacement of 40% to80%. Fetal descent continues and contractions become more intense, occurring every 2 to 5 minutes withduration of 45 to 60 seconds, and discomfort increases. b. Cervical dilation progresses to 3 cm with effacement of 30, indicating the early or latent phase of labor. c. Cervical dilation progresses to 8 cm with effacement of 80%, indicating the transition phase of labor. d. Cervical dilation of 10 cm with effacement is the end of the first stage of labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

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6. You are caring for a woman in labor who is 6 cm dilated with a reassuring FHT pattern

and regularstrong UCs. The fetal heart rate (FHR) should be:a. Monitored continuouslyb.

Monitored every 15 minutesc. Monitored every 30 minutesd. Monitored every 60 minutes ANS: c Feedback a. Assessment of fetal heart rate (FHR) during the active phase of labor with a reassuring

FHR is notindicated continuously. b. Assessment of fetal heart rate (FHR) during the active phase of labor with a reassuring FHR is notindicated every 15 minutes. c. Assessment of fetal heart rate (FHR) during the active phase of labor with a reassuring FHR isindicated every 30 minutes. d. Assessment of fetal heart rate (FHR) during the active phase of labor with a reassuring FHR isindicated every 30 minutes, not every 60 minutes.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 7. A woman you are caring for in labor requests an epidural for pain relief in labor. Included in your preparation for epidural placement is a baseline set of vital signs. The most common vital sign to changeafter epidural placement:a. Blood pressure, hypotension b. Blood pressure, hypertension c. Pulse, tachycardia d. Pulse, bradycardiaANS: a Feedback a. Blood pressure, hypotension, as up to 40% of women may experience hypotension.

Hypotension is defined as systolic BP <100 mm Hg or 20% decrease in BP from preanesthesia levels. Intravenous bolusis typically given to decrease the incidence of hypotension. b. Blood pressure, hypertension is incorrect because hypotension is the common complication afterepidural placement. c. Pulse, tachycardia is incorrect because hypotension is the common complication after epiduralplacement.

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d. Pulse, bradycardia is incorrect because hypotension is the common complication after

epiduralplacement.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 8. The labor patient you are caring for is ambulating in the hall. Her vaginal exam 1 hour ago indicatedshe was 4/70/1 station. She tells you she has fluid running down her leg. Your priority nursing intervention is to:a. Assess the color, odor, and amount of fluid.b. Assist your patient to the bathroom.c.Assess the fetal heart rate.d. Call the care provider.

ANS: c Feedback a. Although assessing the color, odor, and amount of fluid is appropriate, the priority nursing

action is toassess the FHR because of the risk of umbilical cord prolapse with rupture of membranes. b. The fluid is probably related to rupture of membranes rather than the patient needing to go to thebathroom to urinate. c. Assessing the fetal heart rate is the first priority because of the risk of umbilical cord prolapse withrupture of membranes. d. Although you may call the care provider, the priority nursing action is to assess the FHR because of therisk of umbilical cord prolapse with rupture of membranes.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Moderate 9. You are in the process of admitting a multiparous woman to labor and delivery from the triage area. One hour ago her vaginal exam was 4/70/0. While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to:a. Reassure the patient and rapidly complete theadmission.b. Assist your patient to the bathroom to have a bowel movement.c. Assess the fetal heart rate and uterine contractions.d. Perform a vaginal exam.

ANS: d Feedback a. Completing the admission paperwork is not a priority when birth may be imminent.

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b. The urge to have a bowel movement is probably related to fetal descent and complete

dilation ratherthan the patient needing to have a bowel movement. c. Doing a vaginal exam is the first priority as birth may be imminent. d. Perform a vaginal exam to assess the progress of labor. The urge to have a bowel

movement andfeeling like pushing indicate that birth may be imminent.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 10. The Apgar score consists of a rapid assessment of five physiological signs that indicate the

physiological status of the newborn and includes:a. Apical pulse strength, respiratory rate, muscle flexion,reflex irritability, and colorb. Heart rate, clarity of lungs, muscle tone, reflexes, and colorc. Apical pulse strength, respiratory rate, muscle tone, reflex irritability, and color of extremitiesd. Heart rate, respiratoryrate, muscle tone, reflex irritability, and color ANS: d Feedback a. Heart rate, not apical pulse strength, is the criterion for Apgar scoring; muscle tone, not

flexion, isassessed. b. Clarity of lungs and reflexes are not assessed as part of Apgar scoring. Neonatal lungs can be congestednormally at birth, and reflexes are not assessed. Rather, reflex irritability is assessed, based on response totactile stimulation. c. Heart rate, not apical pulse strength, is assessed along with respiratory rate, muscle tone, reflexirritability, and color of extremities. d. The Apgar score includes assessment of heart rate based on auscultation, respiratory rate based on observed movement of chest, muscle tone based on degree of flexion and movement of extremities, reflexirritability based on response to tactile stimulation, and color based on observation.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate 11. The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks gestation in her first pregnancy. She is worried about having her baby too soon, and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by

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the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosiswould be: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks

contractionsANS: d Feedback a. Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the

end of the36th week of gestation. Many patients present with preterm contractions, but only those who demonstratechanges in the cervix are diagnosed with preterm labor. b. Term labor occurs after 37 weeks gestation. c. There is no indication in this scenario that this is back labor. d. Braxton-Hicks contractions are regular contractions occurring after the third month of

pregnancy. Theymay be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer,stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor. KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 12. The perinatal nurse knows that the term to describe a woman at 26 weeks gestation with a

history ofelevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is: a. Preeclampsia b. Chronic hypertension c. Gestational hypertension d. Chronic hypertension with superimposed

preeclampsiaANS: d Feedback a. Preeclampsia is a multisystem, vasopressive disease process that targets the

cardiovascular,hematologic, hepatic, and renal and central nervous systems.

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b. Chronic hypertension is hypertension that is present and observable prior to pregnancy or

hypertensionthat is diagnosed before the 20th week of gestation. c. Gestational hypertension is a nonspecific term used to describe the woman who has a blood pressureelevation detected for the first time during pregnancy, without proteinuria. d. The following criteria are necessary to establish a diagnosis of superimposed preeclampsia: hypertension and no proteinuria early in pregnancy (prior to 20 weeks gestation) and new-onset proteinuria, a sudden increase in proteinurinary excretion of 0.3 g protein or more in a 24-hour specimen,or two dipstick test results of 2+ (100 mg/dL), with the values recorded at least 4 hours apart, with no evidence of urinary tract infection; a sudden increase in blood pressure in a woman whose blood pressure has been well controlled; thrombocytopenia (platelet count lower than 100,000/mmC); and an increase inthe liver enzymes alanine transaminase (ALT) or aspartate transaminase (AST) to abnormal levels. KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 13. A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attendingphysician immediately of which of the following findings? a. Patellar and biceps reflexes of +4 b. Urinary output of 50 mL/hr c. Respiratory rate of 10 rpm d. Serum magnesium level of 5

mg/dLANS: c Feedback a. Magnesium sulfate has been ordered because the patient has severe pregnancy-induced

hypertension.Patellar and biceps reflexes of +4 are symptoms of the disease. b. The urinary output must be above 25 mL/hr. c. The drop in respiratory rate may indicate that the patient is suffering from magnesium

toxicity. Thenurse should report the finding to the physician. d. The therapeutic range of magnesium is 4 to 7 mg/dL. KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level:Application | Content Area: Adverse Effects/Contraindications; Antepartum Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Diagnostic Tests | Client Need: Health

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Promotion and Maintenance; Pharmacological and Parenteral Therapies; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 14. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor.

Which ofthe following common medication effects would the nurse expect to see in the mother? a. Serum potassium level increases b. Diarrhea c. Urticaria d. Complaints of

nervousnessANS: d Feedback a. The nurse would not expect to see a rise in the mothers serum potassium levels. b. The beta agonists are not associated with diarrhea. c. The beta agonists are not associated with urticaria. d. Complaints of nervousness are commonly made by women receiving subcutaneous beta

agonists. KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications and SideEffects | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological andParenteral Therapies | Difficulty Level: Moderate 15. Which of the following signs or symptoms would the nurse expect to see in a woman with concealedabruptio placentae? a. Increasing abdominal girth measurements b. Profuse vaginal bleeding c. Bradycardia with an aortic thrill d. Hypothermia with

chillsANS: a Feedback a. The nurse would expect to see increasing abdominal girth measurements. b. Profuse vaginal bleeding is rarely seen in placental abruption and is never seen when the

abruption isconcealed. c. With excessive blood loss, the nurse would expect to see tachycardia.

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d. The nurse would expect to see a stable temperature.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need:Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate 16. A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complicationsof pregnancy likely contributed to these findings? a. Pyelonephritis b. Pregnancy-induced hypertension c. Gestational diabetes d. Abruptio

placentaeANS: c Feedback a. Pyelonephritis does not lead to the development of hydramnios or macrosomia. b. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia. c. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies. d. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area:Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 17. For the patient with which of the following medical problems should the nurse question a physiciansorder for beta agonist tocolytics? a. Type 1 diabetes mellitus b. Cerebral palsy c. Myelomeningocele d. Positive group B streptococci

cultureANS: a Feedback

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a. Beta agonists often elevate serum glucose levels. The nurse should question the order. b. Beta agonists are not contraindicated for patients with cerebral palsy. c. Beta agonists are not contraindicated for patients with myelomeningocele. d. Beta agonists are not contraindicated for patients with group B streptococci.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level:Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 18. The nurse is caring for two laboring women. Which of the patients should be monitored mostcarefully for signs of placental abruption? a. The patient with placenta previa b. The patient whose vagina is colonized with group B streptococci c. The patient who is hepatitis B surface antigen positive d. The patient with

eclampsiaANS: d Feedback a. Patients with placenta previa are not especially high risk for placental abruption. b. Patients colonized with group B streptococci are not especially high risk for placental abruption. c. Patients who are hepatitis B surface antigen positive are not especially high risk for placental abruption. d. Patients with eclampsia are high risk for placental abruption.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Complications | Client Need: HealthPromotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 19. The nurse is caring for a woman at 28 weeks gestation with a history of preterm delivery.

Which ofthe following laboratory data should the nurse carefully assess in relation to this diagnosis? a. Human relaxin levels b. Amniotic fluid levels c. Alpha-fetoprotein levels d. Fetal fibronectin levels

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ANS: d Feedback a. Relaxin levels are rarely assessed. In addition, they are unrelated to the incidence of preterm labor. b. Amniotic fluid levels are not directly related to the incidence of preterm labor. c. Alpha-fetoprotein levels are not related to the incidence of preterm labor. d. A rise in the fetal fibronectin levels in cervical secretions has been associated with preterm

labor. KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area:Antepartum Care; Reduction of Risk Potential: Laboratory Values | Client Need: Health Promotion andMaintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate 20. Which of the following statements is most appropriate for the nurse to say to a patient with a completeplacenta previa? a. During the second stage of labor you will need to bear down. b. You should ambulate in the halls at least twice each day. c. The doctor will likely induce your labor with oxytocin. d. Please promptly report if you experience any bleeding or feel any back

discomfort.ANS: d Feedback a. This response is inappropriate. This patient will be delivered by cesarean section. b. This response is inappropriate. Patients with placenta previa are usually on bed rest. c. This response is inappropriate. This patient will be delivered by cesarean section. d. Labor often begins with back pain. Labor is contraindicated for a patient with complete

placenta previa.KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 21. A woman at 32 weeks gestation is diagnosed with severe preeclampsia with HELLP syndrome. Thenurse will identify which of the following as a positive patient care outcome? a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of

polycythemiaANS: c

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Feedback a. A rise in serum creatinine indicates that the kidneys are not effectively excreting

creatinine. It is anegative outcome. b. A drop in serum protein indicates that the kidneys are allowing protein to be excreted.

This is anegative outcome. c. Resolution of thrombocytopenia is a positive sign. It indicates that the platelet count is returning tonormal. d. Polycythemia is not related to HELLP syndrome. Rather one sees a drop in red cell and platelet countswith HELLP. A positive sign, therefore, would be a rise in the RBC count.

KEY: Integrated Process: Nursing Process: Evaluation | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Illness Management | Client Need: Health Promotion andMaintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 22. A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia.

The nursemust closely monitor the woman for which of the following? a. High leukocyte count b. Explosive diarrhea c. Fractured pelvis d. Low platelet

countANS: d Feedback a. High leukocyte count is not associated with severe pregnancy-induced hypertension (PIH) or

HELLP(hemolysis, elevated liver enzymes, and low platelets) syndrome. b. Explosive diarrhea is not associated with severe PIH or HELLP syndrome. c. A fractured pelvis is not associated with severe PIH or HELLP syndrome. d. Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver

enzymes, andlow platelets) syndrome.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Diagnostic Tests; Reduction of Risk Potential: Laboratory Data | Client Need: HealthPromotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

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23. A woman at 10 weeks gestation is diagnosed with gestational trophoblastic disease

(hydatidiformmole). Which of the following findings would the nurse expect to see? a. Platelet count of 550,000/mm3 b. Dark brown vaginal bleeding c. White blood cell count 17,000/mm3 d. Macular papular

rashANS: b Feedback a. The nurse would not expect to see an elevated platelet count. b. The nurse would expect to see dark brown vaginal discharge. c. The nurse would not expect to see an elevated white blood cell count. d. The nurse would not expect to see a rash.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area:Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult 24. After an education class, the nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexuallytransmitted infection (STI) control issues is needed? a. I could get an STI even if I just have oral sex. b. Girls over 16 are less likely to get STDs than younger girls. c. The best way to prevent an STI is to use a diaphragm. d. Girls get human immunodeficiency virus (HIV) easier than

boys do.ANS: c Feedback a. This statement is true. Organisms that cause sexually transmitted infections can invade the

respiratoryand gastrointestinal tracts. b. This statement is true. Young women are especially high risk for becoming infected with sexuallytransmitted diseases.

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c. This statement is untrue. The young woman needs further teaching. Condoms protect against

STDs andpregnancy. In addition, condoms can be kept in readiness for whenever sex may occur spontaneously.

Using condoms does not require the teen to plan to have sex. A diaphragm is not an effectiveinfection-control method. Plus, it would require the teen to plan for intercourse. d. This statement is true. Young women are higher risk for becoming infected with HIV than are youngmen.

KEY: Integrated Process: Nursing Process: Evaluation; Teaching and Learning | Cognitive Level: Application | Content Area: Disease Prevention; High Risk Behaviors; Human Sexuality | Client Need: Health Promotion and Maintenance: High Risk Behaviors; Human Sexuality | Difficulty Level: Moderate 25. A woman who is admitted to labor and delivery at 30 weeks gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the followingmaternal vital signs is most important for the nurse to assess each hour? a. Temperature b. Pulse c. Respiratory rate d. Blood

pressureANS: c Feedback a. The temperature should be monitored, but it is not the most important vital sign. b. The pulse rate should be monitored, but it is not the most important vital sign. c. The respiratory rate is the most important vital sign. Respiratory depression is a sign of

magnesiumtoxicity. d. The blood pressure should be monitored, but it is not the most important vital sign.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area:Intrapartum Care; Potential for Complications from Pharmacological Therapies: Adverse Effects/Contraindications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate 26. A primiparous woman has been admitted at 35 weeks gestation and diagnosed with HELLPsyndrome. Which of the following laboratory changes is consistent with this diagnosis? a. Hematocrit dropped to 28%.

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b. Platelets increased to 300,000 cells/mm3. c. Red blood cells increased to 5.1 million cells/mm3. d. Sodium dropped to 132

mEq/dL.ANS: a Feedback a. The nurse would expect to see a drop in the hematocrit: The H in HELLP stands for hemolysis. b. The nurse would expect to see low platelets. c. The nurse would expect to see hemolysis. d. The sodium is usually unaffected in HELLP syndrome.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area:Intrapartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Moderate 27. A labor nurse is caring for a patient, 39 weeks gestation, who has been diagnosed with placentaprevia. Which of the following physician orders should the nurse question? a. Type and cross-match her blood. b. Insert an internal fetal monitor electrode. c. Administer an oral stool softener. d. Assess her complete blood

count.ANS: b Feedback a. It would be appropriate to type and cross-match the patient for a blood transfusion. b. This action is inappropriate. When a patient has a placenta previa, nothing should be inserted

into thevagina. c. To prevent constipation, it is appropriate for a patient to take a stool softener. d. It is appropriate to monitor the patient for signs of anemia.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application Content Area: Antepartum Care; Patient Advocacy; Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological IntegrityReduction of Risk Potential; Safe andEffective Care EnvironmentManagement of Care | Difficulty Level: Moderate

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28. A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels

throughout herpregnancy. Which of the following complications of pregnancy would the nurse expect to see? a. Postpartum hemorrhage b. Neonatal hyperglycemia c. Postpartum oliguria d. Neonatal

macrosomiaANS: d Feedback a. The patient is not especially high risk for a postpartum hemorrhage. b. The nurse would expect to see neonatal hypoglycemia, not hyperglycemia. c. The nurse would expect to see postpartum polyuria. d. The nurse would expect to see neonatal macrosomia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological IntegrityPhysiological Adaptation | Difficulty Level: Difficult 29. According to agency policy, the perinatal nurse provides the following intrapartal nursing care for thepatient with preeclampsia: a. Take the patients blood pressure every 6 hours b. Encourage the patient to rest on her back c. Notify the physician of urine output greater than 30 mL/hr d. Administer magnesium sulfate according to agency

policyANS: d Feedback a. The nurse is the manager of care for the woman with preeclampsia during the intrapartal

period. Careful assessments are critical. The blood pressure is taken every 1 hour or more frequently according tophysician orders or institutional protocol. b. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a sidelying position toenhance uterine perfusion.

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c. The nurse is the manager of care for the woman with preeclampsia during the intrapartal

period.Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria, and thephysician must be notified. d. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere tohospital protocol for a magnesium sulfate infusion.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 30. A woman who is 36 weeks pregnant presents to the labor and delivery unit with a history ofcongestive heart disease. Which of the following findings should the nurse report to the primaryhealth-care practitioner? a. Presence of chloasma b. Presence of severe heartburn c. 10-pound weight gain in a month d. Patellar reflexes

+1ANS: c Feedback a. Chloasma is a normal pregnancy finding. b. Heartburn is an expected finding during the third trimester. c. The weight gain may be due to fluid retention. Fluid retention may occur in patients with

pregnancy-induced hypertension and in patients with congestive heart failure. The physician should benotified. d. Although slightly hyporeflexic, patellar reflexes of +1 are within normal limits.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level:Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult 31. Ms. M is 38 weeks gestation and is a G1 P0. At 10 pm Ms. M has just been informed by the nurse thatshe is 3 to 4 cm dilated, cervix is 100% effaced, and contractions are every 4 to 5 minutes. When the nurse tells her the findings from the SVE, Ms. M states that she had been contracting since early that

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morning and she becomes extremely frustrated stating I should have had this baby by now. What is thebest response by the nurse? a. Remind her that length of labor for the first child can be 18 to 24 hours b. Promote relaxation techniques c. Discuss various analgesic options d. Tell Ms. M that the provider will be contacted immediately about the slow progress

of laborANS: b Women in the latent phase of labor may be frustrated with lack of progress or slow progress of labor and desire companionship and encouragement. The other responses are inappropriate. The nurse should first encourage breathing and relaxation methods as well as provide reassurance, and then contact the provider.KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Analysis | Content Area: Intrapartum Care | Client Need: Health Promotion and MaintenanceIntrapartum Care | Difficulty Level: Difficult 32. Ms. P has delivered her first baby 30 minutes ago and the placenta delivered 15 minutes ago. She isattempting to breastfeed her newborn daughter for the first time. Which action by the nurse would NOTbe appropriate? a. The nurse is checking the BP every 15 minutes b. The nurse is massaging the fundus vigorously c. The nurse is auscultating the infants heart and lungs while on the mothers chest d. The nurse is leaving the patient unattended for 30 minutes to bond with her

newbornANS: d During the fourth stage of labor the mothers should not be left unattended as maternal bleeding needs tobe closely monitored.

KEY: Integrated Process: Safe and Effective Care Environment | Cognitive Level: Application | Content Area: Postpartum Care | Client Need: Safe and Effective Care Environment | Difficulty Level:Moderate 33. It would be most important for a nurse caring for a mother and the infant in the fourth stage of labor todo which of the following? a. Assess and massage the fundus every 15 minutes or more often if needed b. Massage the uterus continuously

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c. Administer oxytocin per protocol d. Assess the patient for a distended

bladdera.A, c b.A, c, d c.C, d d.all of the aboveANS: b A, C, D The fourth stage of labor immediately follows the delivery of the placenta. The nurse should be assessingthe fundus every 15 minutes for position, tone, and location. The provider may order oxytocin at this stage, and the nurse should assist the woman to the bathroom if she has a distended bladder which could interfere with the contraction of the uterus.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Postpartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult 34. Mrs. H is telling you she feels the urge to push. This is most likely caused by what? a. Low fetal station triggering the Ferguson reflex b. A fetal position of occiput posterior (OP) c. The second stage of labor d. Transition

phaseANS: a Once the cervix is fully dilated and the vertex is low in the pelvis and the woman feels the urge to push,she will involuntarily bear down. This is activated when the presenting part as it descends stretches thepelvic floor muscles and triggers the Ferguson reflex.

KEY: Integrated Process: Knowledge | Cognitive Level: Analysis | Content Area: Intrapartum Care |Client Need: Health Promotion and Maintenance: Intrapartum Care | Difficulty Level: Difficult 35. A low-risk patient calls the labor unit and says I need to come in to be checked right now, there werepink streaks on the toilet paper when I went to the bathroom. I think Im bleeding.

What response should the nurse say first? a. How much blood is there? b. You sound concerned, what other labor symptoms do you have? c. Dont worry that sounds like a mucus plug.

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d. Does it burn when you

urinate?ANS: b The nurse is using reflection to acknowledge the womans concerns and asks for further assessment. Thewomans fear must first be acknowledged and then other questions or comments can be made.

KEY: Integrated Process: Nursing Process | Cognitive Level: Analysis | Content Area: Maternity | ClientNeed: Psychological Integrity | Difficulty Level: Moderate Multiple Response 36. The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta

previa riskfactors include (select all that apply): a. Cocaine use b. Tobacco use c. Previous caesarean birth d. Previous use of medroxyprogesterone (Depo-

Provera)ANS: a, b, c Feedback a. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior

history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35years. b. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35years. c. Placenta previa may be associated with conditions that cause scarring of the uterus such as a priorcesarean section, multiparity, or increased maternal age. d. Previous use of medroxyprogesterone (Depo-Provera) is not a risk factor for placenta previa. KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 37. Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks gestation. An appropriate nursing action would beto (select all that apply): a. Assess the fetal heart rate

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b. Obtain urine for culture and sensitivity c. Assess Kerrys blood pressure and pulse d. Palpate Kerrys abdomen for

contractionsANS: a, b, d Feedback a. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like

cramps,increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or withoutdiarrhea. The patients abdomen should be palpated to assess for contractions, and the fetuss heart rate should be monitored. b. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps,increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or withoutdiarrhea. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normalpregnancy complaints (i.e., urgency, frequency). The patients abdomen should be palpated to assess forcontractions, and the fetuss heart rate should be monitored. c. Assessment of blood pressure and pulse is not an important nursing action in this scenario. d. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like

cramps,increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or withoutdiarrhea. The patients abdomen should be palpated to assess for contractions, and the fetuss heart rate should be monitored.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 38. The perinatal nurse knows that tocolytic agents are most often used to (select all that apply): a. Prevent maternal infection b. Prolong pregnancy to 40 weeks gestation c. Prolong pregnancy to facilitate administration of antenatal corticosteroids d. Allow for transport of the woman to a tertiary care

facilityANS: c, d Feedback a. Tocolytics are not used to treat maternal infection.

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b. Tocolytics are generally only effective in delaying delivery for several days. c. Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to

begin theadministration of antenatal corticosteroids to accelerate fetal lung maturity. d. Delaying the birth provides time for maternal transport to a facility equipped with a neonatal intensivecare unit.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 39. The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information provided aboutpreterm labor andbirth prevention includes (select all that apply): a. Encouraging regular, ongoing prenatal care b. Reporting symptoms of urinary frequency and burning to the health-care provider c. Coming to the labor triage unit if back pain or cramping persist or become regular d. Lying on the right side, withholding fluids, and counting fetal movements if contractions

occur every 5minutes ANS: a, b, cFeedback a. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedlyif symptoms of preterm labor occur. b. Educating all women of childbearing age about preterm labor is a crucial component of prevention. Thenurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur. c. Educating all women of childbearing age about preterm labor is a crucial component of prevention. Thenurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider if symptoms of preterm labor occur. d. Lying on the right side; drinking fluids, not withholding fluids; and counting fetal movements ifcontractions occur every 5 minutes are recommended if a woman thinks she is contracting.

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 40. The perinatal nurse describes for the new nurse the various risks associated with prolonged prematurepreterm rupture of membranes. These risks include (select all that apply): a. Chorioamnionitis b. Abruptio placentae c. Operative birth d. Cord

prolapseANS: a, b, d Even though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cordprolapse.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate Short Answer 41. A condition where the placenta attaches to the lower uterine segment of the uterusANS: Placenta previa Refer To: Maternity Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 42. A pregnancy that ends before 20 weeks gestationANS: Miscarriage Refer To: Maternity Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 43. Specks or spots in the vision where the patient cannot see; blind spotsANS: Scotoma Refer To: Maternity Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

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44. A disease characterized by an abnormal placental development that results in the

production offluid-filled grapelike clusters and a vast proliferation of trophoblastic tissue ANS: Hydatidiform mole/Gestational trophoblastic diseaseRefer To: Perinatal Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 45. No expulsion of the products of conception, but bleeding and dilation of the cervix such that apregnancy is unlikely ANS: Inevitable abortion Refer To: Maternity Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 46. Placement of suture to mechanically close a weak cervixANS: Cervical cerclage Refer To: Maternity Nursing Terms and Definitions KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy True/False 47. The perinatal nurse observes the placental inspection by the health-care provider after birth. Thisexamination may help to determine whether an abruption has occurred prior to or during labor. ANS: True Fifty percent of abruptions occur before labor and after the 30th week, 15% occur during labor, and 30%are identified only upon inspection of the placenta after delivery.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 48. It is critical for the perinatal nurse to learn, as part of the facilitys policies and procedures, to immediately perform a vaginal examination on a woman who presents with vaginal bleeding after 24weeks gestation.

ANS: False

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Placenta previa should be suspected in all patients who present with bleeding after 24 completed weeks ofgestation. Because of the risk of placental perforation, vaginal examinations are not performed.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate 49. The perinatal nurse knows that the survival rate for infants born at or greater than 28 to 29 gestationalweeks is greater than 90%.

ANS: True With appropriate medical care, neonatal survival dramatically improves as the gestational age increases,with over 50% of neonates surviving at 25 weeks gestation, and over 90% surviving at 28 to 29 weeks ofgestation.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy Fill-in-the-Blank 50. The perinatal nurse knows that an early pregnancy loss occurs before

latepregnancy loss is one that occurs between 12 and ANS: 12; 20

weeks, and a

weeks.

Not all conceptions result in a live-born infant. Of all clinically recognized pregnancies, 10% to 20% arelost, and approximately 22% of pregnancies detected on the basis of hCG assays are lost before the appearance of any clinical signs or symptoms. By definition, an early pregnancy loss occurs before 12 weeks of gestation; a late pregnancy loss is one that occurs between 12 and 20 weeks of gestation.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 51. Mary, a G3 TPAL 0020 woman at 20 weeks gestation, has had a transvaginal ultrasound.

Mary has been informed that she has cervical incompetence. The perinatal nurse explains that this diagnosis meansthat her cervix has without contractions.

ANS: dilated; regular Patients with cervical incompetence usually present with painless dilation and effacement of the cervix, often during the second trimester of pregnancy. The patient frequently gives a history of repeated secondtrimester losses with no apparent etiology. Incompetent cervix is estimated to cause approximately 15% of all second trimester losses.

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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 52. The perinatal nurse knows that nausea and vomiting are common in pregnancy and usually resolve by weeks gestation. The severe form of this condition is .

ANS: 16; hyperemesis gravidarum Feedback 1: Nausea and vomiting are a common condition of pregnancy which affect 70% to 85% ofpregnant women and usually resolve by the 16th week of gestation.

Feedback 2: Hyperemesis gravidarum represents the extreme end of the nausea/vomiting spectrum interms of severity. Criteria for the diagnosis of hyperemesis gravidarum include persistent vomiting unrelated to other causes, a measure of acute starvation (usually large ketonuria), and some discrete weight loss, most often 5% of the prepregnancy weight.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy 53. The perinatal nurse explains to the student nurse who is assessing the abdomen of a 32-week pregnant woman with placenta previa that it would not be unusual to find the fetus in a or position.

ANS: breech; transverse Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. This condition accounts for 20% of all antepartal hemorrhages. Leopold maneuvers often reveal the fetus to be in a breech or oblique position or transverse lie because of the abnormal location ofthe placenta.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 54. The perinatal nurse knows that a hemorrhage is limited to the uterus, and a hemorrhage moves blood toward and through the cervix.

ANS: concealed; revealed Feedback 1: A concealed hemorrhage occurs in 20% of cases and describes an abruption in which the bleeding is confined within the uterine cavity. The most common abruption is associated with a revealedor external hemorrhage, where the blood dissects downward toward the cervix.

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Feedback 2: The most common abruption is associated with a revealed or external hemorrhage, where theblood dissects downward toward the cervix.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 55. The perinatal nurse encourages Colleen, who has just been discharged from the hospital for intravenous therapy for severe nausea and vomiting, to ensure that she often, eats frequent, meals, and avoids odors.ANS: rests; small; cooking The nurse should counsel the woman with nausea and vomiting to avoid foods and sensory stimuli thatprovoke symptoms (i.e., some women become nauseous when they smell certain foods being prepared)and also to eat small, frequent meals of dry, bland foods and include high-protein snacks in their diet. KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate Matching Match the term with the definition 56. Third stage of labor 57. Transition phase 58. False labor 59. Latent phase a. Early and slow labor. Can last up to 9 hours. Many women choose to stay home. b. Irregular contractions, with no increase in frequency, intensity, and duration, cause little or no

cervicalchange c. Cervical dilation from 8 to 10 cm, contractions every 1 to 2 minutes. Woman may be panicky andirritable. d. Occurs immediately after the delivery of the fetus. Involves the separation and delivery of the placenta.Can last up to 20 minutes.

ANS: 56. d 57. c 58. b

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59. a

Third stage of labor: Begins immediately after the delivery of the fetus and involves separation andexpulsion of the placenta and membranes Transition phase: Third phase of labor; dilation to 10 cm False labor: Irregular contractions with little or no cervical changes Latent phase: First phase of labor; the early and slower part of labor with cervical dilation from 0 to 3 cmKEY: Integrated Process: Knowledge | Cognitive Level: Knowledge | Content Area: Intrapartum Care | Client Need: Health Promotion and MaintenanceIntrapartum Care | Difficulty Level: Moderate

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Chapter 9: Fetal Heart Rate Assessment Multiple Choice 1. The nurse uses the external electronic fetal heart monitor to evaluate fetalstatus. The fetal heart tracing shows accelerations. Accelerations in the fetalheart are: a. Associated with fetal well-being and oxygenation b. An indication of potential fetal intolerance to labor c. Never associated with the uterine contraction pattern d. A reason to notify the care providerANS: a Feedback a. Accelerations are a sign of fetal well-being and are reassuring. There noneed to notify the pcp c. Accelerations may or may not be associated with uterine contractions.

2. The nurse knows that a FHR monitor printout indicates a Category IIIabnormal fetal heart rate pattern when: a. Baseline variability is minimal or absent with decelerations. b. FHR mirrors the uterine contractions. c. Occasional periodic accelerations occur. d. Baseline variability is 6 to 25 bpm with decelerationsANS: a Feedback a. Minimal or absent baseline variability may be an indication of fetal hypoxia. b. FHR mirrors the uterine contractions describes early decelerations that arenot an indication of fetal intolerance of labor. c. Periodic accelerations are a sign of fetal well-being. d. A baseline variability of 6 to 25 bpm is normal.

3. As the nurse explains the purpose of the tocotransducer (Toco), which sheplaces on the abdomen, she states that this monitoring device provides an accurate evaluation of which of the following? a. Uterine hypertonus b. Frequency of contractions c. Intensity of contractions d. Progress of labor ANS: b Feedback a. Uterine tone is palpated or measured with an intrauterine pressure catheter(IUPC). b. A tocotransducer measures frequency and duration of uterine contractions. c. Contraction strength is palpated or measured with an intrauterine pressurecatheter (IUPC). d. Progress of labor is evaluated with a sterile vaginal examination (SVE).

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4. Early decelerations are probably caused by: ICP a. Decreased maternal–fetal exchange b. Umbilical cord occlusion c. Momentary increase in intracranial pressure due to head compression d. Compression of umbilical cord ANS: c Feedback a. Decreased maternal–fetal exchange results in late decelerations. b. Umbilical cord occlusion results in variable deceleration or bradycardia. c. Early decelerations are related to increased intracranial pressure (ICP) due tohead compression. d. Compression of the umbilical cord results in variable decelerations.

5. Which statement correctly describes the nurse’s responsibility related toelectronic fetal monitoring? a. Teach the woman and her family about the monitoring equipment anddiscuss any questions they have. b. Report abnormal findings to the care provider before initiating correctiveactions. c. Inform the support person that the nurse will be responsible for all comfortmeasures when the electronic equipment is in place. d. Document the frequency, duration, and intensity of contractions measuredby the external device.

ANS: a Feedback a. Teaching is an essential part of the nurse’s role. b. Corrective measures for a non-reassuring fetal heart rate are done beforenotifying a provider. c. The support person can help to provide comfort measures for women inlabor. d. Only an IUPC will measure the intensity of uterine contractions.

6. The nurse is caring for a woman, G2 P1001, 40 weeks’ gestation, in labor. A 12 P.M. assessment revealed: cervix 4 cm, 80% effaced, –3 station, and fetalheart 124 with moderate variability.

5 p.m. assessment: cervix 6 cm, 90% effaced, –3 station, and fetal heart 120with minimal variability.

10 a.m. assessment: cervix 8 cm, 100% effaced, –3 station, and fetal heart 124with absent variability.

Based on the assessments, which of the following should the nurse conclude? a. Descent is progressing well. b. Woman is carrying a small-for-gestational age fetus. c. Baby is potentially acidotic. d. Woman should begin to push with the next contraction.

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ANS: c Feedback a. The baby has not descended since admission. The station is still –3. b. The baby may be macrosomic. Because the baby is not descending, thebaby may be too large to traverse through the pelvis. c. The variability is decreasing. This is an indication that the fetus is in distress. d. The woman is only 8 cm dilated. She should not begin to push until she hasreached 10 cm dilation. Plus, the fetal station is still –3.

7. After assessing the FHR tracing shown below, which of the following interventions should the nurse perform? a. Turn the woman on her side. b. Administer oxygen by nasal cannula. c. Encourage the patient to push with each contraction. d. Provide the patient with caring labor support.ANS: a Feedback a. The woman’s position should be changed. The side-lying position is the best. b. If a laboring patient needs oxygen, it should be administered via face mask. c. There is no indication in the scenario that the patient is fully dilated. d. The nurse should not wait to intervene. He or she should intervene asquickly as possible in order to reverse the problem.

8. A nurse is preparing to monitor a patient who is to receive an amnioinfusion.Which of the following actions should the nurse make at this time? a. Attach the patient to an electronic blood pressure cuff. b. Assist in insertion of an internal uterine pressure catheter. c. Attach the patient to an oxygen saturation monitor. d. Perform an amniotic fluid Nitrazine test.

ANS: b Feedback a. The patient’s blood pressure will need to be monitored, but a manual cuff issufficient. b. There is a possibility of uterine rupture during an amnioinfusion. An internalpressure transducer, therefore, must be inserted to monitor the patient’s intrauterine pressures. c. The woman’s oxygen saturation levels need not be monitored during the amnioinfusion. d. Because the woman’s membranes are already ruptured, there is no need fora Nitrazine test to be performed.

9. The perinatal nurse providing care to a laboring woman recognizes a category II, fetal heart rate tracing. The most appropriate initial action is to: a. Assist the laboring woman to a left lateral position b. Decrease the intravenous solution : MUST INCREASE IV INFUSION

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c. Request that the physician/certified nurse-midwife come to the hospital STAT d. Document the fetal heart rate and variabilityANS: a Feedback a. Because Category II fetal heart rate patterns could deteriorate, theyconstitute a risk indicator for fetal hypoxia, the nurse should change thewoman’s position to her side to increase oxygen flow to the baby. b. Because Category II fetal heart rate patterns could deteriorate, they constitute a risk indicator for fetal hypoxia, the nurse should increase, notdecrease, the IV infusion to increase perfusion through the placenta. c. The scenario described does not require STAT intervention but continuedassessment after intrauterine resuscitation interventions. d. Documentation of the FHR is important but not the most important action inthis scenario.

10. The perinatal nurse assists the nursing student who is preparing the patient with oligohydramnios for a fluid infusion into the uterine cavity. Thisprocedure is described as a(n) [amnioinfusion].

ANS: amnioinfusion Pregnancy outcome in patients experiencing variable fetal heart rate decelerations caused by cord compression is improved through the use ofamnioinfusion, which is the instillation of normal saline or lactated Ringer’ssolution into the uterine cavity.

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Chapter 10: High-Risk Labor and Birth Multiple Choice 1. During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2minutes with duration of 60 seconds, of moderate strength to palpation. Based on this assessment, the nurse should take which action? a. Increase oxytocin infusion rate per physician’s protocol. b. Stop oxytocin infusion immediately. c. Maintain present oxytocin infusion rate and continue to assess. d. Decrease oxytocin infusion rate by 2 mU/min and report to physician.ANS: c Feedback a. Increasing the oxytocin infusion could result in uterine hyperstimulation. b. The uterine contraction pattern is normal, and oxytocin infusion should be maintained, not stopped. c. Correct. Maintain present oxytocin infusion rate and continue to assess is thecorrect response, as this question describes a normal uterine contraction pattern. d. The uterine contraction pattern is normal, and oxytocin infusion should be maintained, not stopped or decreased.

2. If the umbilical cord prolapses during labor, the nurse should immediately: a. Type and cross-match blood for an emergency transfusion. b. Await MD order for preparation for an emergency cesarean section. c. Attempt to reposition the cord above the presenting part. d. Apply manual pressure to the presenting part to relieve pressure on thecord.

ANS: d Feedback a. Type and cross-match is one of the interventions with cord prolapse but nota priority. b. Awaiting MD intervention is not appropriate as umbilical cord prolapse is an obstetrical emergency requiring immediate intervention. c. Once the cord has prolapsed, it cannot be repositioned. d. Apply manual pressure to the presenting part to relieve pressure on the cordrepresents the first nursing intervention to attempt to improve circulation to the fetus.

3. Augmentation of labor: a. Is part of the active management of labor instituted when the labor processis unsatisfactory and uterine contractions are inadequate b. Relies on more invasive methods when oxytocin and amniotomy have failed c. Is elective induction of labor d. Is an operative vaginal delivery that uses vacuum cups

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ANS: a Feedback a. Augmentation stimulates uterine contractions after labor has started but notprogressed appropriately. b. Augmentation uses amniotomy and oxytocin. c. Augmentation stimulates labor. d. Vacuum delivery is not part of augmentation of labor.

4. Your patient is a 28-year-old gravida 2 para 1 in active labor. She has been inlabor for 12 hours. Upon further assessment, the nurse determines that she isexperiencing a hypotonic labor pattern. Possible maternal and fetal implications from hypotonic labor patterns are: a. Intrauterine infection and maternal exhaustion with fetal distress usuallyoccurring early in labor. b. Intrauterine infection and maternal exhaustion with fetal distress usuallyoccurring late in labor. c. Intrauterine infection and postpartum hemorrhage with fetal distress early inlabor. d. Intrauterine infection and ruptured uterus and fetal death.ANS: b Feedback a. The risk of hypotonic labor occurs later in labor. b. Hypotonic labor patterns increase risk for infection and maternal exhaustion,with fetal distress occurring late in labor as hypotonic patterns prolong labor. c. There is not an increased risk of postpartum hemorrhage or fetal distress inearly labor. d. Hypotonic patterns do not result in rupture of the uterus.

5. A primigravida woman at 42 weeks’ gestation received Prepidil (dinoprostone) for induction 12 hours ago. The Bishop score is now 3. Which ofthe following actions by the nurse is appropriate? a. Perform Nitrazine analysis of the amniotic fluid. b. Report the lack of progress to the obstetrician. c. Place the woman on her left side. d. Ask the doctor for an order for oxytocin.ANS: b Feedback a. There is nothing in the scenario that implies that the membranes may haveruptured. b. Little progress has taken place. The Bishop score of a primigravida will needto be 9 or higher before oxytocin will be effective. c. There is nothing in the scenario that implies that the patient needs to beplaced on her side. d. The Bishop score of a primigravida will need to be 9 or higher beforeoxytocin will be effective.

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6. The nurse is assisting a physician in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? a. Risk for injury b. Colonic constipation c. Risk for impaired parenting d. Ineffective individual coping ANS: a Feedback a. There is a risk for injury. For example, the patient could suffer a cervical,vaginal, or perineal laceration. b. A diagnosis of colonic constipation is unrelated to the fact that the baby wasdelivered by forceps. c. There is nothing in the scenario that implies that the patient is at risk forimpaired parenting. d. There is nothing in the scenario that implies that the patient is at risk for ineffective individual coping.

7. Four women are close to delivery on the labor and delivery unit. The nurseknows to be vigilant to the signs of neonatal respiratory distress in which delivery? a. 42-week-gestation pregnancy complicated by intrauterine growth restriction b. 41-week-gestation pregnancy with biophysical profile score of 10 thatmorning c. 40-week-gestation pregnancy with estimated fetal weight of 3200 grams d. 39-week-gestation pregnancy complicated by maternal cholecystitisANS: a Feedback a. A post-term baby with intrauterine growth restriction (IUGR) is high risk formeconium aspiration syndrome, cold stress syndrome, hypoglycemia, and acidosis. In each case, the baby may exhibit signs of respiratory distress. b. A biophysical profile (BPP) of 10 is a normal finding. c. The normal birth weight is between 2500 and 4000 grams. d. Maternal gallbladder disease does not place the baby in danger of developing respiratory distress.

8. You are caring for a primiparous woman admitted to labor and delivery forinduction of labor at 42 weeks’ gestation. She asks you to explain the factorsthat contribute to prolonged labor. The best response would be to state thefollowing: a. Primiparous women are not at risk for dystocia because they usually havesmall babies. b. Dystocia is related to uterine contractions, the pelvis, the fetus, the positionof the mother, and psychosocial response.

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c. Labor is primarily associated with pelvic abnormalities. d. Dystocia is typically diagnosed prior to labor based on pelvimetry.ANS: b Feedback a. Dystocia is not exclusively related to fetal size and being primiparous. b. This is the only correct definition of prolonged labor and dystocia. Thesuccess of any labor depends on the complex interrelationship of severalfactors: fetal size, presentation, position, size and shape of the pelvis, andquality of uterine contractions. c. Pelvic abnormality is the least important contributor to dystocia. d. Dystocia is diagnosed during, not prior to, labor.

9. A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor. The following assessments were made on admission: Bishop score of 4,fetal heart rate 140s with good variability and no decelerations, TPR 98.6ºF, 88, 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)? a. Bishop score of 5 b. Fetal heart of 152 bpm c. Respiratory rate of 24 rpm d. Contraction frequency of every 2 minutesANS: d Feedback a. A Bishop score of 9 or higher indicates that the primigravida woman’s cervixis ripe. b. A fetal heart rate of 152 is within normal limits for this fetus. c. A respiratory rate of 24 is within normal limits. d. Cervidil should be removed for tachysystole.

10. A pregnant woman who has a history of cesarean births is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situationsshould the nurse advise the patient that her request may be declined? a. Transverse fetal lie b. Flexed fetal attitude c. Previous low flap uterine incision d. Positive vaginal candidiasis ANS: a Feedback a. A baby in the transverse lie is lying sideways in the uterus. This lie is incompatible physiologically with a vaginal delivery. b. A baby in the flexed fetal attitude is in a physiologic position for a vaginal delivery. c. A previous low flap uterine incision is not incompatible physiologically with a

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vaginal delivery. d. A positive vaginal Candidiasis culture is not an indication for cesarean birth.

11. The physician has ordered intravenous oxytocin for induction for four gravidas. In which of the following situations should the nurse refuse to complywith the order? a. Primigravida with complete placenta previa b. Multigravida with extrinsic asthma c. Primigravida who is 38 years old d. Multigravida who is colonized with group B streptococciANS: a Feedback a. The nurse should refuse to comply with this order because labor is contraindicated for a patient with complete placenta previa. This patient willhave to be delivered via cesarean section. b. Induction is not contraindicated for patients with asthma. c. Induction is not contraindicated for patients who are 38 years old. d. Induction is not contraindicated for patients with group B streptococci.

12. The perinatal nurse notes a rapid decrease in the fetal heart rate that doesnot recover immediately following an amniotomy. The most likely cause of thisobstetrical emergency is: a. Prolapsed umbilical cord b. Vasa previa c. Oligohydramnios d. Placental abruption ANS: a Feedback a. The nurse needs to assess the fetal heart rate immediately before and afterthe artificial rupture of membranes. Changes such as transient fetal tachycardia may occur and are common. However, other FHR patterns such asbradycardia and variable decelerations may be indicative of cord compressionor prolapse. b. Vasa previa is abnormal insertion of the cord into the placenta c. Oligohydramnios is a decreased amount of amniotic fluid. d. Placenta abruption is separation of the placenta from the uterine wall. In thisscenario, prolapsed cord is the most likely cause of the abrupt deceleration inthe FHR.

13. During the postpartum assessment, the perinatal nurse notes that a patient who has just experienced a forceps-assisted birth now has a large quantity of bright red bleeding. Her uterine fundus is firm. The nurse’s mostappropriate action is to notify the physician/certified nurse midwife and describe a: a. Need for vaginal assessment and repair

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b. Requirement for an oxytocin infusion c. Need for further information for the woman/family about forceps d. Requirement for bladder assessment and catheterizationANS: a Feedback a. In the presence of a firm fundus and bright red bleeding, after a forceps- assisted birth there is a need for vaginal assessment and there may be a needfor repair. b. The fundus is firm, and oxytocin is not indicated. c. There is no indication in this scenario that the family needs more information. d. There is no indication in this scenario that the bladder is contributing to thebleeding.

14. The perinatal nurse is providing care to Carol, a 28-year-old multiparouswoman in labor. Upon arrival to the birthing suite, Carol was 7 cm dilated andexperiencing contractions every 1 to 2 minutes which she describes as ―strong.‖ Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states thatshe is feeling some rectal pressure. Carol is most likely experiencing: a. Hypertonic contractions b. Hypotonic contractions c. Precipitous labor d. Uterine hyperstimulation ANS: c Feedback a. Hypertonic contractions result in little cervical change. b. Hypotonic contractions result in little cervical change. c. Contrary to both hypertonic and hypotonic labor, precipitate labor contractions produce very rapid, intense contractions. A precipitous labor lastsless than 3 hours from the beginning of contractions to birth. Patients often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage of labor. d. Patients with precipitous labor often progress through the first stage of laborwith little or no pain and may present to the birth setting already advanced into the second stage of labor. Precipitous labor contractions produce very rapid, intense contractions.

15. Hyperstimulation is defined as: (select all that apply) a. Contractions lasting more than 2 minutes b. Five or more contractions in 10 minutes c. Contractions occurring within 1 minute of each other d. Uterine resting tone below 20 mm/HgANS: a, b, c Contractions lasting more than 2 minutes, five or more contractions in 10

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minutes, and contractions occurring within 1 minute of each other describe thecriteria for hyperstimulation. Uterine resting tone below 20 mm/Hg reflects normal uterine resting tone.

16. Documentation related to vacuum delivery includes which of the following:(select all that apply) a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position ANS: a, b, c Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuumdeliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

17. Contraindications for induction of labor include: (select all that apply) a. Abnormal fetal position b. Postdated pregnancy c. Pregnancy-induced hypertension d. Placental abnormalities ANS: a, d Contraindications for induction of labor include abnormal fetal position becauseof the risk of fetal injury and placental abnormalities because of the risk of hemorrhage. Pregnancyinduced hypertension and placental abnormalities are two of the common indications for induction of labor.

18. Documentation related to vacuum delivery includes which of the following: a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position ANS: a, b, c Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuumdeliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

True/False 19. The perinatal nurse includes the following when explaining the physiologyof artificial rupture of membranes to the student nurse:

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―rupture of membranes causes a release of arachidonic acid, which converts to prostaglandins, substances known to stimulate oxytocin in the pregnant uterus‖ ANS: True At certain points in the labor, an amniotomy, or artificial rupture of themembranes, may be successful in increasing uterine contractility.

20. The perinatal nurse describes asynclitism to students as a presentationthat occurs when the fetal head is turned toward the maternal sacrum or symphysis at an oblique angle.

ANS: True Face and brow presentations are examples of asynclitism (the fetal head is presenting at a different angle than expected). Face and brow presentations hyperextend the neck and increase the overall circumference of the presentingpart. These presentations are uncommon and are usually associated with fetalanomalies.

21. The perinatal nurse explains to the student nurse that the most frequentfetal risk associated with the use of forceps is cord compression.

ANS: False The most frequent fetal risk associated with the use of forceps is superficialscalp or facial marks that will resolve quickly.

Fill-in-the-Blank 22. The perinatal nurse prepares for two potential complications that may accompany a precipitous labor and birth: postpartum _hemorrhage_ and aneed for neonatal _resusitation_.

ANS: hemorrhage; resuscitation Feedback 1: Complications from a precipitate labor pattern result from traumato maternal tissue and to the fetus because of the rapid descent. Hemorrhagemay occur from uterine rupture and vaginal lacerations. The fetus may sufferfrom hypoxia related to the decreased periods of uterine relaxation betweenthe contractions and intracranial hemorrhage related to the rapid birth.

Feedback 2: Complications from a precipitate labor pattern result from traumato maternal tissue and to the fetus because of the rapid descent. Hemorrhagemay occur from uterine rupture and vaginal lacerations. The fetus may sufferfrom hypoxia related to the decreased periods of uterine relaxation betweenthe contractions and intracranial hemorrhage related to the rapid birth.

23. The perinatal nurse understands that the most appropriate nursing actionfollowing an amniotomy is an assessment of the _FHR_ as well as the _color_ and _odor_ of the amniotic fluid.

ANS: fetal heart rate; color; odor The nurse carefully monitors the patient who will undergo an amniotomy. Vital

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signs, cervical effacement and dilation, station of the presenting part, fetalheart rate, and color and amount of amniotic fluid are assessed.

24. The perinatal nurse caring for a laboring woman who is receiving an oxytocin infusion documents the following information: rate of _infusion_,frequency and strength of _contractions_, fetal _HR_, and cervical _dilation_and _effacement_.

ANS: infusion; contractions; heart rate; dilatation; effacement Oxytocin protocols in many institutions require that the nurse remain at the patient’s bedside at all times for careful surveillance. The following data shouldbe placed on a flow sheet in the patient record: patient’s vital signs, fetal heartrate, frequency, duration and strength of contractions, cervical effacement anddilatation, fetal station and lie, rate of oxytocin infusion intake and urine output, and the psychological response of the patient.

25. The perinatal nurse recognizes that the laboring multiparous patient who isattempting a vaginal birth following a previous cesarean birth (VBAC) needs frequent assessments to ensure that there is progress during her labor.

ANS: progress Women with a previous history of cesarean birth may be offered a trial of labor,although a prompt cesarean birth is recommended at the earliest sign of maternal or fetal compromise.

26. During labor, oxytocin is always administered _IV with an infusion pump ANS: intravenously with an infusion pump During labor, oxytocin can only be administered intravenously via an infusionpump to titrate and regulate the dose for safe administration.

27. _Fundal pressure_ is contraindicated with shoulder dystocia.ANS: Fundal pressure Fundal pressure is contraindicated with shoulder dystocia because it mayfurther impact the shoulder and increases risk of fetal injury.

.

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Chapter 11: Intrapartum and Postpartum Care of Cesarean Birth FamiliesMultiple Response 1. Which of the following is a medical indication for a cesarean birth? (Select all that apply.) a. Maternal blood pressure of 130/90b. Cervical dilation of 1.5 cm per hour during the active phase oflaborc. Late deceleration of the fetal heart rate with minimal variabilityd. Complete placenta previae. Arrest of fetal descent ANS: c, d, eA maternal blood pressure of 130/90 may be an indication of mild PHI which is not a medical indication for cesarean birth. Cervical dilation of 1.5 cm/minutes is within normal limits for cervical changes during the active phase. Late decelerations combined with minimal variability in thefetal heart rate reflect fetal intolerance of labor and are an indication for cesarean birth. A complete placenta previa covers the internal os necessitating a cesarean birth. Arrest of fetal descent indicatescephalopelvic disproportion.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult 2. A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor andoperative records indicate that she had premature rupture of membranes followed by 36 hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is 1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that apply.) a. Fluid volume deficitb. Infectionc. Impaired motherinfant attachmentd. Falls ANS: a, b, c, dThe woman is at risk for fluid volume deficit related to blood loss and risk for postpartum hemorrhage due to risk of uterine atony. She is at risk for infection related to prematureand prolonged rupture of membranes. The woman is at risk for impaired motherinfant attachment related to maternal pain and exhaustion. She is at risk for falls related to anesthesia and orthostatic hypotension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area:Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult 3. The perinatal nurse teaches the student nurse that deep breathing exercises following a cesareanbirth are critical to the prevention of (select all that apply): a. Pneumonia b. Atelectasis c. Abdominal distension d. Increased tidal volumeANS: a, b Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns thatcan lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions,patients should be taught how to perform pulmonary exercises. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate Multiple Choice 4. A nurse is admitting a woman for a scheduled cesarean section. Which of the following

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assessmentdata should be immediately reported to the physician?a. White cell count of 11,000b.

Hemoglobin of 11 g/dLc. Hematocrit of 33%d. Platelet count of 97,000 ANS: d Feedback a. This laboratory value is within normal limits for a pregnant woman. b. This laboratory value is within normal limits for a pregnant woman. c. This laboratory value is within normal limits for a pregnant woman.

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d. Normal range of platelets is 150,000 to 400,000. A low platelet count places the woman at

risk forincreased bleeding.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension |Content Area: Maternity | Client Need: Reduction of Risk Potential Difficulty Level: Moderate 5. A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couples anxiety levels.a. Explain the reason for the need for a cesarean section.b. Inform parents that their baby is in distress.c.

Ask thecouple to share their concerns.d. Reassure the couple that both the woman and baby are in no danger.

ANS: c Feedback a. Explaining the reason she is having a cesarean birth is helpful but may not address their concerns. b. It is important to acknowledge that the baby is stable, but this response does not allow the coupleto share their concerns that may be causing an increase in anxiety. c. By asking the couple to share their concerns, the nurse can address these concerns. d. Reassuring the couple that the woman and baby are in no danger is correct, but it is not the bestanswer because it does not allow the couple to verbalize their concerns.

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity | ClientNeed: Psychosocial Integrity | Difficulty Level: Moderate 6. A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediateintervention?a. Itching of the palms and feetb. Nauseac. Urinary output of 300 mL in the past 4 hoursd. Respiratory rate of 10 breaths/minute ANS: d Feedback a. This is a side effect of intrathecal morphine which is not life threatening. b. This is a side effect of intrathecal morphine which is not life threatening. c. A urinary output of 300 mL in 4 hours is within normal limits. d. Correct. An adverse effect of intrathecal morphine that requires immediate intervention isrespiratory distress.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:Maternity | Client Need: Reduction of Risk Potential |Difficulty Level: Moderate 7. A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia.Which of the following interventions should the nurse perform on the mother at this time? a. Maintain the client flat in bed. b. Assess the clients patellar reflexes. c. Monitor hourly urinary outputs. d. Assess the clients respiratory rate.ANS: d Feedback

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a. The client should be assisted to a position of comfort. b. There is no indication in the scenario that the client must have her reflexes assessed. c. The clients hydration should be monitored postsurgery, but hourly assessments are unnecessary. d. The client has undergone major abdominal surgery. Her respiratory function should be

assessedregularly.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Postpartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | ClientNeed: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate

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8. A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the

followingsymptoms would the nurse expect to see? a. Abdominal distension b. Polyuria c. Diastasis recti d. Dependent edemaANS: a Feedback a. The nurse would expect to see a distended abdomen in a client with a paralytic ileus. b. Polyuria is unrelated to a paralytic ileus. c. Diastasis recti is unrelated to a paralytic ileus. d. Dependent edema is unrelated to a paralytic ileus.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | ContentArea: Physiological Adaptation: Alterations in Body Systems; Postpartum Care | Client Need: HealthPromotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Moderate 9. The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will bereceiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse: a. Assists the woman to lie down in a supine position. b. Administers a rapid intravenous infusion of 500 mL of normal saline. c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion. d. Encourages frequent cleansing breaths after the patient has been placed in the correct position forthe anesthesia administration.

ANS: b Complications that may occur with spinal anesthesia block include maternal hypotension, decreasedplacental perfusion, and an ineffective breathing pattern. Prior to administration, the patients fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade(decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities). Following administration of the anesthetic, the patients blood pressure, pulse, and respirations and fetal heart rate must be taken and documented every 5 to 10 minutes.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 10. The perinatal nurse understands that the purpose of combining an opioid with a local anestheticagent in an epidural is primarily to: a. Increase the total anesthetic volume b. Preserve a greater amount of maternal motor function c. Increase the intensity of the motor and sensory block d. Decrease the number of side effectsANS: b Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required

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andhelps to preserve a greater amount of maternal motor function.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult 11. Tanya, a 30-year-old woman, is being prepared for an elective cesarean birth. The perinatal nurseassists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanyasblood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurses best response is to: a. Place a wedge under Tanyas left hip. b. Discontinue Tanyas intravenous administration. c. Have naloxone (Narcan) ready for administration.

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d. Have epinephrine ready for

administration.ANS: a In the event of severe maternal hypotension, the nurse should place the patient in a lateral position oruse a wedge under the hip to displace the uterus, elevate the legs, maintain or increase the IV infusion rate, and administer oxygen by face mask at 10 to 12 L/min, or according to institution protocol.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area:Maternity | Client Need: Physiological Integrity | Difficulty Level: Difficult 12. The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth.

Providingan opportunity to review this experience may assist Chantal in: a. Her role development in the letting go stage b. Decreasing her ambivalence about her labor and birth c. Understanding her guilt involved in her labor and birth d. Developing more positive feelings about her labor and birthANS: d After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to bea less positive experience than a vaginal birth. Unplanned or emergent cesarean deliveries and the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing Chantal to talk about the experience can help her develop a more positive attitude about her own experience.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 13. The best time to give prophylactic antibiotics to the women undergoing cesarean section is: a. One hour before the surgery b. Two hours before the surgery c. Not indicated unless she has an active infection d. At the time the cord is clampedANS: a Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes prior to theskin incision.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 14. During a cesarean section, which action by the nurse is done to prevent compression of thedescending aorta and vena cava? a. Right lateral tilt b. Left lateral tilt c. Elevate head of gurney at 30 degrees d. Administration of IV fluid preload of 500 to 1000 mLANS: b Positioning of the patient with a left tilt maintains a left uterine displacement to decrease the risk ofaortocaval compression related to compression on the aorta and inferior vena cava due

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to weight ofthe gravid uterus.

KEY: Integrated Process: Nursing Process: Intervention | Cognitive Level: Application and Comprehension | Content Area: Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Safe and Effective Care Environment | Difficulty: HardFill-in-the-Blank 15. A post-cesarean section client has been ordered to receive 500 mL of 5% dextrose in water every4 hours. The drop factor of the macrodrip tubing is 10 gtt/mL. To what drip rate should the nurse regulate the IV? gtt/min

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ANS: 21 Feedback: 21 gtt/min The formula for calculating drip rates is: volume multiplied by drop factor = drip ratetime in minutes 500 mL = 10 gtt/cc = 21 gtt/min 4 hours = 60 min/hr KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Synthesis | Content Area: Pharmacological and Parenteral Therapies: Medication Administration | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level:Moderate 16. The perinatal nurse knows that the presence of abdominal distension and gas in the postcesareanbirth mother is due to .

ANS: delayed peristalsis Delayed peristalsis and constipation commonly occur because of slowed peristalsis associated withpregnancy hormones and childbirth anesthesia. In addition, incisional pain may contribute to a decrease in ambulation which contributes to delayed peristalsis.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area:Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 17. The Joint Commission Standard states that the , , and are accurately identified and clearly communicated during the final verification process before the start ofany surgical or invasive procedure.

ANS: site; procedure; patient To decrease the risk of surgery or invasive procedure being done on the wrong patient or in the wrongsite, a time-out is called, and active communication to verify correct procedure, site, and patient is done just prior to the beginning of surgery or invasive procedure.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Knowledge | ContentArea: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate True/False 18. During an emergency cesarean birth the time-out procedure may be omitted based on theobstetrical emergency.

ANS: False Joint commission guidelines for patient safety necessitate there always be a time-out to preventwrong patient, wrong site, wrong procedure, and medical errors.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

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.

Chapter 12 Postpartum Physiological Assessments and Nursing Care Multiple Choice .

Identify the choice that best completes the statement or answers the question.

1. A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurseis ocacw urarreentchee? patient is breastfeeding and associate the patient’rimarily with which 1.

2.

3.

4.

An increase in oxytocin release related to the newborn suckling The presence of intense afterbirth pains related to multiparity An expected response to the daily administration of oxytocin The efforts of the uterus to return to a prepregnancy condition

2. The nurse is palpating a patient’s uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?

1. To prevent uterine prolapse. .

2. To prevent uterine movement 3. To prevent uterine hemorrhage 4. To prevent uterine inversion a birb. o m /test 3. The nurse is providing postpartum care to a patient24ho rsafteravaginal delivery. Which action does the nurse perform prior to assessing the patient’s uterus?

1. Place the patient on the left side.

2. Assess the passage of lochia. .

3. Ask the patient to void.

4. Administer a dose of oxytocin.

4. A postpartum patient calls the OB office 8 days following a vaginal delivery. The patient reports concern regarding vaginal bleeding. Which patienat-breirpbort. cedo smym /tpetosm t causes the nurse concern?

1.

2.

3.

4.

Increased flow noticed with physical activity A description of the lochia as being red in color Discharge that is noted to have a fleshy odor Bleeding that is described as scant .

5. The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?

1. To validate the presence of clotting 2. To determine the presence of tissue .

3. To obtain an accurate description 4. To document the number of clots 6. The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?

1. The signs and symptoms of uterine infection 2. The signs and symptoms of secondary hemorrhage 3. The signs and symptoms of postpartum depression 4. The signs and symptoms of a boggy uterus

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.

7. The nurse in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient?

1. Run warm water over breasts while in the shower.

2. Wear a supportive bra for 24 hours a day. .

3. Express milk by a breast pump or manually.

4. Take analgesics for breast pain management.

8.

The nurse is providing care to a patient who is poastp sin/tgeana b iarrtbu.m c.oUm s t tomy and physiology knowledge,

which expectation does the nurse relate to the cardiovascular system?

1. Patient reporting of being cold related to blood loss 2. WBC laboratory level of 30,000/mm a few hours after delivery 3. Risk for hemorrhage due to decrease in circu.lating clotting factors 9. 4. A normal postpartum hemoglobin laboratory value of less than 11 g/dL Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations? .

1. Discharge with a neonate is discouraged if the mother is not vaccinated.

2. Vaccinating the mother will protect the neonate from serious illnesses.

3. The mother’s immune system has been suppressed during pregnancy. er /itsuensdter medical care.

4. Vaccination is more easily accomplished whailebtihrebm .coothm

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10. A patient who is 12 hours postpartum after a vaginal delivery continues to have difficulty in initiating urination. The nurse is aware that an integrative method used when a woman is unable to void is peppermint oil. In which manner will the.peppermint oil be used?

1. A thin layer is applied to the urinary meatus.

2. A small amount on a cotton ball is left at the bedside.

3. A small amount is added to the water of a vaporizer.

4. A saturated cotton ball is placed in a ―hat‖ on the toilet. .

11. The nurse is discussing contraception with a couple before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend?

1. Emergency contraceptives .

2. Oral estrogen/progesterone pill 3. Depo-Provera 4. Natural family planning Chapter 15: Physiological and Behavioral Responses of theNeonate Multiple Choice 1. A woman gave birth to a 3200 g baby girl with an estimated gestational ageof 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer theirquestions. b. Remove the neonate from the room so the parents will not be distressed byseeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

ANS: a Feedback a. It is important to always explain to parents what and why a procedure isbeing done on the newborn. b. It is best to give parents an option to be with their newborn when givinginjections. c. It is best to keep the newborn covered as much as possible to reduce heatloss. d. A 25 gauge 5/8 needle is used for giving injections to full-term neonates.

2. To accurately measure the neonate’s head, the nurse places the measuringtape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lipANS: a Feedback a. This is the standard measurement for the diameter of the head. b. This is not the standard measurement for the diameter of the head. c. This is not the standard measurement for the diameter of the head.

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d. This is not the standard measurement for the diameter of the head.

3. Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate ANS: c Feedback a. This neonate should have adequate stores of brown fat. b. This neonate is at risk for cold stress due to gestational age that results in

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less brown fat. c. This neonate is at risk for cold stress due to gestational age that results inless brown fat. This neonate is at higher risk because this neonate is SGA andhas a higher probability of less brown fat than the 32-week AGA. d. This neonate should have adequate stores of brown fat.

4. When assessing the apical pulse of the neonate, the stethoscope should beplaced at the: a. First or second intercostal space b. Second or third intercostal space c. Third or fourth intercostal space d. Fourth or fifth intercostal space ANS: c Feedback a. This is not the point of maximal impulse (PMI). b. This is not the point of maximal impulse (PMI). c. This is the point of maximal impulse (PMI). d. This is not the point of maximal impulse (PMI).

5. Which of the following breath sounds are normal to hear in the neonateduring the first few hours postbirth? a. Scattered crackles b. Wheezes c. Stridor d. Grunting ANS: a Feedback a. It is normal to hear scattered crackles during the first few hours. This is dueto retained amniotic fluid that will be absorbed through the lymphatic system. b. This may indicate difficulty in breathing. c. This may indicate respiratory obstruction. d. This may indicate respiratory distress.

6. The nurse assesses that a full-term neonate’s temperature is 36.2°C. Thefirst nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother’s chest with a warm blanket over themother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate’s primary provider.ANS: b Feedback a. Increasing the heat in the room will take a long period of time before it hasan effect on the neonate. b. Skin-to-skin contact along with use of a warm blanket is the best

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intervention with mild temperature decrease in the neonate. c. If the temperature remains low, then the neonate needs to be placed undera radiant warmer. d. The primary health provider is notified if the temperature remains low after interventions.

7. A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a load sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate’s head to the side so that the chin is over the shoulderwhile the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightlydrop back.

ANS: c Feedback a. This will elicit a startle reflex. b. This is not used for eliciting a reflex. c. This is correct. d. This tests for head lag.

8. An infant admitted to the newborn nursery has a blood glucose level of 55mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby’s blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby’s urinary output.

ANS: a Feedback a. This blood glucose level is normal. The nurse should provide routine nursingcare. b. There is no apparent need to assess this baby’s blood pressure. c. There is no apparent need to place the baby under the infant warmer. d. There is no apparent need to monitor the baby’s output.

9. Four babies have just been admitted into the neonatal nursery. Which of thebabies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132ANS: c Feedback a. The baby’s findings are within normal limits. Another baby should be seenfirst. b. The baby’s findings are within normal limits. Another baby should be seen

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first. c. This baby should be assessed first. The baby’s temperature is low; therefore,the baby could develop cold stress syndrome. In addition, the baby is short and, therefore, could be preterm. d. The baby’s findings are within normal limits. Another baby should be seenfirst.

10. The nurse is about to elicit the rooting reflex on a newborn baby. Which ofthe following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the sidethat is touched. b. When the lateral aspect of the sole of the baby’s foot is stroked, the toesextend and fan outward. c. When the baby is suddenly lowered or startled, the neonate’s armsstraighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm onthat same side extends.

ANS: a Feedback a. This is a description of the rooting reflex. b. This is a description of the Babinski reflex. c. This is a description of the Moro reflex. d. This is a description of the tonic neck reflex.

11. A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in thebaby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

ANS: d Feedback a. Dusky coloring is due to poor oxygenation. b. Labile vital signs can be caused by a number of things, including cold stress syndrome, sepsis, and poor oxygenation. c. Subnormal glucose levels can be caused by a number of things, includingprenatal diabetes mellitus, cold stress syndrome, and sepsis. d. The circumcision may ooze blood due to the lack of vitamin K, which isrequired for the hepatic synthesis of blood coagulation factors II, VII, and X.

12. A nurse is assisting a physician during a baby’s circumcision. Which of the following demonstrates that the nurse is acting as the baby’s patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure.

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b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure. d. The nurse provides the physician with an iodine solution for cleansing theskin.

ANS: a Feedback a. This response is correct. Because the baby is unable to ask for pain medication for the procedure, the nurse is advocating for the child. b. The restraint is used to keep the baby from moving during the procedure, asafety precaution. c. The nurse is using aseptic technique during the procedure when he or shewears a mask. d. The nurse is using aseptic technique during the procedure when he or shegives the physician iodine solution for the procedure.

13. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of theassessments should be reported to the health-care practitioner? a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity ANS: d Feedback a. The birth weight is normally between 2500 and 4000 grams. b. With molding, there may be an overlapping sagittal suture at birth. c. With molding, the posterior fontanel may be closed at birth. d. The point of maximum intensity should be felt lateral to the left nipple atabout the third or fourth intracostal space.

14. The nurse is about to elicit the Moro reflex. Which of the followingresponses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the sidethat is touched. b. When the lateral aspect of the sole of the baby’s foot is stroked, the toesextend and fan outward. c. When the baby is suddenly lowered or startled, the neonate’s armsstraighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm onthat same side extends.

ANS: c Feedback a. This is a description of the rooting reflex. b. This is a description of the Babinski reflex.

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c. This is a description of the Moro reflex. d. This is a description of the tonic neck reflex.

15. A nurse is doing a newborn assessment on a new admission to the nursery.Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip? a. Grasp the inner aspects of the baby’s calves with thumbs and forefingers. b. Gently abduct the baby’s thighs. c. Palpate the baby’s patellae to assess for subluxation of the bones. d. Dorsiflex the baby’s feet.

ANS: b Feedback a. The nurse would grasp the baby’s thighs with thumbs and forefingers. b. The nurse would gently abduct the baby’s legs. c. The nurse would palpate the trochanter to assess for changes. d. The nurse would not dorsiflex the feet to assess for developmental dysplasiaof the hip (DDH).

16. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate forthe nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.ANS: b Feedback a. The RN should admit a new baby to the nursery. b. The CNA could bathe and weigh a 3-hour-old baby. c. The RN should provide clients with needed teaching. d. The RN should interpret a bilirubin level.

17. A pregnant patient at 35 weeks’ gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory systemshould the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, whichallows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation,surfactant is produced in sufficient amounts to maintain alveolar stability.ANS: d Feedback a. As the fetus approaches term, there is a decrease in the secretion of

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intrapulmonary fluid, which assists in reducing the pulmonary resistance toblood flow and facilitates the initiation of air breathing. b. Lung expansion after birth stimulates the release of surfactant, a slippery, detergent-like lipoprotein. c. Surfactant causes a decreased surface tension within the alveoli, whichallows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation,surfactant is produced in sufficient amounts to maintain alveolar stability.

18. The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statementsaccurately describes the sequence of these changes? a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonaryartery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetalto newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

ANS: d Feedback a. As air enters the lungs, the PO2 rises in the alveoli. This normal physiologicresponse causes pulmonary artery relaxation and results in a decrease in pulmonary vascular resistance. b. As the pulmonary vascular resistance decreases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. The increased pulmonary blood volume contributes to the conversion fromfetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

19. A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia b. Physiologic anemia of infancy c. Low glomerular filtration rate d. Jaundice ANS: d Feedback a. Signs and symptoms of hypoglycemia include jitteriness, diaphoresis, poor muscle tone, poor sucking reflex, temperature instability, respiratory distress,tachycardia, dyspnea, apnea, high-pitched cry, irritability, lethargy, and seizures or coma.

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b. A low red blood cell (RBC) count signals physiologic anemia of infancy. c. The neonate’s elevated hematocrit (related to the high concentration ofRBCs) and low blood pressure may lead to a decreased glomerular filtration rate. d. Jaundice is a condition characterized by a yellow (icteric) coloration of the skin, sclera, and oral mucous membranes and results from the accumulation ofbile pigments associated with an excessive amount of bilirubin in the blood.

20. The nurse is assessing the neonate’s skin and notes the presence of small,irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis ANS: c Feedback a. Milia presents as small, white papules or sebaceous cysts on the infant’sface that resemble pimples. b. Acne, a skin condition common in adolescents, may also be present in newborns and is related to excessive amounts of maternal hormones. Over time, neonatal acne disappears spontaneously from the infant’s cheeks andchest. c. Erythema toxicum is a newborn rash that consists of small, irregular, flat, redpatches on the checks that develop into singular, small, yellow pimples appearing on the chest, abdomen, and extremities. d. Pustular melanosis is a condition in which small pustules are formed prior to birth. As the pustule disintegrates, a small residue or ―scale‖ in the shape of the pustule is formed, and this lesion later develops into a small (1 to 2 millimeter) macule, or flat spot.

Macules, which are brown in color, appear similar to freckles and are frequently located on the chest and extremities. Pustular melanosis occurs more commonly on African American infants than onCaucasian infants.

21. The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks’ gestation with no birth trauma. The nurse’s findings include the following parameters: heart rate, 136beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F(36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby’s health-care provider? a. Respiratory rate

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b. Presence of a heart murmur c. Absent bowel sounds d. Weight ANS: c Feedback a. The respiratory rate and weight are normal findings. It is not uncommon tohear murmurs in infants less than 24 hours old. b. It is not uncommon to hear murmurs in infants less than 24 hours old. c. Bowel obstruction in the neonate is often first identified by an absence ofbowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported. d. The weight is within normal limits.

22. The nursery nurse notes the presence of diffuse edema on a baby girl’s head.

Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edemahas disappeared. The nurse documents the following condition in the infant’schart. a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls ANS: a Feedback a. Caput succedaneum is diffuse edema that crosses the cranial suture linesand disappears without treatment during the first few days of life. b. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant’s head and persists for weeks while the tissue fluid is slowly broken down and absorbed. c. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant’s head and persists for weeks while the tissue fluid is slowly broken down and absorbed. d. Epstein pearls are whitish, hardened nodules on the gums or roof of themouth.

23. The perinatal nurse contacts the pediatrician about a heart murmur thatwas auscultated during a routine newborn assessment. This finding would beabnormal at: a. 8 to 12 hours b. 12 to 24 hours c. 24 to 48 hours d. 48 to 72 hours

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ANS: d It is not uncommon to hear murmurs in infants less than 24 hours old. The murmurs are characterized by a sound (best heard near the sternal border at the second or third intercostal space on the left side) that grows louder during systole. Although a heart sound arising from a patent ductus arteriosus may beheard initially, the sound disappears within 2 to 3 days when the ductus closes.If a murmur remains audible after the second day of life and intensifies to a ―whoosh‖ sound, further investigation is warranted because this finding is not characteristic of a patent ductus and may indicate the presence of another type of heart lesion.

24. Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall ANS: d Feedback a. This is an example of preventing heat loss due to convection. b. This is an example of reducing heat loss due to conduction. c. This is an example of reducing heat loss due to evaporation. d. Placing the crib near a warm wall is an example of heat loss due to radiation.

Multiple Response 25. A healthy, full-term baby is scheduled for a circumcision. Nursing actionsprior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate’s protime.

ANS: a, b, c Feedback a. Circumcision is a surgical procedure and requires written consent signed bythe parent. b. Administration of acetaminophen is a method of pain management for thenewborn. c. Glucose water is a method of pain management for the newborn. d. It is not a standard protocol to obtain a protime prior to circumcision.

26. A first-time mother informs her nurse that another staff member came inand wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. Thenurse should do which of the following? (Select all that apply.) a. Praise the mother for not allowing a person without proper ID to take herbaby.

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b. Check with the nursery to see if a staff member was recently in the patient’sroom. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

ANS: a, b, c, d Feedback a. Parents are instructed not to allow anyone who does not have proper identification to take their newborn from their room. b. Check and see if there is a staff member who is not wearing picture ID. c. This incident needs to be reported to security. Usually the unit is locked, andthere are security checks for unauthorized persons on the unit. d. All staff on the different shifts need to be alerted so they can watch for unauthorized persons on the unit.

27. The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation.Which of the following are examples of heat lost via convection? (Select all thatapply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window ANS: c, d Feedback a. Evaporation is the loss of heat that occurs when water is converted into avapor, such as inadequately dried skin. b. Conduction is the loss of heat to a cooler surface by direct skin contact, suchas occurs when the infant is placed on a cold surface. c. Convective heat loss occurs when the neonate is exposed to drafts and coolcirculating air, such as when being placed near an open window or fan. d. Convective heat loss occurs when the neonate is exposed to drafts and coolcirculating air, such as when being placed near an open window or fan.

28. A perinatal nurse assesses a term newborn for respiratory functioning. Thenurse knows that which of the following conditions is normal for newborns? (Select all that apply.) a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. The neonate’s lung sounds may sound moist during early auscultationANS: b, d Feedback a. The normal respiratory rate for a healthy term newborn is 40 to 60 breathsper minute. b. The breathing pattern is often shallow, diaphragmatic, and irregular.

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c. Apnea is cessation of breathing that lasts more than 20 seconds; it isabnormal in the term neonate. d. Most fetal fluid is reabsorbed within the first few hours, but in some infantsthis process may take up to 24 hours and the lungs may sound moist for thefirst 24 hours.

29. The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used withthis assessment tool are (select all that apply): a. Physical b. Behavioral c. Reflexive d. Neuromuscular ANS: a, d With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant’s gestational age in weeks.

True/False 30. The nurse assessing a newborn for heat loss is aware that non-shivering thermogenesis utilizes the newborn’s stores of brown adipose tissue (BAT) toprovide heat in the cold-stressed newborn.

ANS: True Brown adipose tissue, also known as ―brown fat,‖ is a unique highly vascular fat found only in newborns. BAT derives its name from the rich abundance of blood vessels, cells, and nerve endings that cause it to appear dark in color. The masses of brown fat cells accelerate triglyceride metabolism, triggering aprocess that produces heat.

Fill-in-the-Blank 31. A newborn was born weighing 2576 grams. On day 2 of life, the babyweighed 2345 grams. What percentage of weight loss did the baby experience? (Calculate to the nearest hundredth.)

ANS: 8.97% The neonate has lost 231 grams (2576 grams – 2345 grams = 231 grams).The percentage lost is 231 grams/2576 grams/100% = 8.97% weight loss.

32. The perinatal nurse explains to the student nurse that successful cardiopulmonary adaptation in the neonate involves five major changes: anincreased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the , the , and the .

ANS: foramen ovale; ductus arteriosus; ductus venosus Following placental separation at birth, the umbilical arteries and vein constrictas the fetal circulatory system is interrupted. Successful cardiopulmonary

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adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure anddecreased pulmonary pressure; and closure of the foramen ovale, the ductusarteriosus, and the ductus venosus.

33. Upon assessment of the temperature of a newborn, the nurse recalls thatthe is the range of temperature in which the newborn’s body temperature can be maintained with minimal metabolic demands and oxygenconsumption.

ANS: neutral thermal environment (NTE) After ensuring effective respirations, facilitating a neutral thermal environmentis an essential nursing action. Ideally, a supply of warm, dry linens should be available to prevent neonatal cold stress.

34. When assessing a newborn for coagulation factors, the perinatal nurse recalls that coagulation factors to enable the newborn to effectively clot bloodafter childbirth are activated by .

ANS: vitamin K Due to the absence of vitamin K at birth, the neonate is at risk for developing ablood clotting deficiency during the first few days of life. The infant is given anintramuscular injection of vitamin K, phytonadione (AquaMEPHYTON), during the initial care and assessment to prevent hemorrhagic disease of the newborn.

35. The nurse explains to a pregnant patient that the mother’s prior exposureto illness and immunizations prompts the development of antibodies in the newborn in a process termed immunity.

ANS: active acquired The pregnant woman’s exposure to illness and immunizations prompts the development of antibodies in a process termed active acquired immunity. Theinfant receives passive acquired immunity through antibodies that have beenpassed through the placenta by way of the IgG immunoglobulins.

36. The nurse is aware that the

state, which generally occurs duringthe first 30 minutes to 1 hour after birth, characterizes the first period of reactivity and provides an excellent time for parents to bond with their infant. ANS: quiet alert The quiet alert state generally occurs during the first 30 minutes to 1 hour after birth and characterizes the first period of reactivity. This period is an excellent time for parents to bond with their infant. After that time, the infant’salert states result from choice or necessity. Stimuli that may prompt wakefulness include hunger, cold, and heat—once the triggering stimuli are removed, the infant tends to fall back to sleep.

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37. The gray, blue, or purple areas on the buttocks of a neonate are referred toas

.

ANS: Mongolian spots Mongolian spots are blue/gray areas on the buttocks that are frequently seenin darkerskinned neonates.

38.

is a vasomotor response to decreased body temperature afterbirth.

ANS: Mottling Mottling is a benign transient pattern of pink and white blotches on the skin inresponse to a cold environment.

39. As the perinatal nurse performs an assessment of the infant’s head, ears,eyes, nose, and throat, the ears are noted to be low set. This clinical findingwould require follow-up due to the potential for .

ANS: chromosomal abnormalities Special attention is paid to the shape, size, and placement of the ears. Low-setears may signal the need for further assessment and evaluation for chromosomal abnormalities.

Placement of one ear slightly lower than the otheris a common finding that generally has no clinical significance.

40. Assessment of the infant’s anterior fontanel is an important part of thephysical examination. The nurse knows that dehydration can cause a in the fontanel and might increase the pressure in the fontanel.

ANS: depression; crying Fontanels should be assessed at least once per shift to make sure that they areopen and flat with no bulging or depression.

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Chapter 16: Discharge Planning and Teaching Multiple Choice 1. A nurse is making a home visit on the seventh postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding isthe method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a littlebefore each feeding. The nurse’s best response is: a. ―This is normal. You only have to be concerned when your baby does notgain weight.‖ b. ―What types of foods are you eating? A lack of protein in the diet can causewatery looking breast milk.‖ c. ―How much fluid are you drinking while you are nursing your baby? Toomuch fluid during the feeding session can dilute the breast milk.‖ d. ―This is normal and is referred to as foremilk which is higher in water content.

Later in the feeding the fat content increases and the milk becomesricher in appearance.‖ ANS: d Feedback a. Correct information but does not provide information for the woman tounderstand the different types of milk. b. Incorrect information. c. Incorrect information. d. Correct. This provides an explanation for the consistency of the milk andreassures the woman that the appearance of the milk is normal.

2. A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patientis: a. ―I understand your concern, but your baby will be okay until your milk comesin.‖ b. ―Your baby seems content, so you should not worry about him gettingenough to eat.‖ c. ―Milk normally comes in around the third day. Prior to that, he is gettingcolostrum which is high in protein and immunoglobulins which are importantfor your baby’s health.‖ d. ―You can bottle feed until your milk comes in.‖ANS: c Feedback a. Incorrect because it does not inform the woman of what to expect with thestages of milk. b. This conveys a message that the woman’s concern is not important. c. This response provides information on the stages of milk production to helpthe woman understand her newborn’s nutritional needs.

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d. Incorrect response. It is important to avoid bottles until breastfeeding hasbeen well established.

3. Which of the following positions for breastfeeding is preferred for a 2-daypostcesarean-birth woman? a. Lying down on side b. Sitting c. Cradle d. Cross-cradle ANS: a Feedback a. Having the woman lying on her side to breastfeed prevents pressure on herabdomen and the pain that can result from the pressure. b. In this position, the baby is on the woman’s abdomen, and this can bepainful for the woman. c. In this position, the baby is on the woman’s abdomen, and this can bepainful for the woman. d. In this position, the baby is on the woman’s abdomen, and this can bepainful for the woman.

4. Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feedingsession and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding sessionANS: a Feedback a. Correct. All of the answers are correct, but problems with latching-on are aprimary cause of nipple irritation. b. All of the answers are correct, but problems with latching-on are a primarycause of nipple irritation. c. All of the answers are correct, but problems with latching-on are a primarycause of nipple irritation. d. All of the answers are correct, but problems with latching-on are a primarycause of nipple irritation.

5. The nurse is developing a discharge teaching plan for a 21-year-old first- time mom. This was an unplanned pregnancy. She had a prolonged labor andan early postpartum hemorrhage. The woman plans to breastfeed her baby.She plans to return to work when her baby is 3 months old. Based on this information, the three primary learning needs of this woman are: a. Breastfeeding, bathing of the newborn, and infant safety b. Breastfeeding, storage of milk, and nutrition

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c. Breastfeeding, contraception, infant safety d. Breastfeeding, storage of milk, and rest ANS: B Feedback a. These are important learning needs but do not reflect an understanding oflearning needs based on early postpartum hemorrhage and returning to workin 3 months. b. Because this is the woman’s first time breastfeeding and she plans to returnto work, it is important that she feels comfortable with her understanding of breastfeeding and knows how to store her milk when she returns to work. Because she had a postpartum hemorrhage, she needs to learn what foods arehigh in iron. c. These are important learning needs but do not reflect an understanding oflearning needs based on early postpartum hemorrhage and returning to workin 3 months. d. These are important learning needs but do not reflect an understanding oflearning needs based on early postpartum hemorrhage.

6. Instructions to a mother of an uncircumcised male infant should includewhich of the following? a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.ANS: d Feedback a. Use of cotton swabs or retracting the foreskin can damage the inner layer ofthe foreskin and cause adhesions. b. Retracting the foreskin can damage the inner layer of the foreskin and causeadhesions. c. Use of alcohol is irritating and painful. d. Parents should not retract the foreskin. The foreskin will fully retract on itsown around 5 years of age.

7. A mother of a 10-day-old infant calls the clinic and reports that her baby ishaving loose, green stools. The mother is breastfeeding her infant. Which ofthe following is the best nursing action? a. Instruct the woman to bring her infant to the clinic. b. Instruct the woman to decrease the amount of feeding for 24 hours and tocall if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back ifthe stools continue to be loose and green.

ANS: a Feedback

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a. The loose, green stools indicate that the baby is having diarrhea. The infantneeds to be evaluated by the primary health provider, because prolonged diarrhea can lead to dehydration and electrolyte imbalance. b. The baby is having diarrhea. Decreasing the amount of feeding can furtherdehydrate the baby. c. This is not a normal stool pattern; the baby is having diarrhea. d. This neonate needs to be evaluated first, before determining a treatmentplan.

8. The perinatal nurse is teaching her new mother about breastfeeding andexplains that the most appropriate time to breastfeed is: a. 3 to 4 hours after the last feeding b. When her infant is in a quiet alert state c. When her infant is in an active alert state d. When her infant exhibits hunger-related cryingANS: b The optimal time to breastfeed is when the baby is in a quiet alert state. Cryingis usually a late sign of hunger, and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.

9. Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity’s mother makes specific, variousrequests of the nurses including bringing warm tea, a cot to sleep on, and thatthe baby not be bathed at this time. Felicity’s mother is also concerned aboutthe amount of work that Felicity may be doing in the provision of infant care.Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and ―feed‖ thebaby. How would the perinatal nurse best respond to Felicity’s mother in a culturally sensitive way? a. Ask Felicity’s mother to leave for 30 minutes to allow for some private timewith Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method,and assess what they already know. c. Convey to Felicity and her mother an understanding of the concepts of ―hot‖and ―cold‖ within their belief system. d. Ask Felicity what she knows about breastfeeding, and provide information toboth women to support Felicity’s decision.

ANS: d In certain multicultural populations such as India, Thailand, and China, the woman’s postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health, and great emphasis is placed on allowing the mother’s body to regain balance after

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the birth of a child. To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Westernhealth beliefs and practices. The nurse should advocate for the patient by inquiring about her feeding preferences and by providing information to themother and her family to support her in her decision.

10. A neonatal nurse caring for newborns knows that the best time for a mother to first attempt breastfeeding is during which one of the followingstages of activity? a. First period of reactivity b. First period of inactivity and sleep c. Second period of reactivity d. Second period of inactivity and sleep ANS: a The best stage for initiating breastfeeding is the first period of active, alert wakefulness that the infant displays immediately after birth, which may lastfrom 30 minutes to 2 hours.

11. A nurse is providing discharge teaching to the parents of a 2-day-oldneonate.

Which of the following information should be included in the discharge teaching on umbilical cord care? a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 daysof age. c. Call the doctor if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.ANS: c Feedback a. There is a controversy in the literature regarding what should be used to clean the cord, but hydrogen peroxide is not one of the recommended agents. b. The cord should be allowed to fall off on its own. c. The green drainage may be a sign of infection. d. There is no need to cover the cord.

12. The nurse is teaching the parents of a 1-day-old baby how to give theirbaby a bath. Which of the following actions should be included? a. Clean the eye from the outer canthus to the inner canthus. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Check the temperature of the water with your fingertip.ANS: c Feedback a. To decrease the risk of infection, the eyes should be cleaned from the innerto the outer canthus. b. Keeping doors open can cause a drop in baby’s temperature by convection.

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c. If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air whenwet. d. The safest way to check the temperature is with a thermometer or, if none,with the elbow or forearm.

13. The nurse is teaching the parents of a female baby how to change a baby’sdiapers.

Which of the following should be included in the teaching? a. Always wipe the perineum from front to back. b. Remove any vernix caseosa from the labia folds. c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.ANS: a Feedback a. To decrease risk of infection from bacteria from the rectum, the perineum offemale babies should always be cleansed from front to back. b. Vernix is a natural lanolin that will be absorbed over time. Actively removingthe vernix can irritate the baby’s skin. c. Powder is not recommended for use on babies. When mixed with urine,powders can produce an irritating paste. d. The number of wet diapers per day should be counted to assess hydration,but weighing diapers of full-term, healthy neonates is not necessary.

14. The nurse is advising parents of a full-term neonate being discharged fromthe hospital regarding car seat safety. Which of the following should be included in the teaching plan? a. Put the car seat facing forward only after the baby reaches 20 pounds. b. The infant car seat should be placed facing the rear seat in the front seat ofthe car. c. A fist should fit between the straps of the seat and the baby’s body. d. Seat belt adjusters should always be used to support infant car seats.ANS: a Feedback a. It is unsafe for infants to be facing forward until they have reached 20pounds, even if they are over 1 year of age. b. The baby should be facing the rear of the back seat and not the front seat. c. The straps of the car seat should fit snugly, allowing only two fingers to beinserted between them and the baby. d. Seat belt adjusters that are being sold as adding to a car seat have not beenshown to be safe.

15. The nurse is teaching the parents of a healthy newborn about infant safety.Which of the following should be included in the teaching plan? a. Water temperature for the infant’s bath should be 39°C. b. Crib slates should be a maximum of 3 inches apart.

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c. Cover electrical outlets once the infant is crawling. d. Remove strings from infant sleepwear.

ANS: d Feedback a. Water temperature should be 38°C. b. Crib slates should be no wider than 2 3/8 inches. c. Electrical covers should be covered before the infant begins to crawl, because infants can roll around to move and reach outlets before they crawl. d. Strings should be removed from bedding, sleepwear, pacifiers, and otherobjects that come in contact with the infant to decrease the risk of strangulation.

16. Which of the following statements indicates that a new mother needsadditional teaching? a. ―I need to supervise my cat when she is in the same room as my baby.‖ b. ―I will place my baby on her back when she is sleeping.‖ c. ―I will not leave my baby on an elevated flat surface after she is able to turnover on her own.‖ d. ―I have asked my husband to install safety latches on the lower cabinets.‖ANS: c Feedback a. Pets should always be supervised when in the same room as the infant,because they can intentionally and unintentionally harm the infant. b. True statement. c. Newborns/infants should never be left on an elevated flat surface becausethey may roll or wiggle and fall off. d. True statement.

17. The let-down reflex occurs in response to the release of oxytocin. Which ofthe following can stimulate the release of oxytocin? (Select all that apply.) a. Prolactin release b. Infant suckling c. Infant crying d. Sexual activity ANS: b, c, d Feedback a. Prolactin stimulates milk production but does not have a direct effect on therelease of oxytocin. b. Infant suckling can cause the release of oxytocin. c. Hearing an infant cry can cause the release of oxytocin. d. An orgasm triggers the release of oxytocin.

18. Which of the following are disadvantages of bottle feeding? (Select all thatapply.) a. Hampers mother–infant attachment

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b. Increases cost c. Increases risk of infection d. Increases risk of childhood obesity ANS: b, c, d Feedback a. Bottle feeding does not interfere with mother–infant attachment. b. The cost of formula is greater than the cost of eating a well-balanced diet. c. Bottle-fed babies are at higher risk for infection because formulas lack the antibiotics that are found in colostrum and human milk. d. There is a relationship between childhood obesity and bottle feeding.

19. The clinic nurse teaches expectant mothers about the differences betweenbreast milk and commercially prepared infant formulas. When compared to commercially prepared formulas, breast milk has (select all that apply): a. More carbohydrates b. Less protein c. Fewer nutrients d. Less cholesterol ANS: a, b Human breast milk contains more carbohydrates, less protein, and more cholesterol than cow’s milk or infant formulas. Commercially prepared infantformulas use vegetable oils which are void of cholesterol.

20. The perinatal nurse is teaching the new mother who has chosen to formulafeed her infant. Appropriate instructions to be given to this mother include (select all that apply): a. Mix the formula with hot water only. b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours. d. Discard any unused formula that remains in a bottle following use.ANS: b, c, d Parents should be advised to read and follow the manufacturer’s instructionsexplicitly when preparing the formula, because some require no water and some need to be diluted with water. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, andany unused formula should be discarded.

The nipples should be checked periodically during feedings for correct flow and should be replaced regularly.

21. The perinatal nurse describes infant feeding cues to a new mother. Thesefeeding cues include (select all that apply): a. Vocalizations b. Mouth movements c. Moving the hand to the mouth d. Yawning

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ANS: a, b, c The infant demonstrates readiness for feeding when he or she begins to stir, bobs the head against the mattress or mother’s neck or shoulder, makes hand-to-mouth or hand-tohand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed andthe hands in a fist.

22. Typical signs of abusive head trauma (Shaken Baby Syndrome) includewhich of the following? (Select all that apply.) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems ANS: b, c, d Symptoms of abusive head trauma are extreme irritability, breathing problems, convulsions, vomiting, and pale or bluish skin.

23. General skin care for full-term infants includes which of the following?(Select all that apply.) a. Avoid daily bathing with soap. b. Use a cleanser with an alkaline pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head andface.

ANS: a, c, d It is not necessary to bathe an infant daily. Daily bathing with soap can causedry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants.

24. A nurse is going to teach her postpartum patient about newborn bathing, diapering, and swaddling. Which of the following indicates that the nurse incorporated teaching/learning principles in her teaching plans? (Select all thatapply.) a. Asked family members to leave b. Turned off TV c. Closed the door of the room d. Administered analgesics a few hours before teaching sessionANS: b, c, d Feedback a. It is often helpful to have family members present, with the woman’s permission, so they can also learn about caring for the newborn. b. Turning off the TV decreases the amount of distractions and allows thewoman to focus on learning about infant care. c. Closing the door decreases the amount of distractions and allows the womanto focus on learning about infant care.

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d. Administering analgesia prior to the teaching session will enhance the woman’s comfort and facilitate her ability to focus on the teaching session.

25. The clinic nurse recognizes that the longer an infant is formula fed, the greater is the immunity and resistance the infant will develop against bacterialand viral infections.

ANS: False One of the primary benefits of breastfeeding, not formula feeding, is the decreased incidence of bacterial and viral infections as a result of passiveimmunity, including the transfer of maternal antibodies.

26. It is a common custom for traditional Chinese women to bottle feed theirinfants until their milk comes in.

ANS: True It is common for traditional Chinese women to bottle feed until their milkcomes in.

27. The clinic nurse discusses gradual warming of expressed breast milk or formula and cautions against use of the _microwave oven_ for heating breastmilk or formula.

ANS: microwave oven With regard to infant feeding and safety, parents should be taught to warm bottles slowly, never to use a microwave oven to heat breast milk or formula,and never to prop a bottle in the infant’s mouth, as this practice creates a choking hazard.

28. The perinatal nurse encourages all mothers to place their infants under 12months of age in the supine position for sleeping, because a leading cause of death for this age group is _SIDS_.

ANS: sudden infant death syndrome Sudden infant death syndrome (SIDS) is a leading cause of death among infants between the ages of 1 and 12 months. Having infants sleep on theirbacks has decreased the risk of SIDS.

29. The perinatal nurse understands that the hormonal processes involved in breastfeeding include decreased serum _ progesterone_ and _estrogen_ levels immediately following birth which lead to an increased serum _ prolactin_ levelthat causes milk production by the fourth to fifth postpartal days.

ANS: progesterone; estrogen; prolactin Circulating levels of estrogen and progesterone decrease dramatically following delivery of the placenta. The decline in these two hormones signalsthe anterior pituitary gland to produce prolactin in readiness for lactation.

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Chapter 17: High-Risk Neonatal Nursing Care Multiple Choice 1. A neonate is born at 33 weeks’ gestation with a birth weight of 2400 grams.This neonate would be classified as: a. Low birth weight b. Very low birth weight c. Extremely low birth weight d. Very premature ANS: a Feedback a. Neonates with a birth weight of less than 2500 grams but greater than 1500grams are classified as low birth weight. b. Neonates with birth weight less than 1500 grams but greater than 1000grams are classified as very low birth weight. c. Neonates with birth weight less than 1000 grams are classified as extremelylow birth weight. d. Neonates born less than 32 weeks’ gestation are classified as very premature.

2. A nurse assesses that a 3-day-old neonate who was born at 34 weeks’ gestation has abdominal distention and vomiting. These assessment findingsare most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC) ANS: d Feedback a. Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring. b. Assessment findings for BPD include chest retractions; audible wheezing,rales, and rhonchi; hypoxia; and bronchospasm. c. Assessment findings for PVH include bradycardia, hypotonia, full and/ortense anterior fontanel, and hyperglycemia. d. Assessment findings related to NEC include abdominal distention, bloodystools, abdominal distention, vomiting, and increased gastric residual. Thesesigns and symptoms are related to the premature neonate’s inability to fullydigest stomach contents and limitation in absorptive function.

3. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. Theneonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipatewhich of the following interventions? a. Phototherapy

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b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count ANS: b Feedback a. Phototherapy is considered when the levels are 12 mg/dL or higher when theneonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility. b. Adequate hydration promotes excretion of bilirubin in the urine. c. Colostrum acts as a laxative and assists in the passage of meconium. d. Assessing RBC is not a treatment for hyperbilirubinemia.

4. A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannotunderstand how her baby became infected. The best response by the nurse is: a. ―Newborns are more susceptible to infections due to an immature immunesystem.

Would you like additional information on the newborn immune system?‖ b. ―The infection was transmitted to your baby during the birthing process. Doyou have a history of sexual transmitted infections?‖ c. ―Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do youhave regarding your baby’s health?‖ d. ―I see that this is very upsetting for you. I will come back later and answer your questions.‖ ANS: c Feedback a. Correct information, but does not fully address the woman’s concern. b. Correct, but GBS is not a sexually transmitted disease. c. Correct. This response answers her questions and allows her to askadditional questions about her baby’s health. d. Acknowledges that she is upset but does not provide immediate information.

5. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal ANS: d Feedback a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability,apnea, lethargy, and temperature instability, but not nasal congestion.

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b. Signs and symptoms of hypercalcemia are vomiting, constipation, andcardiac arrhythmias. c. Signs and symptoms of cold stress are decreased temperature, cool skin,lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting. d. These are common signs and symptoms of neonatal withdrawal.

6. The following four babies are in the neonatal nursery. Which of the babiesshould be seen by the neonatologist as soon as possible? a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring ANS: d Feedback a. A slight tachycardia—170 bpm—is normal when a baby is crying. b. Slight jaundice on day 2 is within normal limits. c. It is normal for a breastfed baby to feed every 2 hours. d. A dusky skin color is abnormal in any neonate, whether or not the respiration rate is normal, although this baby is also slightly tachypneic.

7. A multipara, 26 weeks’ gestation and accompanied by her husband, has justdelivered a fetal demise. Which of the following nursing actions is appropriateat this time? a. Encourage the parents to pray for the baby’s soul. b. Advise the parents that it is better for the baby to have died than to havehad to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby’s death with theirother children.

ANS: c Feedback a. It is inappropriate for the nurse to advise prayer. The parents must decidefor themselves how they wish to express their spirituality. b. This is an inappropriate suggestion. c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during thegrieving process. d. This is an inappropriate suggestion. It is very important for the parents toclearly communicate the baby’s death with their other children.

8. The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a. Intermittent strabismus b. Startling

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c. Grunting d. Vaginal bleeding ANS: c Feedback a. Pseudostrabismus is a normal finding. b. Startling is a normal finding. c. Grunting is a sign of respiratory distress. The neonatologist should benotified. d. Vaginal bleeding is a normal finding.

9. It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse iscritical at this time? a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry.

ANS: c Feedback a. This action is not appropriate. The baby needs tracheal suctioning. b. The baby needs to have tracheal suctioning. The most important action topromote health for the baby is for the health-care team to establish an airwaythat is free of meconium. c. This action is appropriate. The baby needs to be intubated in order for deepsuctioning to be performed by the physician. A nurse would not intubate andsuction but rather would assist with the procedures. d. It is strictly contraindicated to stimulate the baby to cry until the trachea hasbeen suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.

10. A 42-week gestation neonate is admitted to the NICU (neonatal intensivecare unit).

This neonate is at risk for which complication? a. Meconium aspiration syndrome b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage ANS: a Feedback a. Although there is nothing in the scenario that states that the amniotic fluid isgreen tinged, post-term babies are high risk for meconium aspiration syndrome. b. Post-term babies often gain weight very quickly. c. Preterm, not post-term, babies are high risk for necrotizing enterocolitis. d. Preterm, not post-term, babies are high risk for intraventricular hemorrhages.

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11. A 1-day-old neonate in the well-baby nursery is suspected of suffering fromdrug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash ANS: c Feedback a. Babies who are withdrawing from drugs have disorganized behavioral statesand sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemicor anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

12. A baby boy was just born to a mother who had positive vaginal cultures forgroup B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele ANS: a Feedback a. This infant is high risk for respiratory distress. The nurse should observe thisbaby carefully for grunting. b. Acrocyanosis is a normal finding. c. Pseudostrabismus is a normal finding. d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization inthe mother.

13. The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurseinterprets the result as which of the following? a. The baby’s lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby’s kidneys are functioning poorly. d. The mother is high risk for eclampsia.

ANS: a Feedback

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a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature. b. L/S ratios are unrelated to maternal blood loss. c. L/S ratios are unrelated to fetal renal function. d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

14. Which of the following neonatal signs or symptoms would the nurse expectto see in a neonate with an elevated bilirubin level? a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia ANS: b Feedback a. Hypoglycemia is not a sign that is related to an elevated bilirubin level. b. The baby is likely to feed poorly. An elevated bilirubin level adversely affectsthe central nervous system. Babies are often sleepy and feed poorly when thebilirubin level is elevated. c. Hyperactivity is the opposite of the behavior one would expect the baby toexhibit. d. Hyperthermia is not directly related to an elevated bilirubin level.

15. The perinatal nurse is assisting the student nurse with completion of documentation.

The laboring woman has just given birth to a 2700 gram infantat 36 weeks’ gestation.

The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant ANS: a Feedback a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks. b. Term births are infants born between 37 and 40 weeks. c. SAG infants at 36 weeks weigh less than 2000 grams. d. LAG infants at 36 weeks weigh over 3400 grams.

16. The NICU nurse recognizes that respiratory distress syndrome results froma developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium ANS: c Feedback a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess

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maturity of fetal lungs. b. Calcium is needed to prevent undermineralization of bones. c. Respiratory distress syndrome (RDS) is a developmental respiratory disorderthat affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance. d. Magnesium is needed to prevent undermineralization of bones.

17. The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milkevery 3 hours. The nurse’s best response to the patient’s mother would be: a. ―Pumping is hard work and you are doing very well. It is good to get about 1ounce of milk every 3 hours.‖ b. ―Natural breastfeeding will be a challenging goal for your baby. Beginningtoday, you will need to begin to pump your breasts more often.‖ c. ―Your baby will not be ready to go home for at least another week. You canbegin to pump more often in the next few days in preparation for taking your child home.‖ d. ―You have been working hard to give your son your breast milk. We can mapout a schedule to help you begin today to pump more often to prepare to take your baby home.‖ ANS: d Feedback a. This is correct information but does not assist the women in producing moremilk. b. This does not provide her with a plan to increase her milk. c. This does not provide her with a plan. d. The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk willhelp the mother keep her milk flow steady and provide enough nutrients for the infant after discharge.

Multiple Response 18. A nurse is caring for a 2-day-old neonate who was born at 31 weeks’ gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS).Which of the following medical treatments would the nurse anticipate for thisneonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators

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ANS: a, c Feedback a. This is a common medical treatment for RDS. b. Corticosteroids are given to women in preterm labor to decrease the risk ofRDS. c. CPAP is used to assist neonates with RDS. d. Bronchodilators are given to neonates with bronchopulmonary dysplasia(BPD).

19. Which of the following factors increases the risk of necrotizing enterocolitis(NEC) in very premature neonates? (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastic feedings ANS: a, d Feedback a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosisof the bowel. b. Preterm neonates are predisposed to NEC due to alteration in blood flow tothe intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. c. Preterm neonates are predisposed to NEC due to alteration in blood flow tothe intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. d. Bacterial colonization in the intestines can occur from contaminated feedingtubes causing an inflammatory response in the bowel.

20. Nursing actions that decrease the risk of skin breakdown include which ofthe following? (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly ANS: a, b, c Feedback a. Use of gelled mattresses decreases the risk of pressure sores. b. Use of emollients reduces the risk of irritation from urine. c. Use of transparent dressings reduces the risk of friction injuries. d. Drying thoroughly is important in maintaining body heat.

21. Nursing actions that minimize oxygen demands in the neonate includewhich of the following? (Select all that apply.) a. Providing frequent rest breaks when feeding

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b. Placing neonate on back for sleeping c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care ANS: c, d Feedback a. A prolonged feeding session increases energy consumption that increasesoxygen consumption. b. Placing the neonate on the back for sleeping has no effect on oxygen consumption. c. A decrease in environmental temperature leads to a decrease in the neonate’s body temperature which leads to an increase in respiratory andheart rate that leads to an increase in oxygen consumption. d. Clustering of nursing care decreases stress which decreases oxygen requirements.

22. A nurse is caring for a 10-day-old neonate who was born at 33 weeks’ gestation.

Which of the following actions assist the nurse in assessing for signsof feeding tolerance? (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools ANS: a, c, d Feedback a. Feedings should be held and physician notified if bowel sounds are absent. b. The neonate’s temperature has no direct effect on feeding tolerance. c. Aspirated stomach contents are assessed for amount, color, and consistency.This assists in the evaluation of the degree of digestion and absorption. d. Stools are assessed for consistency, amount, and frequency. This assists inthe evaluation of the degree of digestion and absorption.

23. Which of the following are common assessment findings of postmatureneonates?

(Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance ANS: a, b, c, d Feedback a. Vernix caseosa covers the fetus’s body around 17 to 20 weeks’ gestation; aspregnancy advances, the amount of vernix decreases. Vernix prevents water loss from the skin to the amniotic fluid; as the amount of vernix decreases, anincreasing amount of water is lost from the skin. This contributes to the dry and peeling skin seen in postmature neonates.

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b. Vernix caseosa covers the fetus’s body around 17 to 20 weeks’ gestation; as

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pregnancy advances, the amount of vernix decreases. c. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fatstores and glycemic stores. This results in the thin and wasted appearance ofthe neonate and risk for hypoglycemia during the first few hours post-birth. d. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fatstores and glycemic stores. This results in the thin and wasted appearance ofthe neonate and risk for hypoglycemia during the first few hours post-birth.

24. A nurse is caring for a 40 weeks’ gestation neonate. The neonate is 12 hours postbirth and has been admitted to the NICU for meconium aspiration.The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins ANS: a, b, d Feedback a. The presence of meconium in the neonate’s lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. b. The presence of meconium in the neonate’s lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. c. The presence of meconium in the neonate’s lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. d. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant production.

25. A nurse is completing the initial assessment on a neonate of a mother withtype I diabetes. Important assessment areas for this neonate include which ofthe following?

(Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system ANS: a, b, c, d Feedback a. Neonates of mothers with type I diabetes are at higher risk for cardiacanomalies. b. Neonates of mothers with type I diabetes are at higher risk for RDS due to adelay in surfactant production related to high maternal glucose levels.

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c. Neonates of mothers with type I diabetes are usually large and are at risk fora fractured clavicle. d. Neonates of mothers with type I diabetes are at higher risk for neurologicaldamage and seizures due to neonatal hyperinsulinism.

26. A baby was born 4 days ago at 34 weeks’ gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability.

The nurse’s priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby’s temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration.ANS: c, d There are two priority nursing interventions for hyperbilirubinemia. Hydration status is important if the newborn shows signs of dehydration such as dry skinand mucus membranes, poor intake, concentrated urine or limited urine output, and irritability. The newborn should also be kept warm while receivingphototherapy. When an infant is under phototherapy, the temperature needs tobe monitored closely because the lights give off extra heat, but if the newbornis in an open crib and undressed, hypothermia may occur.

Hypomagnesia and hypoglycemia are not related to phototherapy.

27. The perinatal nurse caring for Emily, a 24-year-old mother of an infant bornat 26 weeks’ gestation, is providing discharge teaching. Emily is going to travelto the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select allthat apply): a. In control b. Anxious c. Guilty d. Overwhelmed ANS: b, c, d Feedback a. Parents usually feel out of control. b. Correct answer. c. Correct answer. d. Correct answer.

28. A baby has just been admitted into the neonatal intensive care unit with adiagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) a. Cholecystitis

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b. Hypertension c. Cigarette smoker d. Candidiasis e. Cerebral palsy ANS: b, c Babies born to women with cholecystitis are not especially high risk for IUGR.Babies born to women with PIH or who smoke are high risk for IUGR. Babies born to women with candidiasis or cerebral palsy are not especially high risk for IUGR. Fill-in-the-Blank 29. The perinatal nurse assessing a newborn for jaundice recalls that _ conjugation _ is a process that converts the yellow lipid-soluble (nonexcretable)bilirubin pigment (present in bile) into a water-soluble (excretable) pigment. ANS: conjugation Conjugation of bilirubin constitutes a major function of the newborn’s liver. Conjugation is a process that converts the yellow lipid-soluble (nonexcretable)bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

30. Providing information to parents about jaundice constitutes an important component of the nurse’s discharge teaching. Ensuring that parents know when and who to call if their infant develops signs of jaundice will help decrease the risk of , or permanent brain damage.

ANS: kernicterus All newborns are screened before discharge for physiological jaundice. The central nervous system can be damaged from unconjugated bilirubin. If bilirubin crosses the blood–brain barrier, it can damage the cerebrum, causinga condition called kernicterus.

Kernicterus occurs from brain cell necrosis and can permanently damage a newborn, depending on the amount of time the neurons are exposed to bilirubin, the susceptibility of the nervous system, andthe function of the surviving neurons.

31. The NICU nurse recognizes that the infant who requires ventilation formeconium aspiration syndrome is most often .

ANS: post-term Meconium aspiration pneumonia occurs in 10% to 26% of all deliveries, andthe incidence increases directly with gestational age. (Before 37 weeks’ gestation there is a 2% incidence, and at 42 weeks’ gestation there is a 44%incidence.)

32. The NICU nurse’s patient assignment includes an infant who is 25 weeks’ gestation. The nurse knows that according to the gestational age, this infant would be described as .

ANS: very premature The definition of very premature is a neonate born at less than 32 weeks’

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gestation. The definition of premature is a neonate born between 32 and 34weeks’ gestation. The definition of late premature is a neonate born between34 and 37 weeks’ gestation.

33. Part of the assessment of a preterm infant includes obtaining an abdominalgirth measurement. The NICU nurse performs this assessment because the patient is at risk for .

ANS: necrotizing enterocolitis (NEC) When caring for a child with necrotizing enterocolitis, the nurse must measureand record frequent abdominal circumferences, auscultate bowel sounds before every feeding, and observe the abdomen for distention (observable loops or shiny skin indicating distention).