Maternal-Newborn Nursing : The Critical Components of Nursing
Care Testbank/Study Guide
Maternity Nursing Overview
Chapter 1. Trends and Issues
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1. Since 1995 there has been a significant decrease in the rate of infant death
related to which of the following:
a. Disorders associated with short gestation and low birth weight
b. Accidents
c. Sudden infant death
d. Newborns affected by complications of placenta, cord, and membranes
ANS: c
Feedback
a. The rates of prematurity and low birth weight are increasing.
b. The rates of accidents have increased.
c. Correct. The rate of infant death related to SIDS has decreased from 87.1 to
47.2. The decrease in rate is partially attributed to placing infants on their backs
when sleeping.
d. The rates of newborns affected by complications of placenta, cord, and
membranes have increased.
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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2. Tobacco use during pregnancy is associated with adverse effects on the
unborn infant such as intrauterine growth restriction, preterm births, and
respiratory problems. By race, which has the highest percentages of smokers?
a. American Indian and Alaskan Natives
b. Asian or Pacific Islanders
c. Non-Hispanic blacks
d. Non-Hispanic whites
ANS: a
Feedback
a. 36% of American Indian and Native American women are cigarette smokers.
b. 4.3% of Asian or Pacific Islander women are cigarette smokers.
c. 17.1% of non-Hispanic black women are cigarette smokers.
d. 19.6% of non-Hispanic white women are cigarette smokers.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
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3. Which of the following women is at the highest risk for health disparity?
a. A white, middle-class, 16-year-old woman
b. An African American, middle-class, 25-year-old woman
c. An African American, upper-middle-class, 19-year-old woman
d. An Asian, low-income, 30-year-old woman
ANS: d
Feedback
a. Although age is a risk factor, income contributes to disparity.
b. Although African American women are at increased risk, income accounts for
the largest disparity.
c. Although age and race contribute to increased risk, income accounts for the
largest disparity.
d. Although age and race contribute to increased risk, income accounts for the
largest disparity.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
4. A neonate born at 36 weeks gestation is classified as which of the following?
a. Very premature
b. Moderately premature
c. Late premature
d. Term
ANS: c
Feedback
a. Very premature is less than 32 weeks gestation.
b. Moderately premature is 32 to 33 completed weeks gestation.
c. Correct. Late premature is 34 to 36 completed weeks gestation.
d. Term is 37 to 42 weeks gestation.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Easy
5. The perinatal nurse explains to the student nurse that a goal of the Healthy
People 2020 report is to:
a. Increase proportion of infants who are breastfed to 93.1%.
b. Increase proportion of infants who are breastfed to 90.7%.
c. Increase proportion of infants who are breastfed to 85.6%.
d. Increase proportion of infants who are breastfed to 83.9%.
ANS: d
A goal of Healthy People 2020 is to increase the proportion of infants who are
breastfed from 74% to 81.9%.
KEY: Integrated Process: Teaching and Learning | Client Need: Health Promotion
and Maintenance | Cognitive Level: Application | Content Area: Maternity |
Difficulty Level: Moderate
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6. The perinatal nurse explains to the student nurse that __________ is the
leading cause of infant death in the United States.
a. Sudden Infant Death Syndrome
b. Respiratory distress of newborns
c. Disorders related to short gestation and low birth weight
d. Congenital malformations and chromosomal abnormalities
ANS: d
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Difficult
Multiple Response
7. Which of the following statements are true related to teen pregnancies?
(Select all that apply.)
a. Teen mothers are at higher risk for HIV.
b. Teen mothers are at higher risk for hypertensive problems.
c. The birth rate for teenaged women has increased in the past 15 years.
d. Infants born to teen mothers are at higher risk for health problems.
ANS: a, b, d
Health statistics report higher risk for HIV, for hypertensive problems, and for
health problems to infants born to teen mothers. Birth rates for teen mothers in all
age categories have decreased since 1991.
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Chapter 2. Ethics and Standards of Practice Issues
1. An ethical dilemma unique to perinatal nursing is the:a. Innate conflict between
maternal and fetal rights
b. Intensive use of technologyc. Shortage of health-care resourcesd. Risk of
violation of the principle of veracity
ANS: a
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.
2. The American Nurses Association Code of Ethics for Nurses directs nurses to
provide patient care that is:a. Curativeb. Utilitarianc. Negotiabled. Respectful
ANS: d
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 professions nonnegotiable standard
d. Respect for the inherent dignity, worth, and uniqueness of every individual is
part of the Code of Ethics.
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
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 evidencebased practice.
d. Clinical expertise, as well as clinical experience, defines evidence-based
practice.
4. Infants whose mothers were obese during pregnancy are at higher risk for
which of the following? (Select all that apply.)
a. Childhood diabetes
b. Heart defects
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.
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Antepartal Period
Chapter 3. Genetics, Conception, Fetal Development, and Reproductive
Technology
1. The color of a persons hair is an example of which of the following?a.
Genomeb. Sex-link inheritancec. Genotyped. Phenotype
ANS: d
Feedback
a. Genome is an organisms 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 persons genetic makeup.
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
2. Which of the following statements by a pregnant woman indicates she needs
additional teaching on ways to reduce risks 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 cats 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
uncooked 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 uncooked 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
uncooked 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 known as which of the following?a. Ductus venosusb.
Foramen ovalec. Ductus arteriosusd. 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.
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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 | Client Need: Physiological Adaptation | Difficulty Level:
Easy
4. A woman at 40 weeks 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
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. Cat
b. Dog
c. Hamster
d. Bird
ANS: a
Feedback
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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 take Clomiphene Citrate for infertility. Which of the following is the
expected action of this medication?
a. Decrease the symptoms of endometriosis
b. Increase serum progesterone levels
c. Stimulate release of FSH and LH
d. Reduce the acidity of vaginal secretions
ANS: c
Feedback
a. Clomiphene Citrate will not reduce a clients symptoms of endometriosis.
b. Clomiphene Citrate will not increase a clients 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 | Client Need: Physiological Integrity:
Pharmacological and Parenteral Therapies | Difficulty Level: Moderate
8. The nurse takes 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 amblyopia
b. Subdural hematoma
c. Sickle cell anemia
d. 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. Sickle 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
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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 follicle
b. Multiplication of the fimbriae
c. Secretion of human chorionic gonadotropin
d. Proliferation of the endometrium
ANS: d
Feedback
a. The maturation of the graafian follicle occurs during the follicular phase.
b. There is no such thing as the multiplication of the fimbriae.
c. Human chorionic gonadotropin is secreted by the fertilized ovum during the
early weeks 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 knows that the part of the endometrial cycle occurring from
ovulation to just prior to menses is known as the:
a. Menstrual phase
b. Proliferative phase
c. Secretory phase
d. Ischemic phase
ANS: c
Feedback
a. The menstrual phase is the time of vaginal bleeding, approximately days 1 to
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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 weeks gestation is approximately:
a. 500 mL
b. 750 mL
c. 800 mL
d. 1000 mL
ANS: c
Amniotic fluid first appears at about 3 weeks. There are approximately 30 mL of
amniotic fluid present at 10 weeks gestation, and this amount increases to
approximately 800 mL at 24 weeks 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 limbs
b. Cushions the fetus from mechanical injury
c. Promotes development of muscle tone
d. 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.
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 weeks
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b. 4 to12 weeks
c. 5 to 10 weeks
d. 6 to 15 weeks
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 likely 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 weeks gestation is:
a. The average fetal weight is 450 grams
b. Lanugo covers entire body
c. Brown fat begins to develop
d. Teeth begin to form
ANS: d
Feedback
a. The average fetal weight at 16 weeks is 200 grams.
b. Lanugo is present on the head.
c. Brown fat begins to develop at 20 weeks.
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
asks about caring for her cat as she has heard that she should not touch the cat
during pregnancy. The clinic nurses best response is:
a. It is best if someone other than you changes the cats 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-like 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 cats litter pan and also to avoid consuming uncooked
meat.
ANS: d
Feedback
a. The nurse should also explain that the patient should not eat uncooked meat
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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 like 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 cooked 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 mans
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
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 womans 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 working with an infertile couple has made the following nursing
diagnosis: Sexual dysfunction related to decreased libido. Which of the following
assessments is the likely 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
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a. Couples who schedule intercourse often complain that their sexual relationship
is unsatisfying.
b. Years of marriage are not directly related to a couples sexual relationship.
c. The fact that the couple lives with one set of parents is unlikely 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 couples
sexual relationship.
KEY: Integrated Process: Critical Thinking | 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
The highest oxygen concentration (PO2 = 3035 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 takes
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 __________ is
the hormone responsible for stimulating milk production.
ANS: prolactin
Following 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; chorion
The 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
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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 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 ovale
Blood 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 weeks of gestational age.
ANS: fetus
Major organs are being formed (organogenesis) during the first weeks following
fertilization. During this time, the developing organism is called an embryo. By the
end of 8 weeks, 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: teratogen
Teratogens (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 Area: Maternity | Client Need: Physiological Integrity | Difficulty Level:
Easy
25. __________ __________ __________ is when sperm and oocytes are mixed
outside the womans body and then placed into the fallopian tube via laparoscopy.
ANS: Gamete intrafallopian transfer
Gamete intrafallopian transfer, also referred to as GIFT, is used when there is a
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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 seeks 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 sampling
b. Endometrial biopsy
c. Hysterosalpingogram
d. 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
endometriums 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 seeking
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.)
a. Anger at others who have babies.
b. Feelings of failure because they cannot make 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.)
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a. Maternal age over 35 years
b. Partner who has a genetic disorder
c. Maternal type 1 diabetes
d. Paternal heart disease
ANS: a, b
Fertility decreases after 35 years. A partner contributes half of the chromosomal
makeup, 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 phase
b. Secretory phase
c. Ovulatory phase
d. Luteal phase
e. Menstrual phase
ANS: a, c, d
Follicular phase, ovulatory phase, and luteal phase are part of the ovarian cycle.
Secretory 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 workup. 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 bike to and from work each day.
b. The man takes a calcium channel blocker for the treatment of hypertension.
c. The man drinks 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, b
The daily riding of a bike 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 blockers, 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 mans 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 |
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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 pregnancy
b. Are awaiting genetic testing results
c. Are experiencing a first pregnancy
d. Are trying to conceal this pregnancy as long as possible
ANS: b, d
A second pregnancy is not an indication of a woman in need of additional
support. A support system may be lacking for women who are trying to conceal a
pregnancy or for women who are trying to keep the news of their pregnancy from
relatives or friends until results from genetic tests are known. 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: Comprehension | Content Area: Maternity
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Chapter 4. Physiological Aspects of Antepartum Care
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.
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
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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 pseudoanemia 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.
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d. IPV crosses all ethnic, racial, religious, and socioeconomic levels.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level:
Moderate
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 Leopolds 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:
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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 nurses 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.
c. This is abnormal; tell the doctor about this problem because diagnostic testing
may be necessary.
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.
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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. Tamaras 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
ANS: b
Feedback
a. The values are low normal for adults but represent normal findings for
pregnant women.
b. During pregnancy the womans 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 pseudoanemia. 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 womans 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
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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 nurses hands are placed on the maternal
abdomen to gently palpate the fundal region of the uterus. This action is best
described as the:
a. First maneuver
b. Second maneuver
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 patients 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
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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: Application | Content Area: Maternity | Client Need: Safe and Effective
Care Environment | Difficulty Level: Moderate
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. Linas 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
nurses 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 nurses responsibility to provide education and
counseling concerning dietary intake, weight management, and potentially
harmful nutritional practices. To facilitate this process, it is the nurses
responsibility to gather more information on the womans dietary practices
through a food diary.
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b. Nutrition and weight management play an essential role in the development of
a healthy pregnancy. To facilitate this process, it is the nurses 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 nurses 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 nurses 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
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 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
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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 Leopolds 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.
b. The fetal attitude is flexed.
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
Leopolds 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
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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
a. A body mass index of 23 is normal.
b. A blood pressure of 100/60 is normal.
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.
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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 Level: Easy
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. Leopolds 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 Naegeles rule, which of the following would the nurse
determine to be the patients estimated date of delivery (EDC)?
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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. Naegeles 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
24. Which of the following findings, seen in pregnant women in the third trimester,
would the nurse consider to be within normal limits?
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.
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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
ANS: c
Feedback
a. The etiology of developmental dysplasia of the hip is unrelated to the mothers
nutritional status.
b. Achondroplasia is an inherited defect. Its etiology is unrelated to the mothers
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 mothers 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 patients 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.
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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 hormone tested forhuman chorionic gonadatropin (hCG)may be
being produced by, for example, a hydatidiform mole.
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. cup vanilla yogurt
c. 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 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?
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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.
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 PotentialPotential 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?
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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 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.
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.
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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, changes that allow bacterial
ascent into the bladder.
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 22year-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
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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. Suzys nausea and vomiting are most likely
caused by (select all that apply):
a. Increased levels of estrogen
b. Increased levels of progesterone
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
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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 estrogen-induced 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.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
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 womans 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
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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
c. The use of cock splints to prevent wrist flexion
d. Massaging the hands and wrists with alcohol
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
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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 | Difficulty Level: Moderate
45. The clinic nurse schedules Tracy for her first prenatal appointment with the
certified nurse-midwife (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 womans journey through the pregnancy experience can have long-term effects
on her self-perception 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
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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
b. Hemorrhage
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
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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
Anticipatory guidance for urinary tract infection prevention includes delaying
urination, wipe front to back, and maintaining adequate hydration.
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
Jorginas 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 Jorginas 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
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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 pregnant woman. Kim-Lys hemoglobin is 9.8 g/dL. This laboratory
finding places Kim-Lys pregnancy at risk for (select all that apply):
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 bloods 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 firsttrimester 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
Teeras 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.
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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
55. During the initial antenatal visit, the clinic nurse asks questions about the
womans 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
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.
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
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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
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
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.
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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
64. Cecilia, a pregnant woman at 30 weeks gestation, has her vital signs
assessed during a routine prenatal visit. Cecilias blood pressure has remained at
110/70 for the last few visits, and 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.
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Chapter 5. The Psycho-Social-Cultural Aspects of the Antepartum Period
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 maternalfetal adaptation.
b. Delusions are not real, and the fetus is real.
c. Correct, because talking 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: Moderate
2. What is the most common expected emotional reaction of a woman to the
news that she is pregnant? a. Jealousyb. Acceptancec. Ambivalenced.
Depression
ANS: c
Feedback
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 weeks gestation? 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
womans 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 awkwardness and
bulkiness and may require couples to modify intercourse positions for the
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pregnant womans 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 tasks.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 tasks of 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
tasks 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. Janes husband Brian has begun to put on weight. What is this a possible sign
of? a. Culturalism syndromeb. Couvade syndromec. Moratorium phased.
Attachment
ANS: b
Feedback
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 fathers 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 asks you what she should do to help him get ready for the
expected birth. What is the nurses 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 Stevens 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
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attachment. d. Steven should be encouraged to plan an elaborate welcome for
the newborn.
ANS: b
Feedback
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 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 knows that this is an
example of:a. Cultural prescriptionb. Cultural tabooc. Cultural restrictiond.
Cultural demonstration
ANS: a
Feedback
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. Drinking chamomile tea would not be in this category.
c. Restrictions are activities during the childbearing period which are limited for
the pregnant woman. Drinking 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: b
Feedback
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.
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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 weeks 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. Ive started calling my mom
every day.c. My partner and I cant stop talking about the baby.d. I still dont know
much time Im going to take off work after the baby comes.
ANS: a
Feedback
a. Experiencing quickening 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 20 weeks 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 asks the nurse why she should attend childbirth classes.
The nurses response would be based on which of the following information? a.
Attending childbirth class is a good way to make new friends.b. Childbirth classes
will help new families develop skills 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: b
Feedback
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 linking attendance at childbirth
classes with a decreased incidence of cesarean section and shorter labors.
d. Evidence remains inconclusive regarding linking attendance at childbirth
classes with 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 weeks gestation by LMP. Which of
the following findings would the nurse expect to see?
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a. Multiple pillow orthopnea
b. Maternal ambivalence
c. Fundus at the umbilicus
d. Pedal and ankle edema
ANS: b
Feedback
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 fundus should be at the umbilicus at 20 weeks 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 likely to exhibit
which of the following symptoms or behaviors?
a. Urinary frequency
b. Hypotension
c. Bradycardia
d. Prostatic hypertrophy
ANS: a
Feedback
a. Urinary frequency is a common symptom of couvade.
b. The fathers blood pressure is not usually affected.
c. The fathers 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
weeks gestation, the nurse would expect to observe which of the following signs?
a. Ambivalence
b. Depression
c. Anxiety
d. Happiness
ANS: d
Feedback
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
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14. An example of a cultural prescriptive belief during pregnancy is:
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
ANS: a
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.
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 consequences
b. Have serious clinical consequences
c. Have superstitious consequences
d. Are functional and neutral practices
ANS: 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.
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 weeks gestation with her first pregnancy. The clinic nurses 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 cant 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 and
then weekly.
d. Jenny, by your information, you are 31 weeks gestation in this pregnancy. Do
you have questions for me before I begin your prenatal history and information
sharing?
ANS: d
Feedback
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 care and not making assumptions about
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prior care. The prenatal nurses 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 nurses 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 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
ANS: b
Feedback
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 tasks. 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 father in (select all that apply):
a. Prenatal visits
b. Ultrasound appointments
c. Prenatal class information
d. History taking and obtaining prenatal screening information
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ANS: b, c, d
Pregnancy 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 fathers 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 fathers)
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. Adolescence
b. Low educational level
c. History of depression
d. A strong support system for the pregnancy
ANS: a, b, c
Maternal 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 patients ability to bond with and care for the infant. A
strong support system can facilitate the patients 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
20. Strategies for culturally responsive care include (select all that apply):
a. Practicing ethnocentrism
b. Applying stereotyping
c. Examining ones own biases
d. Learning another language
ANS: c, d
The only actions among the choices that are culturally responsive are examining
ones own biases and learning another language. Ethnocentrism and stereotyping
are not culturally responsive actions.
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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 talks with Becky, a 16-year-old woman who is now 28 weeks
gestation. Todays visit is only the second prenatal appointment that Becky has
kept. The nurse wonders if Beckys failure to come for routine prenatal checks is,
in part, related to an adolescents orientation to the __________, rather than to
the __________.
ANS: present; future
The 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 known as
__________.
ANS: self-concept; binding in
The mother-to-be needs to accept the pregnancy and incorporate it into her own
reality and self-concept. This process is known as binding in. 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
23. The clinic nurse asks 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; increases
Intimate 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 womens advocate, nurses have a duty to
be observant, to actively listen, and to use communication skills to gain
clarification and understanding.
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Chapter 6. Antepartal Tests
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 babys
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.
ANS: b
Feedback
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 weeks 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 reply by the nurse is: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 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: b
Feedback
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: d
Feedback
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
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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 weeks pregnant and during a regular prenatal visit tells you
she does not understand how to do kick counts. The best response by the nurse
would be to explain: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 twice a
day, and you should feel 10 fetal movements in 2 hours.
ANS: d
Feedback
a. Providing written information may not be enough, and the patient may need a
verbal explanation.
b. Kick counts are indicated for all pregnancies.
c. Kick counts are a reliable indicator of fetal well-being after 32 to 34 weeks
gestation.
d. This response provides the patient with information on how to do kick counts
and the rationale for doing kick 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 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 available more quickly.
ANS: d
Feedback
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
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experiencing her first pregnancy. Rebeccas quadruple marker screen result is
positive at 17 weeks gestation. The nurse explains that Rebecca needs a referral
to:
a. A genetics counselor/specialist
b. An obstetrician
c. A gynecologist
d. A social worker
ANS: a
Feedback
a. All women should be offered screening with maternal serum markers. The
Triple Marker screen and the Quadruple Marker screen test for the presence of
alpha-fetoprotein (AFP), estradiol, human chorionic gonadotropin (hCG), and
other markers. 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 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 weeks 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 site
b. Macular rash on the abdomen
c. Decrease in urinary output
d. Cramping of the uterus
ANS: d
Feedback
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:
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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 babys lung fields are mature.
b. The mother is high risk for hemorrhage.
c. The babys kidneys are functioning poorly.
d. The mother is high risk for eclampsia.
ANS: a
Feedback
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
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 risk for decreased respiratory 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 membranesb.
Gestational diabetesc. Ectopic pregnancyd. Pregnancy-induced hypertension
ANS: c
Feedback
a. Multiple partners do not increase a womans risk of premature rupture of
membranes.
b. Genetics and client diet and weight are contributing factors to 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 blockage, 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 bleedingb. Board-like abdomen with
severe painc. Sudden onset of bright red vaginal bleedingd. 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.
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b. The hallmark for abruptio placenta is pain and a board-like 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
BPMb. FHR moderate variability without accelerationsc. Dark brown vaginal
discharge when voidingd. Oral temperature of 99.9F
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 clients hydration status. It should
be reassessed. Cause for concern is a temperature of 100.4F 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.
Hyperglycemiab. IUGRc. Hypoglycemiad. 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
ANS: a
Feedback
a. Correct. The client is at high risk for hypovolemia which is life threatening and
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takes 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 clients 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 clients
blood glucose levels?a. Nifedipineb. Betamethasone c. Magnesium sulfated.
Indomethacin
ANS: b
Feedback
a. Nifedipine does not affect maternal blood glucose levels.
b. Beta-sympathomimetics 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
9. While educating the client with class II cardiac disease, at 28 weeks gestation,
the nurse instructs the client to notify the physician if she experiences which of
the following conditions? a. Emotional stress at workb. Increased dyspnea while
restingc. Mild pedal and ankle edemad. Weight gain of 1 pound in 1 week
ANS: b
Feedback
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a. Emotional stress increases cardiac workload; 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 working 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 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
ANS: d
Feedback
a. This finding is normal. Quickening is usually felt between 16 and 20 weeks
gestation.
b. This finding is normal. The fundal height at 20 weeks 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 womans 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 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 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
ANS: d
Feedback
a. Preterm labor (PTL) is defined as regular uterine contractions and cervical
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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 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. They may 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 of elevated 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 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
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 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
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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
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 increases
b. Diarrhea
c. Urticaria
d. Complaints of nervousness
ANS: 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 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 measurements
b. Profuse vaginal bleeding
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c. Bradycardia with an aortic thrill
d. 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 likely
contributed to these findings?
a. Pyelonephritis
b. Pregnancy-induced hypertension
c. Gestational diabetes
d. 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 | 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 physicians order for beta agonist tocolytics?
a. Type 1 diabetes mellitus
b. Cerebral palsy
c. Myelomeningocele
d. Positive group B streptococci culture
ANS: 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 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
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
19. 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 assess in relation to this diagnosis?
a. Human relaxin levels
b. Amniotic fluid levels
c. Alpha-fetoprotein levels
d. 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.
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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 Risk Potential | 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 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. The nurse 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 polycythemia
ANS: c
Feedback
a. A rise in serum creatinine indicates that the kidneys are not effectively
excreting creatinine. It is a negative outcome.
b. A drop in serum protein indicates that the kidneys 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
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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 leukocyte count
b. Explosive diarrhea
c. Fractured pelvis
d. Low platelet count
ANS: 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, 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 weeks gestation is diagnosed with gestational trophoblastic
disease (hydatiform mole). 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 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 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 sexually transmitted infection
(STI) control issues is needed?
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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 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 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 effective infectioncontrol 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 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 following maternal vital signs is most important for the
nurse to assess each hour?
a. Temperature
b. Pulse
c. Respiratory rate
d. 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
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26. 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?
a. Elevate head of the bed
b. Notify the MD
c. Discontinue magnesium sulfate
d. 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-weeks 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. Kyphosis
b. Urinary tract infection
c. Congestive heart failure
d. Cerebral palsy
ANS: b
Feedback
a. Kyphosis is unrelated to preterm labor.
b. Urinary tract infections often precipitate preterm labor.
c. It is unlikely 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 weeks 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
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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 weeks 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 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 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 hemorrhage
b. Neonatal hyperglycemia
c. Postpartum oliguria
d. 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:
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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. Take the patients 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
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 taken
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 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 weeks gestation. The nurse
is preparing to administer the second dose of beta-methasone prescribed by the
physician. Marilyn asks: What is this injection for again? The nurses best
response is:
a. This is to help your babys 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
weeks 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
weeks and childbirth can be delayed for 48 hours.
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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
weeks and childbirth can be delayed for 48 hours.
d. 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
weeks 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 weeks 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 chloasma
b. Presence of severe heartburn
c. 10-pound weight gain in a month
d. Patellar reflexes +1
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 Risk Potential: 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 anomalies
b. Infection
c. Increased BMI
d. Prior preterm birth
ANS: d
The 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 weeks 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?
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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 patients 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.
KEY: Integrated Process: Critical Thinking | 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. lower
b. increase
c. maintain
d. 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: FalseThere 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.
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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
39. 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 24 weeks gestation.
ANS: False
Placenta previa should be suspected in all patients who present with bleeding
after 24 completed weeks 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 knows that the survival rate for infants born at or greater
than 28 to 29 gestational weeks 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 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 patients 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 patients 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 knows that the laboring diabetic patients blood glucose
level should always be less than 120 mg/dL.
ANS: True
Blood 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
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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 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 35 years.
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 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 weeks
gestation. An appropriate nursing action would be to (select all that apply):
a. Assess the fetal heart rate
b. Obtain urine for culture and sensitivity
c. Assess Kerrys blood pressure and pulse
d. Palpate Kerrys abdomen for contractions
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Intrapartal Period
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Chapter 8. Intrapartum Assessment and Interventions
1. In caring for a primiparous woman in labor, one of the factors to evaluate is
uterine activity. This is referred to as the __________ of labor.a. Passengerb.
Passagec. Powersd. Psyche
ANS: c
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 anxiety and 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 a Doula 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 false labor, 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 show, 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 no
cervical changes.
ANS: d
Feedback
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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 by expectations 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 labor there 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 fetus goes 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 occurs early 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 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 the anteroposterior 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
of the 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
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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 2 to 5 minutes with duration of 45 to 60
seconds.d. Cervical dilation progresses to 10 cm with effacement of 90%,
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% to 80%. Fetal descent
continues and contractions become more intense, occurring every 2 to 5 minutes
with duration 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
6. You are caring for a woman in labor who is 6 cm dilated with a reassuring FHT
pattern and regular strong 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 not indicated continuously.
b. Assessment of fetal heart rate (FHR) during the active phase of labor with a
reassuring FHR is not indicated every 15 minutes.
c. Assessment of fetal heart rate (FHR) during the active phase of labor with a
reassuring FHR is indicated every 30 minutes.
d. Assessment of fetal heart rate (FHR) during the active phase of labor with a
reassuring FHR is indicated 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 change after epidural placement:a. Blood
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pressure, hypotension
b. Blood pressure, hypertension
c. Pulse, tachycardia
d. Pulse, bradycardia
ANS: 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 bolus is typically given to
decrease the incidence of hypotension.
b. Blood pressure, hypertension is incorrect because hypotension is the common
complication after epidural placement.
c. Pulse, tachycardia is incorrect because hypotension is the common
complication after epidural placement.
d. Pulse, bradycardia is incorrect because hypotension is the common
complication after epidural placement.
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 indicated she 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 to assess 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 the bathroom to urinate.
c. Assessing the fetal heart rate is the first priority because of the risk of umbilical
cord prolapse with rupture of membranes.
d. Although you may call the care provider, the priority nursing action is to assess
the FHR because of the risk 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
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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.
ANS: d
Feedback
a. Completing the admission paperwork is not a priority when birth may be
imminent.
b. The urge to have a bowel movement is probably related to fetal descent and
complete dilation rather than 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 and feeling 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, respiratory rate, 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, is assessed.
b. Clarity of lungs and reflexes are not assessed as part of Apgar scoring.
Neonatal lungs can be congested normally at birth, and reflexes are not
assessed. Rather, reflex irritability is assessed, based on response to tactile
stimulation.
c. Heart rate, not apical pulse strength, is assessed along with respiratory rate,
muscle tone, reflex irritability, 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, reflex irritability 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 the
health-care provider reveals that the cervix is closed, long, and posterior. The
most likely diagnosis would be:
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a. Preterm labor
b. Term labor
c. Back labor
d. Braxton-Hicks 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 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. They may 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 of elevated 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 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
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
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(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 +4
b. Urinary output of 50 mL/hr
c. Respiratory rate of 10 rpm
d. Serum magnesium level of 5 mg/dL
ANS: 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. 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 increases
b. Diarrhea
c. Urticaria
d. Complaints of nervousness
ANS: 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
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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 measurements
b. Profuse vaginal bleeding
c. Bradycardia with an aortic thrill
d. 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 likely
contributed to these findings?
a. Pyelonephritis
b. Pregnancy-induced hypertension
c. Gestational diabetes
d. 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 | Content Area: Antepartum Care; Physiological Adaptation:
Alterations in Body Systems | Client Need: Health Promotion and Maintenance;
Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult
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17. For the patient with which of the following medical problems should the nurse
question a physicians order for beta agonist tocolytics?
a. Type 1 diabetes mellitus
b. Cerebral palsy
c. Myelomeningocele
d. 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 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 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
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
19. 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 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 and Maintenance;
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 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.
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. The nurse 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 polycythemia
ANS: c
Feedback
a. A rise in serum creatinine indicates that the kidneys are not effectively
excreting creatinine. It is a negative outcome.
b. A drop in serum protein indicates that the kidneys are allowing protein to be
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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 leukocyte count
b. Explosive diarrhea
c. Fractured pelvis
d. Low platelet count
ANS: 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, 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 weeks gestation is diagnosed with gestational trophoblastic
disease (hydatidiform mole). 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 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 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.
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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 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 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 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 effective infectioncontrol 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 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 following maternal vital signs is most important for the
nurse to assess each hour?
a. Temperature
b. Pulse
c. Respiratory rate
d. 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.
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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 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
27. A labor nurse is caring for a patient, 39 weeks 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 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
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IntegrityReduction of Risk Potential; Safe and Effective Care
EnvironmentManagement of Care | Difficulty Level: Moderate
28. 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 hemorrhage
b. Neonatal hyperglycemia
c. Postpartum oliguria
d. 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 IntegrityPhysiological Adaptation | Difficulty Level: Difficult
29. According to agency policy, the perinatal nurse provides the following
intrapartal nursing care for the patient 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 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 taken
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 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
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30. A woman who is 36 weeks 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 chloasma
b. Presence of severe heartburn
c. 10-pound weight gain in a month
d. Patellar reflexes +1
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 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 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
the SVE, Ms. M states that she had been contracting since early that morning
and she becomes extremely frustrated stating I should have had this baby by
now. What is the best 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 labor
ANS: 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 is attempting to breastfeed her newborn daughter for the
first time. Which action by the nurse would NOT be appropriate?
a. The nurse is checking the BP every 15 minutes
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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
newborn
ANS: d
During the fourth stage of labor the mothers should not be left unattended as
maternal bleeding needs to be 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 to do which of the following?
a. Assess and massage the fundus every 15 minutes or more often if needed
b. Massage the uterus continuously
c. Administer oxytocin per protocol
d. Assess the patient for a distended bladder
a.A, c
b.A, c, d
c.C, d
d.all of the above
ANS: b 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.
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 phase
ANS: 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 the pelvic floor muscles and triggers the
Ferguson reflex.
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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 were pink 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.
d. Does it burn when you urinate?
ANS: b
The nurse is using reflection to acknowledge the womans concerns and asks for
further assessment. The womans 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 | Client Need: Psychological Integrity | Difficulty Level: Moderate
Multiple Response
36. The perinatal nurse describes risk factors for placenta previa to the student
nurse. Placenta previa risk factors 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 35 years.
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 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
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 be to (select all that apply):
a. Assess the fetal heart rate
b. Obtain urine for culture and sensitivity
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c. Assess Kerrys blood pressure and pulse
d. Palpate Kerrys abdomen for contractions
ANS: 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 without diarrhea. 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 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 patients
abdomen should be palpated to assess for contractions, 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 without diarrhea. 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 facility
ANS: c, d
Feedback
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.
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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 about preterm labor and birth 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 5 minutes
ANS: a, b, c
Feedback
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; drinking fluids, not withholding fluids; and counting fetal
movements if contractions occur every 5 minutes are recommended if a woman
thinks she is contracting.
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 premature preterm rupture of membranes. These risks include
(select all that apply):
a. Chorioamnionitis
b. Abruptio placentae
c. Operative birth
d. Cord prolapse
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ANS: 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 cord prolapse.
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
uterus
ANS: 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 gestation
ANS: 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 spots
ANS: 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
44. A disease characterized by an abnormal placental development that results in
the production of fluid-filled grapelike clusters and a vast proliferation of
trophoblastic tissue
ANS: Hydatidiform mole/Gestational trophoblastic disease
Refer 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 a pregnancy 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 cervix
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ANS: 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. 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 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 24 weeks gestation.
ANS: False
Placenta previa should be suspected in all patients who present with bleeding
after 24 completed weeks 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
49. The perinatal nurse knows that the survival rate for infants born at or greater
than 28 to 29 gestational weeks 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 of gestation.
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
__________ weeks, and a late pregnancy loss is one that occurs between 12
and __________ weeks.
ANS: 12; 20
Not 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
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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 means that 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 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
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% 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 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 of
the placenta.
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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
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 revealed or external hemorrhage, where
the blood dissects downward toward the cervix.
Feedback 2: The most common abruption is associated with a revealed or
external hemorrhage, where the blood 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 that provoke 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 cervical change
c. Cervical dilation from 8 to 10 cm, contractions every 1 to 2 minutes. Woman
may be panicky and irritable.
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
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57. c
58. b
59. a
Third stage of labor: Begins immediately after the delivery of the fetus and
involves separation and expulsion 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 cm
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Chapter 9. Fetal Heart Rate Assessment
Multiple Choice
1. 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:
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 provider
ANS: a
Feedback
a. Accelerations are a sign of fetal well-being.
b. Accelerations are a sign of fetal well-being and are reassuring.
c. Accelerations may or may not be associated with uterine contractions.
d. Accelerations are reassuring, and there is no need to notify the care provider.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
2. The nurse knows that a FHR monitor printout indicates a Category III abnormal
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 decelerations
ANS: a
Feedback
a. Minimal or absent baseline variability may be an indication of fetal hypoxia.
b. This answer describes early decelerations that are not 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
3. As the nurse explains the purpose of the tocotransducer (Toco), which she
places 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
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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 pressure
catheter (IUPC).
d. Progress of labor is evaluated with a sterile vaginal examination (SVE).
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Basic Care and Comfort | Difficulty Level:
Easy
4. Early decelerations are probably caused by:
a. Decreased maternalfetal 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 maternalfetal exchange results in late decelerations.
b. Umbilical cord occlusion results in variable deceleration or bradycardia.
c. Early decelerations are related to increased intracranial pressure due to head
compression.
d. Compression of the umbilical cord results in variable decelerations.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
5. Which statement correctly describes the nurses responsibility related to
electronic fetal monitoring?
a. Teach the woman and her family about the monitoring equipment and discuss
any questions they have.
b. Report abnormal findings to the care provider before initiating corrective
actions.
c. Inform the support person that the nurse will be responsible for all comfort
measures when the electronic equipment is in place.
d. Document the frequency, duration, and intensity of contractions measured by
the external device.
ANS: a
Feedback
a. Teaching is an essential part of the nurses role.
b. Corrective measures for a non-reassuring fetal heart rate are done before
notifying a provider.
c. The support person can help to provide comfort measures for women in labor.
d. Only an IUPC will measure the intensity of uterine contractions.
KEY: Integrated Process: Teaching and Learning | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Basic Care and Comfort
| Difficulty Level: Difficult
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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 fetal
heart 124 with moderate variability.
5 p.m. assessment: cervix 6 cm, 90% effaced, 3 station, and fetal heart 120 with
minimal variability.
10 a.m. assessment: cervix 8 cm, 100% effaced, 3 station, and fetal heart 124
with 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.
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, the baby
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 has
reached 10 cm dilation. Plus, the fetal station is still 3.
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: Difficult
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 womans 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 as quickly
as possible in order to reverse the problem.
KEY: Integrated Process: 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: Intrapartum Care; Physiological Integrity: Reduction of Risk
Potential | Difficulty Level: Moderate
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?
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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 patients blood pressure will need to be monitored, but a manual cuff is
sufficient.
b. There is a possibility of uterine rupture during an amnioinfusion. An internal
pressure transducer, therefore, must be inserted to monitor the patients
intrauterine pressures.
c. The womans oxygen saturation levels need not be monitored during the
amnioinfusion.
d. Because the womans membranes are already ruptured, there is no need for a
Nitrazine test to be performed.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Intrapartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
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
c. Request that the physician/certified nurse-midwife come to the hospital STAT
d. Document the fetal heart rate and variability
ANS: a
Feedback
a. Because Category II fetal heart rate patterns could deteriorate, they constitute
a risk indicator for fetal hypoxia, the nurse should change the womans 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, not decrease, the IV
infusion to increase perfusion through the placenta.
c. The scenario described does not require STAT intervention but continued
assessment after intrauterine resuscitation interventions.
d. Documentation of the FHR is important but not the most important action in
this scenario.
Fill-in-the-Blank
10. The perinatal nurse assists the nursing student who is preparing the patient
with oligohydramnios for a fluid infusion into the uterine cavity. This procedure is
described as a(n) __________.
ANS: amnioinfusion--Pregnancy outcome in patients experiencing variable fetal
heart rate decelerations caused by cord compression is improved through the
use of amnioinfusion, which is the instillation of normal saline or lactated Ringers
solution into the uterine cavity.
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Chapter 10. High-Risk Labor and Birth
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 2
minutes 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 physicians 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 the
correct 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies |
Difficulty Level: Moderate
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 the cord.
ANS: d
Feedback
a. Type and cross-match is one of the interventions with cord prolapse but not a
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 cord
represents the first nursing intervention to attempt to improve circulation to the
fetus.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
3. Augmentation of labor:
a. Is part of the active management of labor instituted when the labor process is
unsatisfactory and uterine contractions are inadequate
b. Relies on more invasive methods when oxytocin and amniotomy have failed
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c. Is elective induction of labor
d. Is an operative vaginal delivery that uses vacuum cups
ANS: a
Feedback
a. Augmentation stimulates uterine contractions after labor has started but not
progressed appropriately.
b. Augmentation uses amniotomy and oxytocin.
c. Augmentation stimulates labor.
d. Vacuum delivery is not part of augmentation of labor.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
4. 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 implications
from hypotonic labor patterns are:
a. Intrauterine infection and maternal exhaustion with fetal distress usually
occurring early in labor.
b. Intrauterine infection and maternal exhaustion with fetal distress usually
occurring late in labor.
c. Intrauterine infection and postpartum hemorrhage with fetal distress early in
labor.
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 in
early labor.
d. Hypotonic patterns do not result in rupture of the uterus.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty
Level: Moderate
5. A primigravida woman at 42 weeks gestation received Prepidil (dinoprostone)
for induction 12 hours ago. The Bishop score is now 3. Which of the 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 have
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ruptured.
b. Little progress has taken place. The Bishop score of a primigravida will need to
be 9 or higher before oxytocin will be effective.
c. There is nothing in the scenario that implies that the patient needs to be placed
on her side.
d. The Bishop score of a primigravida will need to be 9 or higher before oxytocin
will be effective.
KEY: Integrated Processes: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Intrapartum Care; Pharmacological and Parenteral
Therapies: Unexpected Response to Medication | Client Need: Health Promotion
and Maintenance; Physiological Integrity: Pharmacological and Parenteral
Therapies | Difficulty Level: Difficult
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 was
delivered by forceps.
c. There is nothing in the scenario that implies that the patient is at risk for
impaired parenting.
d. There is nothing in the scenario that implies that the patient is at risk for
ineffective individual coping.
KEY: Integrated Process: Nursing Process: Analysis | 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:
Moderate
7. Four women are close to delivery on the labor and delivery unit. The nurse
knows 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 that morning
c. 40-week-gestation pregnancy with estimated fetal weight of 3200 grams
d. 39-week-gestation pregnancy complicated by maternal cholecystitis
ANS: a
Feedback
a. A post-term baby with intrauterine growth restriction (IUGR) is high risk for
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meconium 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.
KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Planning |
Cognitive Level: Analysis | Content Area: Intrapartum Care; Potential for
Alterations in Body Systems; Reduction of Risk Potential: Potential for
Complications of Delivery | Client Need: Health Promotion and Maintenance;
Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult
8. You are caring for a primiparous woman admitted to labor and delivery for
induction of labor at 42 weeks gestation. She asks you to explain the factors that
contribute to prolonged labor. The best response would be to state the following:
a. Primiparous women are not at risk for dystocia because they usually have
small babies.
b. Dystocia is related to uterine contractions, the pelvis, the fetus, the position of
the mother, and psychosocial response.
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. The success
of any labor depends on the complex interrelationship of several factors: fetal
size, presentation, position, size and shape of the pelvis, and quality of uterine
contractions.
c. Pelvic abnormality is the least important contributor to dystocia.
d. Dystocia is diagnosed during, not prior to, labor.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application
and Comprehension | Content Area: Maternity | Client Need: Psychosocial
Integrity | Difficulty Level: Difficult
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 98.6F, 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 minutes
ANS: d
Feedback
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a. A Bishop score of 9 or higher indicates that the primigravida womans cervix is
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.
KEY: Integrated Process: Nursing Process: Analysis; Nursing Process:
Implementation | Cognitive Level: Application | Content Area: Intrapartum Care;
Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications |
Client Need: Health Promotion and Maintenance; Physiological Integrity:
Pharmacological and Parenteral Therapies | Difficulty Level: Difficult
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 situations should
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
vaginal delivery.
d. A positive vaginal Candidiasis culture is not an indication for cesarean birth.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Comprehension | Content Area: Intrapartum Care | Client Need: Health
Promotion and Maintenance | Difficulty Level: Moderate
11. The physician has ordered intravenous oxytocin for induction for four
gravidas. In which of the following situations should the nurse refuse to comply
with 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 streptococci
ANS: 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 will have
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.
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KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Adverse Effects/Contraindications; Intrapartum Care;
Pharmacological and Parenteral Therapies: Intravenous Therapies | Client Need:
Health Promotion and Maintenance; Physiological Integrity: Pharmacological and
Parenteral Therapies | Difficulty Level: Difficult
12. The perinatal nurse notes a rapid decrease in the fetal heart rate that does
not recover immediately following an amniotomy. The most likely cause of this
obstetrical 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 after
the artificial rupture of membranes. Changes such as transient fetal tachycardia
may occur and are common. However, other FHR patterns such as bradycardia
and variable decelerations may be indicative of cord compression or 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 this
scenario, prolapsed cord is the most likely cause of the abrupt deceleration in the
FHR.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
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 nurses most appropriate
action is to notify the physician/certified nurse midwife and describe a:
a. Need for vaginal assessment and repair
b. Requirement for an oxytocin infusion
c. Need for further information for the woman/family about forceps
d. Requirement for bladder assessment and catheterization
ANS: a
Feedback
a. In the presence of a firm fundus and bright red bleeding, after a forcepsassisted birth there is a need for vaginal assessment and there may be a need
for 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 the
bleeding.
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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Peds/Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Moderate
14. The perinatal nurse is providing care to Carol, a 28-year-old multiparous
woman in 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
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 lasts less 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 labor
with 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
Multiple Response
15. Hyperstimulation is defined as:
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/Hg
ANS: 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 hyperstimulation. Uterine resting tone below 20 mm/Hg reflects normal
uterine resting tone.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
16. Documentation related to vacuum delivery includes which of the following:
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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 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.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
17. Contraindications for induction of labor include:
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 because of
the risk of fetal injury and placental abnormalities because of the risk of
hemorrhage. Pregnancy-induced hypertension and placental abnormalities are
two of the common indications for induction of labor.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Reduction of Risk
Potential | Difficulty Level: Difficult
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 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.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
True/False
19. The perinatal nurse includes the following when explaining the physiology of
artificial rupture of membranes to the student nurse: rupture of membranes
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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 the
membranes, may be successful in increasing uterine contractility.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
20. The perinatal nurse describes asynclitism to students as a presentation that
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 presenting
part. These presentations are uncommon and are usually associated with fetal
anomalies.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
21. The perinatal nurse explains to the student nurse that the most frequent fetal
risk associated with the use of forceps is cord compression.
ANS: False
The most frequent fetal risk associated with the use of forceps is superficial scalp
or facial marks that will resolve quickly.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
Fill-in-the-Blank
22. The perinatal nurse prepares for two potential complications that may
accompany a precipitous labor and birth: postpartum __________ and a need for
neonatal __________.
ANS: hemorrhage; resuscitation
Feedback 1: Complications from a precipitate labor pattern result from trauma to
maternal tissue and to the fetus because of the rapid descent. Hemorrhage may
occur from uterine rupture and vaginal lacerations. The fetus may suffer from
hypoxia related to the decreased periods of uterine relaxation between the
contractions and intracranial hemorrhage related to the rapid birth.
Feedback 2: Complications from a precipitate labor pattern result from trauma to
maternal tissue and to the fetus because of the rapid descent. Hemorrhage may
occur from uterine rupture and vaginal lacerations. The fetus may suffer from
hypoxia related to the decreased periods of uterine relaxation between the
contractions and intracranial hemorrhage related to the rapid birth.
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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
23. The perinatal nurse understands that the most appropriate nursing action
following an amniotomy is an assessment of the __________ as well as the
__________ and __________ of the amniotic fluid.
ANS: fetal heart rate; color; odor
The nurse carefully monitors the patient who will undergo an amniotomy. Vital
signs, cervical effacement and dilation, station of the presenting part, fetal heart
rate, and color and amount of amniotic fluid are assessed.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
24. The perinatal nurse caring for a laboring woman who is receiving an oxytocin
infusion documents the following information: rate of __________, frequency and
strength of __________, fetal __________, and cervical __________ and
__________.
ANS: infusion; contractions; heart rate; dilatation; effacement
Oxytocin protocols in many institutions require that the nurse remain at the
patients bedside at all times for careful surveillance. The following data should be
placed on a flow sheet in the patient record: patients vital signs, fetal heart rate,
frequency, duration and strength of contractions, cervical effacement and
dilatation, fetal station and lie, rate of oxytocin infusion intake and urine output,
and the psychological response of the patient.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Application | Content Area: Maternity | Client Need: Physiological Integrity |
Difficulty Level: Moderate
25. The perinatal nurse recognizes that the laboring multiparous patient who is
attempting a vaginal birth following a previous cesarean birth (VBAC) needs
frequent assessments to ensure that there is __________ 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
26. During labor, oxytocin is always administered __________.
ANS: intravenously with an infusion pumpDuring labor, oxytocin can only be
administered intravenously via an infusion pump to titrate and regulate the dose
for safe administration.
27. __________ is contraindicated with shoulder dystocia.
ANS: Fundal pressureFundal pressure is contraindicated with shoulder dystocia
because it may further impact the shoulder and increases risk of fetal injury.
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Chapter 11. Intrapartum and Postpartum Care of the Cesarean Birth
Families
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 of laborc. 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 the fetal 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 indica tes cephalopelvic 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 and operative 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 premature and 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 cesarean birth are critical to the prevention of (select all that apply):
a. Pneumonia
b. Atelectasis
c. Abdominal distension
d. Increased tidal volume
ANS: a, b
Incisional pain and abdominal distension often cause patients to adopt shallow
breathing patterns that can lead to decreased gas exchange and a reduced tidal
volume. To facilitate adequate lung functions, patients should be taught how to
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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 assessment data 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.
d. Normal range of platelets is 150,000 to 400,000. A low platelet count places
the woman at risk for increased 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 the couple 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 couple to 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 best answer because it does not allow the couple to verbalize
their concerns.
KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area:
Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate
6. A nurse is caring for a woman 10 hours post-cesarean birth. She received a
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dose of intrathecal morphine at the time of the birth. Which of the following
assessment data would require immediate intervention?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 is respiratory 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
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 assessed regularly.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Postpartum 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
8. A post-cesarean birth woman has been diagnosed with paralytic ileus. Which
of the following symptoms would the nurse expect to see?
a. Abdominal distension
b. Polyuria
c. Diastasis recti
d. Dependent edema
ANS: a
Feedback
a. The nurse would expect to see a distended abdomen in a client with a paralytic
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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 | Content Area: Physiological Adaptation: Alterations in Body
Systems; Postpartum Care | Client Need: Health Promotion 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 be receiving 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 for the anesthesia administration.
ANS: b
Complications that may occur with spinal anesthesia block include maternal
hypotension, decreased placental 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 anesthetic agent 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 effects
ANS: b
Combining an opioid with a local anesthetic agent reduces the total amount of
anesthetic required and helps 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 nurse assists the anesthesiologist with the spinal block and
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then positions Tanya in a supine position. Tanyas blood 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.
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 or use 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. Providing an 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 birth
ANS: 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 be a 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 clamped
ANS: a
Administration of narrow-spectrum prophylactic antibiotics should occur within 60
minutes prior to the skin incision.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
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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 the descending 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 mL
ANS: b
Positioning of the patient with a left tilt maintains a left uterine displacement to
decrease the risk of aortocaval compression related to compression on the aorta
and inferior vena cava due to weight of the 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: Hard
Fill-in-the-Blank
15. A post-cesarean section client has been ordered to receive 500 mL of 5%
dextrose in water every 4 hours. The drop factor of the macrodrip tubing is 10
gtt/mL. To what drip rate should the nurse regulate the IV? __________ gtt/min
ANS: 21
Feedback: 21 gtt/min
The formula for calculating drip rates is:
volume multiplied by drop factor = drip rate
time 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 post-cesarean birth mother is due to __________.
ANS: delayed peristalsis
Delayed peristalsis and constipation commonly occur because of slowed
peristalsis associated with pregnancy 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 of any surgical or invasive procedure.
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ANS: site; procedure; patient
To decrease the risk of surgery or invasive procedure being done on the wrong
patient or in the wrong site, 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 | Content Area: 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 the obstetrical emergency.
ANS: False
Joint commission guidelines for patient safety necessitate there always be a
time-out to prevent wrong patient, wrong site, wrong procedure, and medical
errors.
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Postpartal Period
Chapter 12. Postpartum Physiological Assessments and Nursing Care
1. A 25 year-old woman gave birth to her second child 6 hours ago. She informs
the nurse that she is bleeding more than with her previous birth experience. The
initial nursing action is to:
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.
ANS: b
Feedback
a. The nurse should not inform the patient that this is normal until she has
assessed for the degree and potential cause of bleeding.
b. It is important to first assess for uterine atony or displaced uterus from full
bladder.
c. If the uterus is firm and midline, then the nurse should change the pad and
return within 30 minutes to assess the amount of lochia.
d. The nurse would give oxytocin if the uterus is boggy and does not respond to
uterine massage.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty
Level: Moderate
2. Which of these medications is commonly used to control postpartum bleeding
related to uterine atony?
a. Magnesium sulfate
b. Phytonadione
c. Oxytocin
d. Warfarin
ANS: c
Feedback
a. Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth
muscle relaxant and can cause the uterus to relax.
b. Phytonadione (vitamin K) is important for clotting but will not cause the uterus
to contract.
c. Oxytocin is commonly used to control postpartum bleeding related to uterine
atony.
d. Warfarin is an anticoagulant and will increase the risk of hemorrhage.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies |
Difficulty Level: Easy
3. During a postpartum assessment, the nurse notes that the uterus is midline
and boggy. The immediate nursing action is:a. To notify the patients midwife or
physician
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b. Massage the fundus until firm and reevaluate within 30 minutes
c. Give Syntocinon as per orders
d. Assist the patient to the bathroom and ask her to void
ANS: b
Feedback
a. If the uterus does not respond to massage, then the nurse would give
Syntocinon and notify the primary health provider.
b. The first nursing action for a boggy uterus is to massage the fundus.
c. If the uterus does not respond to massage, then the nurse would give
Syntocinon and notify the primary health provider.
d. You would assist the woman to the bathroom if the uterus is boggy and
displaced to the side.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty
Level: Easy
4. On day four following the birth of an average size baby, the nurse would
expect the fundus to be at:
a. 1 cm below umbilicus
b. 2 cm below umbilicus
c. 3 cm below umbilicus
d. 4 cm below umbilicus
ANS: d
Feedback
a. Expected location for day 1
b. Expected location for day 2
c. Expected location for day 3
d. Correct. The uterus on the average descends 1 centimeter per day.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Easy
5. A nurse is preparing to administer RhoGam to a client who delivered a fetal
demise. Which of the following must the nurse check before giving the injection?
a. Verify that the direct Coombs test results are positive.
b. Check that the fetus was at least 28 weeks gestation.
c. Make sure that the client is at least 3 days postdelivery.
d. Confirm that the client is Rh negative.
ANS: d
Feedback
a. The direct Coombs test is irrelevant, and because the baby has died, the
Coombs will likely not be performed.
b. RhoGam should be given no matter how old the fetus was.
c. RhoGam must be administered before 72 hours postpartum.
d. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must
confirm that any client receiving RhoGam is Rh negative.
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KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Assessment | Content Area: Disease Prevention; Health Promotion;
Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications |
Client Need: Health Promotion and Maintenance; Physiological Integrity:
Pharmacological and Parenteral Therapies | Difficulty Level: Moderate
6. A nurse is performing a postpartum assessment 30 minutes after a vaginal
delivery. Which of the following actions indicates that the nurse is performing the
assessment correctly?
a. The nurse measures the fundal height in relation to the symphysis pubis.
b. The nurse monitors the clients central venous pressure.
c. The nurse assesses the clients perineum for edema and ecchymoses.
d. The nurse performs a sterile vaginal speculum exam.
ANS: c
Feedback
a. The fundal height should be measured in relation to the umbilicus.
b. The central venous pressure is not monitored during postpartum assessments.
c. The nurse should assess the perineum for signs of edema and ecchymoses.
d. If a speculum exam were needed, a physician or midwife would perform the
procedure. Speculum exams are rarely needed postpartum.
KEY: Integrated Process: Nursing Process: Evaluation | Cognitive Level:
Comprehension | Content Area: Postpartum Care | Client Need: Health
Promotion and Maintenance | Difficulty Level: Moderate
7. A woman is 2 days postpartum from a normal vaginal delivery over an intact
perineum of a 3000-gram baby. Where would the nurse expect to palpate the
clients fundus?
a. At the umbilicus
b. 2 cm below the umbilicus
c. 2 cm above the symphysis
d. At the symphysis
ANS: b
Feedback
a. Expected location for 6 to 12 hours postpartum.
b. The firm fundus should be 2 cm below the umbilicus.
c. This is an abnormal finding and may be related to subinvolution of the uterus.
d. Expected location for 6 days postpartum.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Application | Content Area: Postpartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Easy
8. Which of the following clients is most likely to complain of afterbirth pains
during her postpartum period?
a. G1 P0, diagnosed with preeclampsia
b. G2 P0, group B streptococci in the vagina
c. G3 P2, gave birth to a 4100-gram baby
d. G4 P1, diagnosed with preterm labor
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ANS: c
Feedback
a. This client is a primipara. The nurse would not expect her to complain
excessively of afterbirth pains.
b. This client is a primipara. The nurse would not expect her to complain
excessively of afterbirth pains.
c. This client is a multipara and she delivered a macrosomic baby. She is likely to
complain of severe afterbirth pains.
d. Although this client is a gravida 4, she is a para 1. The nurse would not expect
her to complain excessively of afterbirth pains.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Postpartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Difficult
9. The nurse is providing discharge counseling to a woman who is breastfeeding
her baby. The nurse advises the woman that if she experiences unilateral breast
inflammation, she should do which of the following?
a. Apply warm soaks to the reddened area.
b. Consume an herbal galactagogue.
c. Bottle feed the baby during the next day.
d. Take expressed breast milk to the laboratory for analysis.
ANS: a
Feedback
a. The client may be developing mastitis. She should apply warm soaks to the
area.
b. There is no need for a galactagogue.
c. It is essential that the client continue to breastfeed. If she were to stop feeding,
she could develop a breast abscess.
d. Unless ordered by the physician, the milk need not be cultured.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Postpartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
10. The nurse is working with a 36-year-old, married client, G6 P6, who smokes.
The woman states, I dont expect to have any more kids, but I hate the thought of
being sterile. Which of the following contraceptive methods would be best for the
nurse to recommend to this client?
a. Intrauterine device
b. Contraceptive patch
c. Bilateral tubal ligation
d. Birth control pills
ANS: a
Feedback
a. An intrauterine device (IUD) is an excellent contraceptive method for women
who have had at least one delivery, are in a monogamous relationship, and wish
to have long-term contraception.
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b. The contraceptive patch is not recommended for women over 35 or for women
who smoke.
c. A bilateral tubal ligation is a sterilization procedure.
d. Birth control pills are not recommended for women over 35 or for women who
smoke.
KEY: Integrated Process: Nursing Process: Implementation; Teaching and
Learning | Cognitive Level: Application | Content Area: Family Planning | Client
Need: Health Promotion and Maintenance | Difficulty Level: Difficult
11. The perinatal nurse demonstrates for the student nurse the correct technique
of postpartum uterine palpation. Support for the lower uterine segment is critical,
as without it, there is an increased risk of:
a. Uterine edema
b. Uterine inversion
c. Incorrect measurement
d. Intensifying the patients level of pain
ANS: b
Feedback
a. Placing the hand over the base of the uterus does not cause uterine edema.
b. The uterine fundus is palpated by placing one hand on the base of the uterus
immediately above the symphysis pubis and the other hand at the level of the
umbilicus. The nurse presses inward and downward with the hand positioned on
the umbilicus until the fundus is located. It should feel like a firm, globular mass
located at or slightly above the umbilicus during the first hour after birth. The
uterus should never be palpated without supporting the lower uterine segment.
Failure to do so may result in uterine inversion and hemorrhage.
c. Measurement is the same with or without the hand supporting the lower uterine
segment.
d. Not supporting the lower uterine segment has no effect on the level of pain felt
by the patient.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
12. Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter.
She experiences severe cramps with breastfeeding. The perinatal nurse best
describes this condition as:
a. Afterpains
b. Uterine hypertonia
c. Bladder hypertonia
d. Rectus abdominis diastasis
ANS: a
Afterpains (afterbirth pains) are intermittent uterine contractions that occur during
the process of involution. Afterpains are more pronounced in patients with
decreased uterine tone due to overdistension, which is associated with
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multiparity and macrosomia. Patients often describe the sensation as a
discomfort similar to menstrual cramps.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
13. A 35-year-old G1 P0 postpartum woman is Rh0(D)-negative and needs
Rh0(D) immune globulin to be administered. The most appropriate dose that the
perinatal nurse would expect to be ordered would be:
a. 120 ug
b. 250 ug
c. 300 ug
d. 350 ug
ANS: c
Nonsensitized women who are Rh0(D)-negative and have given birth to an
Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin
(RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether
or not the mother received RhoGAM during the antepartum period. In some
situations, depending on the extent of hemorrhage and exchange of maternalfetal
blood, a larger dose of RhoGAM may be indicated.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
14. Heather, a postpartum woman who experienced a spontaneous vaginal birth
12 hours ago, describes a headache that is worsening. Heather was given two
regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago
but has had no relief from the pain. Several friends and family members are
presently visiting Heather. The nurse notes that Heathers pain relief during labor
consisted of a single dose of an IM narcotic. The most appropriate nursing action
at this time is to:
a. Notify Heathers health-care provider about Heathers headache.
b. Dim the lights in Heathers room so that she is able to get some rest.
c. Ask Heathers visitors to leave now to decrease Heathers environmental
stimuli.
d. Ask Heather where she is experiencing this headache and to identify the pain
score that best describes the intensity of the pain.
ANS: d
The nurse should perform routine, comprehensive pain assessments to include
onset, location, intensity, quality, characteristics, and aggravating and alleviating
factors of the discomfort in order to provide interventions in a timely manner and
enhance effectiveness of medications. The nurse should also ask the patient to
rate her pain on a standard 0 to 10 pain scale before and after interventions and
to identify her own acceptable comfort level on the scale.
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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
15. The perinatal nurse teaches the postpartum woman about the normal
process of diuresis that she can expect to occur approximately 6 to 8 hours after
birth. A decrease in which of the following hormones is primarily responsible for
the diuresis?
a. Prolactin
b. Progesterone
c. Oxytocin
d. Estrogen
ANS: d
Maternal diuresis occurs almost immediately after birth and urinary output
reaches up to 3000 mL each day by the second to fifth postpartum days. After
childbirth, a decrease in the level of estrogen naturally occurs and contributes to
the diuresis.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
16. During change of shift report, the nurse hears the following information on a
newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous
vaginal delivery over 3 laceration, vitals110/70, 98.6F, 82, 18, fundus firm at
umbilicus, moderate lochia, ambulated to bathroom to void three times for a total
of 900 mL, breastfeeding every 2 hours. Which of the following nursing
diagnoses should the nurse include in this clients nursing care plan?
a. Fluid volume deficit
b. Impaired skin integrity
c. Impaired urinary elimination
d. Ineffective breastfeeding
ANS: b
Feedback
a. There is nothing in the scenario that indicates that this client has had a
significant blood loss.
b. The client has a 3 laceration. A nursing diagnosis of impaired skin integrity is
appropriate.
c. The client is voiding well. There is no indication of impaired urinary elimination.
d. The client is feeding q 2 h. There is no indication of impaired breastfeeding.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Postpartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
True/False
17. The perinatal nurse teaches the postpartum woman that the most critical time
to achieve effectiveness from the application of ice packs to the perineum is
during the first 24 hours following birth.
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ANS: True
To reduce perineal swelling and pain that result from bruising, ice packs may be
applied every 2 to 4 hours. Patients obtain the most relief when ice packs are
applied within the first 24 hours after childbirth.
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
18. When reviewing potential causes for postpartum hemorrhage with the student
nurse, the nurse is sure to include the finding of a(n) __________ bladder.
ANS: overdistended
An overdistended bladder, which displaces the uterus above and to the right of
the umbilicus, can cause uterine atony and lead to hemorrhage.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
19. The postpartum period is the first __________ weeks following childbirth.
ANS: 6
Postpartum is the 6-week period of time following childbirth. It is a time of rapid
physiological changes within the womans body as it returns to a prepregnant
state.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
20. The serosa stage of lochia usually occurs between day __________ and
__________ and the lochia is a __________ or __________ color, and the
amount is normally __________.
ANS: 1 4; 10; pink; brown; scant
Lochia rubra (first stage) occurs during the first 3 days postpartum. Lochia rubra
is bright red blood and is moderate to scant. Lochia alba (third stage) begins
around the tenth day. The lochia is yellow to white in appearance and is scant in
amount.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
21. Mastitis is an inflammation of the __________.
ANS: Breast
Mastitis is an inflammation or infection of the breast. This can occur when
bacteria enter the breast through cracks around the nipple area.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
22. Primary breast engorgement is an increase in the __________ and
__________ systems that precedes the initiation of milk production.
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ANS: vascular; lymphatic
Primary breast engorgement is an increase in the vascular and lymphatic
systems that precedes the initiation of milk production. Subsequent breast
engorgement is related to distention of milk glands.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
Multiple Response
23. Which of the following nursing actions are important in the care of a
postpartum woman who is at risk for orthostatic hypotension? (Select all that
apply.)
a. Have patient remain in bed for the first 4 hours postbirth.
b. Instruct patient to slowly rise to a standing position.
c. Open an ammonia ampule and have the patient smell the ammonia prior to
getting out of bed.
d. Explain to the patient the cause and incidence of orthostatic hypotension.
ANS: b, d
Postpartum women are at risk for orthostatic hypotension during the first few
hours postdelivery. Orthostatic hypotension is a sudden drop in the blood
pressure when the woman stands up due to decreased vascular resistance in the
pelvis. The woman should be instructed to sit on the edge of her bed for a few
minutes and then slowly stand up. The nurse or aide should be with the woman
the first few times she ambulates. Ammonia ampules are used when the woman
faints and is not given prior to fainting.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
24. A woman who gave birth 2 hours ago has a temperature of 37.9C. Select all
of the immediate nursing actions.
a. Have patient drink two glasses of fluid over the next hour.
b. Explain to the patient that she needs to rest and assist her into a comfortable
position.
c. Medicate the patient with 500 mg of acetaminophen as per orders.
d. Call the patients physician or midwife to report the elevated temperature.
ANS: a, b
A mild temperature elevation within a few hours of birth can be related to
dehydration and exhaustion. Acetaminophen is given if the temperature remains
elevated after the woman has been hydrated and rested. The physician or
midwife is notified if temperature remains elevated after initial interventions.
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Chapter 13. Transition to Parenthood
1. The nurse is caring for a recently immigrated Chinese woman in the
postpartum unit. Based on cultural beliefs and practices of the woman, the nurse
would anticipate which of the following? (Select all that apply.)
a. The woman prefers cold water for drinking.
b. The woman prefers not to shower.
c. The woman prefers to have her female relatives care for her baby.
d. The woman prefers to have her family bring her food to eat.
ANS: b, c, d
In traditional Chinese beliefs and practices, the woman is to rest and female
family members take care of the woman and her infant. During the first month,
the woman is to avoid yin energy by eating specific foods and avoiding drinking
or touching cold water.
KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area:
Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate
2. The nurse is caring for a postpartum woman who gave birth to a healthy, fullterm baby girl. She has a 2-year-old son. She voices concern about her older
childs adjustment to the new baby. Nursing actions that will facilitate the older
sons adjustment to having a new baby in the house would include which of the
following? (Select all that apply.)
a. Explain to the mother that she can have her son lie in bed with her when he is
visiting her in the hospital.
b. Teach her son how to change the babys diapers.
c. Assist her son in holding his new baby sister.
d. Recommend that she spend time reading to her older son while he sits in her
lap.
ANS: a, c, d
Two-year-olds enjoy being close to their mothers, including lying next to their
mothers or being held. Changing diapers is not viewed as a pleasurable
experience and is not developmentally appropriate for a 2-year-old. Children
enjoy being able to hold their sibling and feeling grown up.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level:
Easy
3. Which of the following nursing actions are directed at assisting men in their
transition to fatherhood? (Select all that apply.)
a. Encourage the woman to take on the major responsibility for infant care.
b. Talk to the man, away from his partner, about his expectations of the fathering
role.
c. Praise the father for his interactions with his infant.
d. Provide information on infant care and behavior to both parents.
ANS: c, d
It is important to first have the couple discuss with each other their expectations
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of the fathering role. Once this has occurred, then the woman and nurse need to
support the man in his role of infant care. Both parents need to receive
information about infant care and infant behaviors, and both parents need to be
praised for their interactions with their baby.
KEY: Integrative Process: Teaching and Learning | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Psychological Integrity | Difficulty Level:
Moderate
4. Which of the following nursing actions are directed at promoting bonding?
(Select all that apply.)
a. Providing opportunity for parents to hold their newborn as soon as possible
following the birth.
b. Providing opportunities for the couple to talk about their birth experience and
about becoming parents.
c. Promoting rest and comfort by keeping the newborn in the nursery at night.
d. Providing positive comments to parents regarding their interactions with their
newborn.
ANS: a, b, d
Parent bonding can be delayed by prolonged periods of separation from their
child. The other three actions support parent bonding with their newborn.
KEY: Integrative Process: Caring | Cognitive Level: Application | Content Area:
Maternity | Client Need: Psychological Integrity | Difficulty Level: Moderate
5. Which of the following factors place a new mother at risk for parenting? (Select
all that apply.)
a. She is 17 years old.
b. Family income is below the average income.
c. Her parents live in the same city and are perceived as helpful.
d. She dropped out of school at age 13.
ANS: a, b, d
Adolescent parents may have a more difficult transition to parenthood because
they have not made the transition to adulthood. Financial concerns can hamper
the transition to parenthood because the focus of attention may be on where to
get money to pay for daily living expenses versus on the care of their newborn.
Decreased ability to read and comprehend information regarding child care may
hamper the ability to gain knowledge about the care of their child.
KEY: Integrative Process: Safe and Effective Care Environment | Cognitive Level:
Analysis | Content Area: Maternity | Client Need: Psychological Integrity |
Difficulty Level: Moderate
6. Which of the following nursing actions can assist a man in his transition to
fatherhood? (Select all that apply.)
a. Ask the man to share his ideas of what it means to be a father.
b. Demonstrate infant care such as diapering and feeding.
c. Engage couple in a discussion regarding each others expectations of the
fathering role.
d. Provide the man with information on infant care.
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ANS: a, b, c, d
Each of these actions can assist the father in his transition. It is important for the
man to be able to learn and practice infant care skills in a nonthreatening
environment. It is also important for the man to be able to openly talk about his
feelings regarding fatherhood and for the couple to identify mutual expectations
of the fathering role.
KEY: Integrative Process: Safe and Effective Care Environment | Cognitive Level:
Analysis | Content Area: Maternity | Client Need: Psychological Integrity |
Difficulty Level: Moderate
Multiple Choice
7. A 16-year-old woman delivers a healthy, full-term male infant. The nurse notes
the following behaviors 2 hours after the birth: Woman holds baby away from her
body; woman refers to baby as he; woman verbalizes she wanted a baby girl;
woman requests that baby be placed in the bassinet so she can eat her lunch.
The most appropriate nursing diagnosis for this woman is:
a. At risk for impaired parenting related to disappointment with baby as
evidenced by verbalizing she wanted a girl
b. At risk for impaired parenting related to nonnurturing behaviors as evidenced
by holding baby away from body
c. At risk for impaired motherinfant attachment as evidenced by woman
requesting baby being placed in bassinet
d. At risk for impaired motherinfant attachment related to disappointment as
evidenced by calling baby he
ANS: a
Feedback
a. The potential is for impaired parenting related to disappointment in the gender
of the baby.
b. Holding baby away from her body during the first few hours is part of the
maternal touch process.
c. Focusing on eating during the first few hours is a behavior of taking-in and is
anticipated during this phase.
d. Some parents have not selected a name for their baby and will refer to their
baby as he or she. There is concern if the woman calls her baby it.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level:
Moderate
8. The nurse notes that a new father gazes at his baby for prolonged periods of
time and comments that his baby is beautiful and he is very happy having a
baby. These behaviors are commonly associated with:
a. Bonding
b. Engrossment
c. Couvade syndrome
d. Attachment
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ANS: b
Feedback
a. Bonding is defined as the emotional feelings that begin during pregnancy or
shortly after birth between the parent and the newborn. Bonding is unidirectional
from parent to newborn.
b. Correct. Characteristics of engrossment are visual awareness of baby, tactile
awareness of baby, perception that baby is perfect, strong attraction to baby,
feeling of strong elation, and increased self-esteem.
c. Couvade syndrome relates to a set of pregnancy symptoms the father
experiences during pregnancy of the woman.
d. Attachment is a connection that forms from parent to infant and infant to
parent. Attachment has a lifelong impact on the developing individual.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Analysis | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty
Level: Moderate
9. A woman on the day of discharge from the postpartum unit requests clean
towels so she can take a shower, asks a number of questions regarding
breastfeeding, and shares that she is nervous about taking her baby home and
not being able to remember everything she has been taught. These are
behaviors associated with:
a. Bonding
b. Taking in
c. Taking hold
d. Attachment
ANS: c
Feedback
a. Bonding is defined as the emotional feelings that begin during pregnancy or
shortly after birth between the parent and the newborn. Bonding is unidirectional
from parent to newborn.
b. In the taking-in phase, women are dependent and need assistance with selfcare and care of the infant.
c. Correct. These are common behaviors of women in the taking-hold phase.
Women during this phase have moved to being more independent and able to
initiate self-care. They are highly interested in learning about the care of their
baby but can easily become frustrated and discouraged when they do not
immediately master a new skill.
d. Attachment is a connection that forms from parent to infant and infant to
parent. Attachment has a lifelong impact on the developing individual.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level:
Moderate
10. The nurse is developing a plan of care for a client who is in the taking-in
phase after delivering a healthy baby boy. Which of the following should the
nurse include in the plan?
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a. Provide the client with a nutritious meal.
b. Teach baby care skills like diapering.
c. Discuss the pros and cons of circumcision.
d. Counsel her regarding future sexual encounters.
ANS: a
Feedback
a. Mothers are very hungry immediately after delivery. The nurse should provide
the client with food.
b. Baby care skills should be taught during the taking-hold phase.
c. Baby care needs should be discussed during the taking-hold phase.
d. A discussion of sexual issues should be deferred until the taking-hold phase or
the letting go phase.
KEY: Integrated Process: Nursing Process: Implementation; Teaching and
Learning | Cognitive Level: Application | Content Area: Health and Wellness;
Postpartum Care | Client Need: Health Promotion and Maintenance | Difficulty
Level: Difficult
11. The perinatal nurse observes the new mother watching her baby daughter
closely, touching her face, and asking many questions about infant feeding. This
stage of mothering is best described as:
a. Taking in
b. Taking hold
c. Taking charge
d. Taking time
ANS: b
As the mothers physical condition improves, she begins to take charge and
enters the taking-hold phase where she assumes care for herself and her infant.
At this time, the mother eagerly wants information about infant care and shows
signs of bonding with her infant. During this phase, the nurse should closely
observe motherinfant interactions for signs of poor bonding, and if present,
implement actions to facilitate attachment.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
12. The postpartum nurse caring for a 20-year-old G1 P0 woman who 3 hours
ago delivered a healthy full-term infant, observes the woman who is lightly
touching her baby girl with her fingertips but who seems to be uncomfortable
holding her baby close to her body. Which of the following is an accurate
interpretation of these observed behaviors?
a. The woman is in the initial stage of maternal touch.
b. The woman is in the taking-in phase.
c. The woman is having difficulty in bonding with her baby.
d. The woman needs to be medicated for pain.
ANS: a
These are classical signs of the initial stage of Rubins maternal touch.
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KEY: Integrative Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Psychological Integrity | Difficulty Level:
Moderate
True/False
13. Eye movements are an example of newborn/infant style of communication.
ANS: True
Crying, cooing, facial expressions, eye movements, cuddling, and arm and leg
movements are all examples of newborn/infant style of communication.
KEY: Integrative Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Psychological Integrity | Difficulty Level:
Easy
14. Bonding is bidirectional from parent to infant and infant to parent.
ANS: False
Bonding is unidirectional from parent to infant. Attachment is bidirectional.
KEY: Integrative Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Psychological Integrity | Difficulty Level:
Easy
15. The postpartum nurse is caring for a couple who experienced an unplanned
emergency cesarean birth. The nurse observes the following behaviors:
Parents are gently touching their newborn.
Mother is softly singing to her baby.
Father is gazing into his babys eyes.
Based on this data, the correct nursing diagnosis is altered parentinfant bonding
related to emergency cesarean birth.
Cesarean birth can place the parents at risk for bonding, but based on the
observed interaction with their newborn, the parents display positive signs of
bonding.
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Chapter 14. High-Risk Postpartum Nursing Care
Multiple Choice
1. A postpartum woman has been diagnosed with postpartum psychosis. Which
of the following actions should the nurse perform?
a. Supervise all infant care.
b. Maintain client on strict bed rest.
c. Restrict visitation to her partner.
d. Carefully monitor toileting.
ANS: a
Feedback
a. It is essential that a client diagnosed with postpartum (PP) psychosis not be
left alone with her infant.
b. There is no need for a client with PP psychosis to be on strict bed rest.
c. Visitation is not usually restricted to the womans partner.
d. There is no need to monitor the clients toileting.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Postpartum Care; Psychopathology | Client Need:
Health Promotion and Maintenance; Psychosocial Integrity | Difficulty Level:
Difficult
2. Which of the following sites is priority for the nurse to assess when caring for a
breastfeeding client, G8 P5, who is 1 hour postdelivery?
a. Nipples
b. Fundus
c. Lungs
d. Rectum
ANS: b
Feedback
a. Her nipples should be assessed, but this is not the priority assessment.
b. This client is a grand multipara. She is high risk for uterine atony and
postpartum hemorrhage. The nurse should monitor her fundus very carefully.
c. Her lungs should be assessed bilaterally, but this is not the priority
assessment.
d. Her rectum should be assessed for hemorrhoids, but this is not the priority
assessment.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Application | Content Area: Postpartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
3. A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy
of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate
for this mother?
a. Risk for altered parenting
b. Risk for imbalanced nutrition: less than body requirements
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c. Risk for ineffective individual coping
d. Risk for fluid volume deficit
ANS: d
Feedback
a. Although the baby is macrosomic, there is no evidence that this mother is high
risk for altered parenting.
b. This womans baby is macrosomicthere is no indication that this woman is
consuming a diet that is less than body requirements.
c. There is no evidence that this mother is high risk for altered coping.
d. This client is high risk for fluid volume deficit. Women who deliver macrosomic
babies are high risk for uterine atony, which can lead to heavy flow of lochia.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Physiological Adaptation: Fluid and Electrolyte
Imbalances; Postpartum Care; Reduction of Risk Potential: Potential for
Alterations in Body Systems | Client Need: Health Promotion and Maintenance;
Physiological Adaptation; Physiological Integrity: Reduction of Risk Potential |
Difficulty Level: Difficult
4. The perinatal nurse accurately defines postpartum hemorrhage by including a
decrease in hematocrit levels from pre- to postbirth by:
a. 5%
b. 8%
c. 10%
d. 15%
ANS: c
Historically, practitioners have defined postpartum hemorrhage as a blood loss
greater than 500 mL following a vaginal birth and 1000 mL or more following a
cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth
measurements are also included in the definition.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
5. The perinatal nurse teaches the postpartum woman about warning signs
regarding development of postpartum infection. Signs and symptoms that merit
assessment by the health-care provider include the development of a fever and:
a. Breast engorgement
b. Uterine tenderness
c. Diarrhea
d. Emotional lability
ANS: b
During the immediate postpartum period, the most common site of infection is the
uterine endometrium. This infection presents with a temperature elevation over
101F, often within the first 24 to 48 hours after childbirth, followed by uterine
tenderness and foul-smelling lochia.
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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
6. The perinatal nurse recognizes that a risk factor for postpartum depression is:
a. Inadequate social support
b. Age >35 years
c. Gestational hypertension
d. Regular schedule of prenatal care
ANS: a
Recognized risk factors for postpartum depression include an undesired or
unplanned pregnancy, a history of depression, recent major life changes such as
the death of a family member, moving to a new community, lack of family or
social support, financial stress, marital discord, adolescent age, and
homelessness.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
7. Karen, a G2, P1, experienced a precipitous birth 90 minutes ago. Her infant is
4200 grams and a repair of a second-degree laceration was needed following the
birth. As part of the nursing assessment, the nurse discovers that Karens uterus
is boggy. Furthermore, it is noted that Karens vaginal bleeding has increased.
The nurses most appropriate first action is to:
a. Assess vital signs including blood pressure and pulse.
b. Massage the uterine fundus with continual lower segment support.
c. Measure and document each perineal pad changed in order to assess blood
loss.
d. Ensure appropriate lighting for a perineal repair if it is needed.
ANS: b
As the primary caregiver, the registered nurse may be the first person to identify
excessive blood loss and initiate immediate actions. The nurse should first locate
the uterine fundus and initiate fundal massage. Nursing actions performed after
the massage are frequent vital sign measurements with an automatic device,
measuring the length of time it takes for blood loss to saturate a pad, and
assessing for bladder distention.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
8. The nurse is massaging a boggy uterus. The uterus does not respond to the
massage. Which medication would the nurse expect would be given first:
a. Methergine
b. Ergotrate
c. Carboprost
d. Oxytocin or pitocin
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ANS: d
If the cause of the hemorrhage is uterine atony, continual fundal massage with
lower uterine segment support is mandatory. While one member of the team
massages the fundus, another nurse establishes intravenous access with a large
bore needle and administers oxytocic drugs in the following order: oxytocin
(Pitocin), followed by methylergonovine (Methergine) or ergonovine (Ergotrate),
and carboprost (Hemabate).
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
9. Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2
hours of pushing. She required an episiotomy and an assisted birth (forceps) due
to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing
an assessment of Juanitas perineal area. A slight bulge is palpated and the
presence of ecchymoses to the right of the episiotomy is noted. The area feels
full and is approximately 4 cm in diameter. Juanita describes this area as very
tender. The most likely cause of these signs and symptoms is:
a. Hematoma formation
b. Sepsis in the episiotomy site
c. Inadequate repair of the episiotomy
d. Postpartum hemorrhage
ANS: a
A hematoma is a localized collection of blood in connective or soft tissue under
the skin that follows injury of or laceration to a blood vessel without injury to the
overlying tissue. The most common sign or symptom of a hematoma is
unremitting pain and pressure. Upon examination of the perineal or vulvar areas,
the nurse may notice discoloration and bulging of the tissue at the hematoma
site. If touched, the patient complains of severe tenderness, and the clinician
generally describes the tissue as full.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
10. The perinatal nurse notifies the physician of the findings related to Juanitas
assessment. The first step in care will most likely be to:
a. Prepare Juanita for surgery
b. Administer intravenous fluids
c. Apply ice to the perineum
d. Insert a urinary catheter
ANS: c
If the hematoma is less than 3 to 5 centimeters in diameter, the physician usually
orders palliative treatments such as ice to the area for the first 12 hours along
with pain medication. After 12 hours, sitz baths are prescribed to replace the
application of ice. However, a hematoma larger than 5 centimeters may require
incision and drainage with the possible placement of a drain.
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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
11. The clinic nurse sees Xiao and her infant in the clinic for their 2-week followup visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she
does not make eye contact with her infant. She is carrying her son in the infant
carrier and when asked to put him on the examining table, she holds him away
from her body. The clinic nurses most appropriate question to ask would be:
a. What has happened to you?
b. Do you have help at home?
c. Is there anything wrong with your son?
d. Would you tell me about the first few days at home?
ANS: d
The well-baby checkup that generally takes place 1 to 2 weeks following the
hospital discharge may offer the first opportunity to assess the motherbaby dyad.
In this setting, the nurse needs to be alert for subtle cues from the new mother,
such as making negative comments about the baby or herself, ignoring the babys
or other childrens needs, as well as the mothers physical appearance. In a
private area, the nurse should take time to explore the new mothers feelings. A
nonthreatening way to open the dialogue might be to say: Tell me how the first
few days at home have gone. This statement provides the new mother with an
opportunity to share both positive and negative impressions.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
12. A postpartum nurse has received an exchange report on the four following
motherbaby couplets. Based on the provided information, which couplet should
the nurse first assess?
a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty
breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is
moderate to scant.
b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported
that she refers to her baby boy as it and that she requested to have her baby
stay in the nursery so she could sleep.
c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago
after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm
above umbilicus with moderate lochia.
d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective
cesarean birth. She had spinal anesthesia and was given intrathecal
preservative-free morphine for postoperative pain management. Her vital signs
are B/P 115/75, P 80, R 18 T 98.
ANS: c
Feedback
a. The priority need for this woman is breastfeeding assistance which does not
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require immediate attention.
b. The data indicate that the woman is experiencing a delay in bonding and that
social services should become involved. This needs to be done prior to discharge
but does not require immediate attention.
c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented
labor, high parity, and immediate postpartum). This woman needs to be
assessed first to determine whether the fundus is firm and if lochia is within
normal limits.
d. Based on data provided, this woman is stable, but should be assessed
second.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Difficult
13. Which of the following is an indication for the administration of
methylergonovine?
a. Boggy uterus that does not respond to massage and oxytocin therapy
b. Woman with a large hematoma
c. Woman with a deep vein thrombosis
d. Woman with severe postpartum depression
ANS: a
Feedback
a. Methylergonovine (methergine) is ordered for PPH due to uterine atony or
subinvolution. It is used when massage and oxytocin therapy have failed to
contract the uterus.
b. Hematoma occurs when blood collects within the connective tissues of the
vagina or perineal areas related to a vessel that ruptured and continues to bleed.
Methylergonovine stimulates contraction of the smooth muscle of the uterus and
would not have an effect on the vaginal or perineal areas.
c. Heparin is usually prescribed for treatment of thrombosis.
d. Methylergonovine is prescribed for treatment of uterine atony.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
14. A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at
2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and
firm, and her lochia was moderate rubra. An hour later, her fundus is midline and
boggy, and the lochia is heavy with small clots. Based on this assessment data,
the first nursing action is:
a. Massage the fundus of the uterus.
b. Assist the woman to the bathroom and reassess the fundus.
c. Notify the physician or midwife.
d. Start IV oxytocin therapy as per standing orders.
ANS: a
Feedback
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a. Correct. Based on the assessment data that the uterus is midline and boggy,
the woman is experiencing uterine atony.
b. Assisting the woman to the bathroom would be a nursing action if the uterus
was not midline.
c. Oxytocin would be given and the primary health provider would be notified if
the uterus did not respond to uterine massage.
d. Oxytocin would be given and the primary health provider would be notified if
the uterus did not respond to uterine massage.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty
Level: Moderate
15. A woman who is 12 weeks postpartum presents with the following behavior:
she reports severe mood swings and hearing voices, believes her infant is going
to die, she has to be reminded to shower and put on clean clothes, and she feels
she is unable to care for her baby. These behaviors are associated with which of
the following?
a. Postpartum blues
b. Postpartum depression
c. Postpartum psychosis
d. Maladaptive motherinfant attachment
ANS: c
Feedback
a. Postpartum blues usually occurs within the first few weeks of the postpartum
period. Women experiencing postpartum blues will have mild mood swings, and
they can take care of themselves as well as their baby.
b. Women with PPD are predominately depressed and do not have mood swings.
c. Postpartum psychosis is associated with a break from reality reflected in the
woman hearing voices.
d. The symptoms reported are reflective of a psychiatric disorder beyond
maladaptive attachment.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level:
Moderate
True/False
16. A hematoma is the collection of blood beneath the intact skin layer following
an injury to a blood vessel.
ANS: True
A hematoma is a localized collection of blood in connective or soft tissue under
the skin that follows injury of or laceration to a blood vessel without injury to the
overlying tissue. At the time of injury, pressure necrosis and inadequate
hemostasis occur.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Moderate
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17. Abruptio placenta is a risk factor for amniotic fluid embolism.
ANS: True
Risk factors for amniotic fluid embolism include induction of labor, maternal age
over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios,
eclampsia, and cervical or uterine lacerations.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
18. Metritis is an infection that usually starts at the placental site.
ANS: True
Metritis is an infection of the endometrium that usually starts at the placental site
and spreads to encompass the entire endometrium.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Difficult
Fill-in-the-Blank
19. The development of a large hematoma can place the postpartum woman at
risk for __________.
ANS: shock
Upon examination of the perineal or vulvar areas, the nurse may notice
discoloration and bulging of the tissue at the hematoma site. If touched, the
patient complains of severe tenderness, and the clinician generally describes the
tissue as full. If the hematoma is large, signs of shock may be evident, and the
patient may exhibit an absence of lochia and an inability to void.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
20. The perinatal nurse explains to a new mother that the first sign of a
postpartum infection will most likely be an increased __________.
ANS: temperature
During the immediate postpartum period, the most common site of infection is the
uterine endometrium. This infection presents with a temperature elevation over
101F (38.4C), often within the first 24 to 48 hours after childbirth, followed by
uterine tenderness and foul-smelling lochia.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
21. The perinatal nurse provides information about postpartum depression to all
families members because of the potential danger not only to the mother but also
to the __________.
ANS: infant
The earlier that postpartum depression is recognized and treatment begun, the
better is the prognosis for a full recovery. The nurse should involve the family in
helping the patient cope with her feelings and assisting with infant care.
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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
22. A postpartum woman who describes symptoms of hallucinations and suicidal
thoughts is most likely experiencing postpartum __________.
ANS: psychosis
Postpartum psychosis is a rare but severe form of mental illness that severely
affects not only the new mother, but the entire family. Postpartum psychosis may
present with symptoms of postpartum depression. However, the distinguishing
signs of psychosis are hallucinations, delusions, agitation, confusion,
disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of
touch with reality.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
23. Postpartum woman are at an increased risk of thrombus formation
immediately following birth due to an increased __________ level.
ANS: plasma fibrinogen
Levels of plasma fibrinogen tend to remain elevated during the first few postpartal
weeks. Although this alteration exerts a protective effect against hemorrhage, it
increases the patients risk of thrombus formation.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Moderate
24. A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2
hours ago. The nurse notes that the womans labor was only 2 hours and that the
infant was delivered by the labor nurse. The nurses assessment findings are:
Fundus firm and midline at umbilicus
Lochia heavysaturates pad within 15 minutes and bleeding is a steady stream
without clots
Perineum intact, slight bruising
Ice pack on perineum
Vital signs are B/P 105/65, P 98, R 20, T 38
Based on this information, the nurse is concerned that the woman has a
__________ of the __________ or __________.
ANS: laceration; cervix; vagina
Based on the assessment data, the woman is experiencing an early postpartum
hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony
because the fundus is firm and midline. Laceration of the cervix or vagina is the
second most common cause of early PPH. This woman is displaying typical
signs and symptoms of laceration of cervix or vaginafirm, midline fundus with
steady stream of blood without clots.
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KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
Multiple Response
25. Which of the following are primary risk factors for subinvolution of the uterus?
(Select all that apply.)
a. Fibroids
b. Retained placental tissue
c. Metritis
d. Urinary tract infection
ANS: a, b, c
Uterine fibroids can interfere with involution. Retained placental tissue does not
allow the uterus to remain contracted. Infection in the uterus is a risk factor for
subinvolution. UTI does not interfere with involution of the uterus.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
26. A woman is 3 hours post-early-postpartum hemorrhage of 800 mL at delivery.
Select the nursing actions for care of this patient. (Select all that apply.)
a. Limit fluid intake to prevent nausea and vomiting.
b. Assess fundus every 4 hours during the first 8 hours.
c. Explain the importance of preventing an overdistended bladder.
d. Provide assistance with ambulation.
ANS: c, dFluid intake should be increased following a postpartum hemorrhage to
decrease the risk of hypovolemia. The fundus should be assessed a minimum of
every hour for the first 4 hours following a PPH. The woman needs to know the
importance of preventing an overdistended bladder to decrease the risk of further
hemorrhage. After postpartum hemorrhage, a woman is at risk for orthostatic
hypotension.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty
Level: Moderate
27. Which of the following actions can decrease the risk for a postpartum
infection? (Select all that apply.)
a. Diet high in protein and vitamin C
b. Increased fluid intake
c. Ambulating within a few hours after delivery
d. Washing nipples with soap prior to each breastfeeding session
ANS: a, b, c
Protein and vitamin C assist with tissue healing. Rehydrating a woman after
delivery can assist with decreasing risk for infections. Early ambulation
decreases risk for infection by promoting uterine drainage. The woman should
not wash her breasts with soap because soap can dry the tissue and increase
the womans risk for tissue breakdown.
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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment;
Safety/Infection Control | Difficulty Level: Moderate
28. Nursing actions focused at reducing a postpartum womans risk for cystitis
include which of the following? (Select all that apply.)
a. Voiding within a few hours post-birth
b. Oral intake of a minimum of 1000 mL per day
c. Changing peri-pads every 3 to 4 hours or more frequently as indicated
d. Reminding the woman to void every 3 to 4 hours while awake
ANS: a, c, d
Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will
decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media
for bacterial growth. It is recommend that a postpartum woman drink a minimum
of 3000 mL/day to help dilute urine and promote frequent voiding.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
29. A G2 P1 woman who experienced a prolonged labor and prolonged rupture
of membranes is at risk for metritis. Which of the following nursing actions are
directed at decreasing this risk? (Select all that apply.)
a. Instruct woman to increase her fluid intake
b. Instruct woman to change her peri-pads after each voiding
c. Instruct woman to ambulate in the halls four times a day
d. Instruct woman to apply ice packs to the perineum
ANS: a, b, c
Feedback
a. Maintaining adequate hydration can decrease a persons risk for infection.
b. Lochia is a media for bacterial growth, so it is important to frequently change
the peri-pads.
c. Ambulation can decrease the risk of infection by promoting uterine drainage.
d. Ice pack therapy is directed at decreasing edema of the perineum and
promoting comfort. It has no effect on metriosis.
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Neonatal Period
Chapter 15. Physiological and Behavioral Responses of the Neonate
1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of
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 their questions.
b. Remove the neonate from the room so the parents will not be distressed by
seeing 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 is being
done on the newborn.
b. It is best to give parents an option to be with their newborn when giving
injections.
c. It is best to keep the newborn covered as much as possible to reduce heat
loss.
d. A 25 gauge 5/8 needle is used for giving injections to full-term neonates.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
2. To accurately measure the neonates head, the nurse places the measuring
tape 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 lip
ANS: 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.
d. This is not the standard measurement for the diameter of the head.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
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
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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 less
brown fat.
c. This neonate is at risk for cold stress due to gestational age that results in less
brown fat. This neonate is at higher risk because this neonate is SGA and has a
higher probability of less brown fat than the 32-week AGA.
d. This neonate should have adequate stores of brown fat.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
4. When assessing the apical pulse of the neonate, the stethoscope should be
placed 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).
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Basic Care and Comfort | Difficulty Level:
Easy
5. Which of the following breath sounds are normal to hear in the neonate during
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 due to
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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
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6. The nurse assesses that a full-term neonates temperature is 36.2C. The first
nursing action is to:
a. Turn up the heat in the room.
b. Place the neonate on the mothers chest with a warm blanket over the mother
and baby.
c. Take the neonate to the nursery and place in a radiant warmer.
d. Notify the neonates primary provider.
ANS: b
Feedback
a. Increasing the heat in the room will take a long period of time before it has an
effect on the neonate.
b. Skin-to-skin contact along with use of a warm blanket is the best intervention
with mild temperature decrease in the neonate.
c. If the temperature remains low, then the neonate needs to be placed under a
radiant warmer.
d. The primary health provider is notified if the temperature remains low after
interventions.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
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 neonates head to the side so that the chin is over the shoulder
while the neonate is in a supine position.
d. Holding the neonate in a semi-sitting position and letting the head slightly drop
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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Easy
8. An infant admitted to the newborn nursery has a blood glucose level of 55
mg/dL. Which of the following actions should the nurse perform at this time?
a. Provide the baby with routine feedings.
b. Assess the babys blood pressure.
c. Place the baby under the infant warmer.
d. Monitor the babys urinary output.
ANS: a
Feedback
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a. This blood glucose level is normal. The nurse should provide routine nursing
care.
b. There is no apparent need to assess this babys 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 babys output.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Newborn Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
9. Four babies have just been admitted into the neonatal nursery. Which of the
babies 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 96.3F, length 17 inches
d. The baby with glucose 60 mg/dL, heart rate 132
ANS: c
Feedback
a. The babys findings are within normal limits. Another baby should be seen first.
b. The babys findings are within normal limits. Another baby should be seen first.
c. This baby should be assessed first. The babys temperature is low; therefore,
the baby could develop cold stress syndrome. In addition, the baby is short and,
therefore, could be preterm.
d. The babys findings are within normal limits. Another baby should be seen first.
KEY: Integrated Process: Nursing Process: Assessment; Nursing Process:
Implementation | Cognitive Level: Analysis | Content Area: Newborn Care;
Reduction of Risk Potential: Potential for Alterations in Body Systems | Client
Need: Health Promotion and Maintenance: Newborn Care; Physiological
Integrity: Reduction of Risk Potential | Difficulty Level: Difficult
10. The nurse is about to elicit the rooting reflex on a newborn baby. Which of the
following responses should the nurse expect to see?
a. When the cheek of the baby is touched, the newborn turns toward the side that
is touched.
b. When the lateral aspect of the sole of the babys foot is stroked, the toes
extend and fan outward.
c. When the baby is suddenly lowered or startled, the neonates arms straighten
outward and the knees flex.
d. When the newborn is supine and the head is turned to one side, the arm on
that 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.
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KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Comprehension | Content Area: Growth and Development; Newborn Care | Client
Need: Health Promotion and Maintenance | Difficulty Level: Easy
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 the baby 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, including
prenatal diabetes mellitus, cold stress syndrome, and sepsis.
d. The circumcision may ooze blood due to the lack of vitamin K, which is
required for the hepatic synthesis of blood coagulation factors II, VII, and X.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Expected Effects/Outcomes; Newborn Care;
Pharmacological and Parenteral Therapies: Pharmacological Actions; Reduction
of Risk Potential: Potential for Complications from Surgical Procedures | Client
Need: Health Promotion and Maintenance; Physiological Integrity:
Pharmacological and Parenteral Therapies; Reduction of Risk Potential |
Difficulty Level: Moderate
12. A nurse is assisting a physician during a babys circumcision. Which of the
following demonstrates that the nurse is acting as the babys patient care
advocate?
a. The nurse requests that oral sucrose be ordered as a pain relief measure.
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 the skin.
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, a
safety precaution.
c. The nurse is using aseptic technique during the procedure when he or she
wears a mask.
d. The nurse is using aseptic technique during the procedure when he or she
gives the physician iodine solution for the procedure.
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KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Management of Care: Advocacy; Newborn Care |
Client Need: Health Promotion and Maintenance; Safe and Effective Care
Environment: Management of Care | Difficulty Level: Moderate
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 the
assessments 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 at about
the third or fourth intracostal space.
KEY: Integrated Process: Nursing Process: Analysis; Nursing Process:
Implementation | Cognitive Level: Application | Content Area: Newborn Care |
Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult
14. The nurse is about to elicit the Moro reflex. Which of the following responses
should the nurse expect to see?
a. When the cheek of the baby is touched, the newborn turns toward the side that
is touched.
b. When the lateral aspect of the sole of the babys foot is stroked, the toes
extend and fan outward.
c. When the baby is suddenly lowered or startled, the neonates arms straighten
outward and the knees flex.
d. When the newborn is supine and the head is turned to one side, the arm on
that same side extends.
ANS: c
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.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Comprehension | Content Area: Newborn Care | Client Need: Health Promotion
and Maintenance | Difficulty Level: Moderate
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?
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a. Grasp the inner aspects of the babys calves with thumbs and forefingers.
b. Gently abduct the babys thighs.
c. Palpate the babys patellae to assess for subluxation of the bones.
d. Dorsiflex the babys feet.
ANS: b
Feedback
a. The nurse would grasp the babys thighs with thumbs and forefingers.
b. The nurse would gently abduct the babys legs.
c. The nurse would palpate the trochanter to assess for changes.
d. The nurse would not dorsiflex the feet to assess for developmental dysplasia
of the hip (DDH).
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Application | Content Area: Health Screening; Newborn Care | Client Need:
Health Promotion and Maintenance | Difficulty Level: Moderate
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 for the
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.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Management of Care: Delegation | Client Need: Safe
and Effective Care Environment: Management of Care | Difficulty Level: Difficult
17. A pregnant patient at 35 weeks gestation gives birth to a healthy baby boy.
What factors regarding the development of the normal respiratory system should
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, which allows
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
intrapulmonary fluid, which assists in reducing the pulmonary resistance to blood
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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, which allows
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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
18. The perinatal nurse explains to a student nurse the cardiopulmonary
adaptations that occur in the neonate. Which one of the following statements
accurately describes the sequence of these changes?
a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary
artery 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 fetal to
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 physiologic
response 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 from
fetal to newborn circulation.
d. Once the pulmonary circulation has been functionally established, blood is
distributed throughout the lungs.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level:
Moderate
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
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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.
b. A low red blood cell (RBC) count signals physiologic anemia of infancy.
c. The neonates elevated hematocrit (related to the high concentration of RBCs)
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 of bile
pigments associated with an excessive amount of bilirubin in the blood.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
20. The nurse is assessing the neonates 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 infants face
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 infants cheeks and chest.
c. Erythema toxicum is a newborn rash that consists of small, irregular, flat, red
patches 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 on Caucasian infants.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
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 nurses findings include the following parameters: heart rate, 136 beats per
minute; respiratory rate, 64 breaths per minute; temperature, 98.2F (36.8C);
length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a
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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
babys health-care provider?
a. Respiratory rate
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 to
hear 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 of bowel
sounds in a small, distinct section of the intestines; therefore, this finding should
be reported.
d. The weight is within normal limits.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Physiological Integrity |
Difficulty Level: Difficult
22. The nursery nurse notes the presence of diffuse edema on a baby girls head.
Review of the birth record indicates that her mother experienced a prolonged
labor and difficult childbirth. By the second day of life, the edema has
disappeared. The nurse documents the following condition in the infants chart.
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 lines and
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 infants 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 infants 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 the
mouth.
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KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Moderate
23. The perinatal nurse contacts the pediatrician about a heart murmur that was
auscultated during a routine newborn assessment. This finding would be
abnormal at:
a. 8 to 12 hours
b. 12 to 24 hours
c. 24 to 48 hours
d. 48 to 72 hours
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 be
heard 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Difficult
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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
Multiple Response
25. A healthy, full-term baby is scheduled for a circumcision. Nursing actions
prior 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 neonates protime.
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ANS: a, b, c
Feedback
a. Circumcision is a surgical procedure and requires written consent signed by
the parent.
b. Administration of acetaminophen is a method of pain management for the
newborn.
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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
26. A first-time mother informs her nurse that another staff member came in and
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. The nurse
should do which of the following? (Select all that apply.)
a. Praise the mother for not allowing a person without proper ID to take her baby.
b. Check with the nursery to see if a staff member was recently in the patients
room.
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, and
there 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.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Analysis | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Moderate
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 that
apply.)
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 a
vapor, such as inadequately dried skin.
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b. Conduction is the loss of heat to a cooler surface by direct skin contact, such
as occurs when the infant is placed on a cold surface.
c. Convective heat loss occurs when the neonate is exposed to drafts and cool
circulating 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 cool
circulating air, such as when being placed near an open window or fan.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
28. A perinatal nurse assesses a term newborn for respiratory functioning. The
nurse 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 neonates lung sounds may sound moist during early auscultation
ANS: b, d
Feedback
a. The normal respiratory rate for a healthy term newborn is 40 to 60 breaths per
minute.
b. The breathing pattern is often shallow, diaphragmatic, and irregular.
c. Apnea is cessation of breathing that lasts more than 20 seconds; it is abnormal
in the term neonate.
d. Most fetal fluid is reabsorbed within the first few hours, but in some infants this
process may take up to 24 hours and the lungs may sound moist for the first 24
hours.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
29. The perinatal nurse observed the pediatrician completing the Ballard
Gestational Age by Maturity Rating tool. The maturity components used with this
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 infants gestational age in weeks.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
True/False
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30. The nurse assessing a newborn for heat loss is aware that nonshivering
thermogenesis utilizes the newborns stores of brown adipose tissue (BAT) to
provide 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 a process
that produces heat.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level:
Easy
Fill-in-the-Blank
31. A newborn was born weighing 2576 grams. On day 2 of life, the baby
weighed 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.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Synthesis
| Content Area: Newborn 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
32. The perinatal nurse explains to the student nurse that successful
cardiopulmonary adaptation in the neonate involves five major changes: an
increased 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 constrict as
the fetal circulatory system is interrupted. Successful cardiopulmonary adaptation
in the neonate involves five major changes: an increased aortic pressure and
decreased venous pressure; an increased systemic pressure and decreased
pulmonary pressure; and closure of the foramen ovale, the ductus arteriosus, and
the ductus venosus.
KEY: Integrated Process: Teaching and Learning | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Physiological Integrity |
Difficulty Level: Difficult
33. Upon assessment of the temperature of a newborn, the nurse recalls that the
__________ is the range of temperature in which the newborns body
temperature can be maintained with minimal metabolic demands and oxygen
consumption.
ANS: neutral thermal environment (NTE)
After ensuring effective respirations, facilitating a neutral thermal environment is
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an essential nursing action. Ideally, a supply of warm, dry linens should be
available to prevent neonatal cold stress.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
34. When assessing a newborn for coagulation factors, the perinatal nurse
recalls that coagulation factors to enable the newborn to effectively clot blood
after childbirth are activated by __________.
ANS: vitamin K
Due to the absence of vitamin K at birth, the neonate is at risk for developing a
blood clotting deficiency during the first few days of life. The infant is given an
intramuscular injection of vitamin K, phytonadione (AquaMEPHYTON), during the
initial care and assessment to prevent hemorrhagic disease of the newborn.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
35. The nurse explains to a pregnant patient that the mothers prior exposure to
illness and immunizations prompts the development of antibodies in the newborn
in a process termed __________ immunity.
ANS: active acquired
The pregnant womans exposure to illness and immunizations prompts the
development of antibodies in a process termed active acquired immunity. The
infant receives passive acquired immunity through antibodies that have been
passed through the placenta by way of the IgG immunoglobulins.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
36. The nurse is aware that the __________ state, which generally occurs during
the 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 infants alert states
result from choice or necessity. Stimuli that may prompt wakefulness include
hunger, cold, and heatonce the triggering stimuli are removed, the infant tends to
fall back to sleep.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
37. The gray, blue, or purple areas on the buttocks of a neonate are referred to
as __________.
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ANS: Mongolian spots
Mongolian spots are blue/gray areas on the buttocks that are frequently seen in
darker-skinned neonates.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
38. __________ is a vasomotor response to decreased body temperature after
birth.
ANS: Mottling
Mottling is a benign transient pattern of pink and white blotches on the skin in
response to a cold environment.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
39. As the perinatal nurse performs an assessment of the infants head, ears,
eyes, nose, and throat, the ears are noted to be low set. This clinical finding
would 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-set
ears may signal the need for further assessment and evaluation for chromosomal
abnormalities. Placement of one ear slightly lower than the other is a common
finding that generally has no clinical significance.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
40. Assessment of the infants anterior fontanel is an important part of the
physical 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 are
open and flat with no bulging or depression.
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Chapter 16. Discharge Planning and Teaching
1. A nurse is making a home visit on the seventh postpartum day to assess a 23year-old primipara woman and her full-term, healthy baby. Breastfeeding is the
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 little before each
feeding. The nurses best response is:
a. This is normal. You only have to be concerned when your baby does not gain
weight.
b. What types of foods are you eating? A lack of protein in the diet can cause
watery looking breast milk.
c. How much fluid are you drinking while you are nursing your baby? Too much
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 becomes richer in
appearance.
ANS: d
Feedback
a. Correct information but does not provide information for the woman to
understand the different types of milk.
b. Incorrect information.
c. Incorrect information.
d. Correct. This provides an explanation for the consistency of the milk and
reassures the woman that the appearance of the milk is normal.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
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 patient is:
a. I understand your concern, but your baby will be okay until your milk comes in.
b. Your baby seems content, so you should not worry about him getting enough
to eat.
c. Milk normally comes in around the third day. Prior to that, he is getting
colostrum which is high in protein and immunoglobulins which are important for
your babys 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 the
stages of milk.
b. This conveys a message that the womans concern is not important.
c. This response provides information on the stages of milk production to help the
woman understand her newborns nutritional needs.
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d. Incorrect response. It is important to avoid bottles until breastfeeding has been
well established.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
3. Which of the following positions for breastfeeding is preferred for a 2-day postcesarean-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 her
abdomen and the pain that can result from the pressure.
b. In this position, the baby is on the womans abdomen, and this can be painful
for the woman.
c. In this position, the baby is on the womans abdomen, and this can be painful
for the woman.
d. In this position, the baby is on the womans abdomen, and this can be painful
for the woman.
KEY: Integrated Process: Teaching and Learning | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Moderate
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 feeding
session and rub it on her nipples
d. Air drying nipples for 10 minutes at the end of the feeding session
ANS: a
Feedback
a. Correct. All of the answers are correct, but problems with latching-on are a
primary cause of nipple irritation.
b. All of the answers are correct, but problems with latching-on are a primary
cause of nipple irritation.
c. All of the answers are correct, but problems with latching-on are a primary
cause of nipple irritation.
d. All of the answers are correct, but problems with latching-on are a primary
cause of nipple irritation.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
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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 and an
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
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 of
learning needs based on early postpartum hemorrhage and returning to work in 3
months.
b. Because this is the womans first time breastfeeding and she plans to return to
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 are
high in iron.
c. These are important learning needs but do not reflect an understanding of
learning needs based on early postpartum hemorrhage and returning to work in 3
months.
d. These are important learning needs but do not reflect an understanding of
learning needs based on early postpartum hemorrhage.
KEY: Integrated Process: Teaching and Learning | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Health Promotion and
Maintenance | Difficulty Level: Difficult
6. Instructions to a mother of an uncircumcised male infant should include which
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 of
the foreskin and cause adhesions.
b. Retracting the foreskin can damage the inner layer of the foreskin and cause
adhesions.
c. Use of alcohol is irritating and painful.
d. Parents should not retract the foreskin. The foreskin will fully retract on its own
around 5 years of age.
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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
7. A mother of a 10-day-old infant calls the clinic and reports that her baby is
having loose, green stools. The mother is breastfeeding her infant. Which of the
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 to call
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 if the
stools continue to be loose and green.
ANS: a
Feedback
a. The loose, green stools indicate that the baby is having diarrhea. The infant
needs 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 further
dehydrate 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 treatment plan.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty
Level: Moderate
8. The perinatal nurse is teaching her new mother about breastfeeding and
explains 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 crying
ANS: b
The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is
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.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
9. Felicity Chan, a new mother, is accompanied by her mother during her hospital
stay on the postpartum unit. Felicitys mother makes specific, various requests of
the nurses including bringing warm tea, a cot to sleep on, and that the baby not
be bathed at this time. Felicitys mother is also concerned about the amount of
work that Felicity may be doing in the provision of infant care. Felicity asks for
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help with breastfeeding. After Felicity has finished breastfeeding, her mother
asks for a bottle so they can warm it and feed the baby. How would the perinatal
nurse best respond to Felicitys mother in a culturally sensitive way?
a. Ask Felicitys mother to leave for 30 minutes to allow for some private time with
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 to
both women to support Felicitys decision.
ANS: d
In certain multicultural populations such as India, Thailand, and China, the
womans 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 mothers body to regain balance after the birth of a child. To
provide sensitive, appropriate care, nurses need to adopt a flexible approach
when caring for women who embrace non-Western health beliefs and practices.
The nurse should advocate for the patient by inquiring about her feeding
preferences and by providing information to the mother and her family to support
her in her decision.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
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 following stages 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 last from
30 minutes to 2 hours.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
11. A nurse is providing discharge teaching to the parents of a 2-day-old
neonate. 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 days of
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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.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
12. The nurse is teaching the parents of a 1-day-old baby how to give their baby
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 inner to
the outer canthus.
b. Keeping doors open can cause a drop in babys temperature by convection.
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 when wet.
d. The safest way to check the temperature is with a thermometer or, if none,
with the elbow or forearm.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
13. The nurse is teaching the parents of a female baby how to change a babys
diapers. 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 of
female babies should always be cleansed from front to back.
b. Vernix is a natural lanolin that will be absorbed over time. Actively removing
the vernix can irritate the babys skin.
c. Powder is not recommended for use on babies. When mixed with urine,
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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.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
14. The nurse is advising parents of a full-term neonate being discharged from
the 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 of the
car.
c. A fist should fit between the straps of the seat and the babys 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 20 pounds,
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 be
inserted between them and the baby.
d. Seat belt adjusters that are being sold as adding to a car seat have not been
shown to be safe.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
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 infants bath should be 39C.
b. Crib slates should be a maximum of 3 inches apart.
c. Cover electrical outlets once the infant is crawling.
d. Remove strings from infant sleepwear.
ANS: d
Feedback
a. Water temperature should be 38C.
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 other
objects that come in contact with the infant to decrease the risk of strangulation.
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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16. Which of the following statements indicates that a new mother needs
additional 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 turn
over 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 because they
may roll or wiggle and fall off.
d. True statement.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
Multiple Response
17. The let-down reflex occurs in response to the release of oxytocin. Which of
the 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 the
release 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Easy
18. Which of the following are disadvantages of bottle feeding? (Select all that
apply.)
a. Hampers motherinfant attachment
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 motherinfant attachment.
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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.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy
19. The clinic nurse teaches expectant mothers about the differences between
breast 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 cows milk or infant formulas. Commercially prepared infant
formulas use vegetable oils which are void of cholesterol.
KEY: Integrated Process: Teaching/Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Difficult
20. The perinatal nurse is teaching the new mother who has chosen to formula
feed 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 manufacturers instructions
explicitly 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, and any unused
formula should be discarded. The nipples should be checked periodically during
feedings for correct flow and should be replaced regularly.
KEY: Integrated Process: Teaching and Learning | Client Need: Safe and
Effective Care Environment | Cognitive Level: Application | Content Area:
Maternity | Difficulty Level: Moderate
21. The perinatal nurse describes infant feeding cues to a new mother. These
feeding 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 mothers neck or shoulder, makes hand-tomouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting,
and demonstrates increased activity with the arms and legs flexed and the hands
in a fist.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
22. Typical signs of abusive head trauma (Shaken Baby Syndrome) include
which 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.
KEY: Integrated Process: Knowledge | Cognitive Level: Application | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty
Level: Moderate
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 and
face.
ANS: a, c, d
It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry
skin in the infant. The cleanser should be of neutral pH and free of additives such
as fragrances that could be irritants.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
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 that
apply.)
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 session
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ANS: b, c, d
Feedback
a. It is often helpful to have family members present, with the womans
permission, so they can also learn about caring for the newborn.
b. Turning off the TV decreases the amount of distractions and allows the woman
to focus on learning about infant care.
c. Closing the door decreases the amount of distractions and allows the woman
to focus on learning about infant care.
d. Administering analgesia prior to the teaching session will enhance the womans
comfort and facilitate her ability to focus on the teaching session.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Moderate
True/False
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 bacterial
and 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 passive
immunity, including the transfer of maternal antibodies.
KEY: Integrated Process: Clinical Problem Solving | Client Need: Health
Promotion and Maintenance | Cognitive Level: Application | Content Area:
Peds/Maternity | Difficulty Level: Moderate
26. It is a common custom for traditional Chinese women to bottle feed their
infants until their milk comes in.
ANS: True
It is common for traditional Chinese women to bottle feed until their milk comes
in.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
Fill-in-the-Blank
27. The clinic nurse discusses gradual warming of expressed breast milk or
formula and cautions against use of the __________ for heating breast milk 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 infants mouth, as this practice creates a choking
hazard.
KEY: Integrated Process: Teaching and Learning | Client Need: Health Promotion
and Maintenance | Cognitive Level: Application | Content Area: Peds/Maternity |
Difficulty Level: Moderate
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28. The perinatal nurse encourages all mothers to place their infants under 12
months of age in the supine position for sleeping, because a leading cause of
death for this age group is __________.
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 their backs has
decreased the risk of SIDS.
KEY: Integrated Process: Teaching and Learning | Client Need: Health Promotion
and Maintenance | Cognitive Level: Application | Content Area: Maternity |
Difficulty Level: Moderate
29. The perinatal nurse understands that the hormonal processes involved in
breastfeeding include decreased serum __________ and __________ levels
immediately following birth which lead to an increased serum __________ level
that 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 signals the anterior
pituitary gland to produce prolactin in readiness for lactation.
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Chapter 17. High-Risk Neonatal Nursing Care
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 weightb. Very low birth weightc.
Extremely low birth weightd. Very premature
ANS: a
Feedback
a. Neonates with a birth weight of less than 2500 grams but greater than 1500
grams are classified as low birth weight.
b. Neonates with birth weight less than 1500 grams but greater than 1000 grams
are classified as very low birth weight.
c. Neonates with birth weight less than 1000 grams are classified as extremely
low birth weight.
d. Neonates born less than 32 weeks gestation are classified as very premature.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
2. A nurse assesses that a 3-day-old neonate who was born at 34 weeks
gestation has abdominal distention and vomiting. These assessment findings are
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/or tense
anterior fontanel, and hyperglycemia.
d. Assessment findings related to NEC include abdominal distention, bloody
stools, abdominal distention, vomiting, and increased gastric residual. These
signs and symptoms are related to the premature neonates inability to fully digest
stomach contents and limitation in absorptive function.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
3. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The
neonate has a yellowish tint to the skin of the face. The mother is breastfeeding
her newborn. The nurse caring for this neonate would anticipate which of the
following interventions?a. Phototherapyb. Feeding neonate every 2 to 3 hoursc.
Switch from breastfeeding to bottle feeding
d. Assess red blood cell count
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ANS: b
Feedback
a. Phototherapy is considered when the levels are 12 mg/dL or higher when the
neonate 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
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 cannot
understand how her baby became infected. The best response by the nurse is:a.
Newborns are more susceptible to infections due to an immature immune
system. Would you like additional information on the newborn immune system?b.
The infection was transmitted to your baby during the birthing process. Do you
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 you have regarding your babys 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 womans concern.
b. Correct, but GBS is not a sexually transmitted disease.
c. Correct. This response answers her questions and allows her to ask additional
questions about her babys health.
d. Acknowledges that she is upset but does not provide immediate information.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity |
Difficulty Level: Difficult
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. Hypoglycemiab. Hypercalcemiac.
Cold stressd. Neonatal withdrawal
ANS: d
Feedback
a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability,
apnea, lethargy, and temperature instability, but not nasal congestion.
b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac
arrhythmias.
c. Signs and symptoms of cold stress are decreased temperature, cool skin,
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lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting.
d. These are common signs and symptoms of neonatal withdrawal.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Physiological Integrity; Physiological
Adaptation | Difficulty Level: Moderate
6. The following four babies are in the neonatal nursery. Which of the babies
should be seen by the neonatologist as soon as possible?
a. 1-day-old, HR 170 bpm, crying
b. 2-day-old, T 98.9F, 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 tachycardia170 bpmis 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.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Analysis |
Content Area: Newborn Care; Physiological Adaptation: Alterations in Body
Systems | Client Need: Health Promotion and Maintenance; Physiological
Integrity: Physiological Adaptation | Difficulty Level: Difficult
7. A multipara, 26 weeks gestation and accompanied by her husband, has just
delivered a fetal demise. Which of the following nursing actions is appropriate at
this time?
a. Encourage the parents to pray for the babys soul.
b. Advise the parents that it is better for the baby to have died than to have had
to live with a defect.
c. Encourage the parents to hold the baby.
d. Advise the parents to refrain from discussing the babys death with their other
children.
ANS: c
Feedback
a. It is inappropriate for the nurse to advise prayer. The parents must decide for
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 the
grieving process.
d. This is an inappropriate suggestion. It is very important for the parents to
clearly communicate the babys death with their other children.
KEY: Integrated Process: Caring; Communication and Documentation; Nursing
Process: Implementation | Cognitive Level: Application | Content Area: Coping
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Mechanisms; Grief and Loss; Support System | Client Need: Psychosocial
Integrity | Difficulty Level: Moderate
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
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 be notified.
d. Vaginal bleeding is a normal finding.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Newborn Care; Physiological Adaptation: Medical
Emergencies | Client Need: Health Promotion and Maintenance; Physiological
Integrity: Physiological Adaptation | Difficulty Level: Moderate
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 is critical 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 to
promote health for the baby is for the health-care team to establish an airway that
is free of meconium.
c. This action is appropriate. The baby needs to be intubated in order for deep
suctioning to be performed by the physician. A nurse would not intubate and
suction but rather would assist with the procedures.
d. It is strictly contraindicated to stimulate the baby to cry until the trachea has
been suctioned. The baby would aspirate the meconium-stained fluid, which
could result in meconium-aspiration syndrome.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Newborn 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
10. A 42-week gestation neonate is admitted to the NICU (neonatal intensive
care unit). This neonate is at risk for which complication?
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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 is
green 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.
KEY: Integrated Process: Nursing Process: Analysis | Client Need: Health
Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential |
Cognitive Level: Application | Content Area: Newborn Care; Reduction of Risk
Potential: Potential for Alterations in Body Systems | Difficulty Level: Moderate
11. A 1-day-old neonate in the well-baby nursery is suspected of suffering from
drug 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 states
and sleep very poorly.
b. There is nothing in the scenario that indicates that this child is hypovolemic or
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.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Application | Content Area: Chemical and Other Dependencies; Newborn Care;
Physiological Adaptation: Alterations in Body Systems | Client Need: Health
Promotion and Maintenance; Physiological Integrity: Physiological Adaptation;
Psychosocial Integrity | Difficulty Level: Moderate
12. A baby boy was just born to a mother who had positive vaginal cultures for
group 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
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ANS: a
Feedback
a. This infant is high risk for respiratory distress. The nurse should observe this
baby 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 in the
mother.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Application | Content Area: Newborn 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
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 nurse
interprets the result as which of the following?
a. The babys lung fields are mature.
b. The mother is high risk for hemorrhage.
c. The babys kidneys are functioning poorly.
d. The mother is high risk for eclampsia.
ANS: a
Feedback
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.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Antepartum Care; Developmental Stages and
Transitions | Client Need: Health Promotion and Maintenance | Difficulty Level:
Moderate
14. Which of the following neonatal signs or symptoms would the nurse expect to
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 affects
the central nervous system. Babies are often sleepy and feed poorly when the
bilirubin level is elevated.
c. Hyperactivity is the opposite of the behavior one would expect the baby to
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exhibit.
d. Hyperthermia is not directly related to an elevated bilirubin level.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Application | Content Area: Newborn Care; Potential for Alterations in Body
Systems; Reduction of Risk Potential: Laboratory Values | Client Need: Health
Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential |
Difficulty Level: Difficult
15. The perinatal nurse is assisting the student nurse with completion of
documentation. The laboring woman has just given birth to a 2700 gram infant at
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.
KEY: Integrated Process: Communication and Documentation | Cognitive Level:
Analysis | Content Area: Peds/Maternity | Client Need: Safe and Effective Care
Environment | Difficulty Level: Difficult
16. The NICU nurse recognizes that respiratory distress syndrome results from a
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
maturity of fetal lungs.
b. Calcium is needed to prevent undermineralization of bones.
c. Respiratory distress syndrome (RDS) is a developmental respiratory disorder
that 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
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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 milk every 3
hours. The nurses best response to the patients mother would be:
a. Pumping is hard work and you are doing very well. It is good to get about 1
ounce of milk every 3 hours.
b. Natural breastfeeding will be a challenging goal for your baby. Beginning
today, 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 can
begin 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 map
out 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 more
milk.
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 will help
the mother keep her milk flow steady and provide enough nutrients for the infant
after discharge.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
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 this
neonate? (Select all that apply.)
a. Exogenous surfactant
b. Corticosteroids
c. Continuous positive airway pressure (CPAP)
d. Bronchodilators
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 of
RDS.
c. CPAP is used to assist neonates with RDS.
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d. Bronchodilators are given to neonates with bronchopulmonary dysplasia
(BPD).
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation
| Difficulty Level: Moderate
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 necrosis of
the bowel.
b. Preterm neonates are predisposed to NEC due to alteration in blood flow to
the intestines, impaired gastrointestinal host defense, and alteration in
inflammatory response.
c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the
intestines, impaired gastrointestinal host defense, and alteration in inflammatory
response.
d. Bacterial colonization in the intestines can occur from contaminated feeding
tubes causing an inflammatory response in the bowel.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Health Promotion and
Maintenance |Difficulty Level: Difficult
20. Nursing actions that decrease the risk of skin breakdown include which of the
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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
21. Nursing actions that minimize oxygen demands in the neonate include which
of the following? (Select all that apply.)
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a. Providing frequent rest breaks when feeding
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 increases
oxygen 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 neonates
body temperature which leads to an increase in respiratory and heart rate that
leads to an increase in oxygen consumption.
d. Clustering of nursing care decreases stress which decreases oxygen
requirements.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation
| Difficulty Level: Difficult
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 signs
of 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 neonates 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 in
the evaluation of the degree of digestion and absorption.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
23. Which of the following are common assessment findings of postmature
neonates? (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
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a. Vernix caseosa covers the fetuss body around 17 to 20 weeks gestation; as
pregnancy advances, the amount of vernix decreases. Vernix prevents water loss
from the skin to the amniotic fluid; as the amount of vernix decreases, an
increasing amount of water is lost from the skin. This contributes to the dry and
peeling skin seen in postmature neonates.
b. Vernix caseosa covers the fetuss body around 17 to 20 weeks gestation; as
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 fat
stores and glycemic stores. This results in the thin and wasted appearance of the
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 fat
stores and glycemic stores. This results in the thin and wasted appearance of the
neonate and risk for hypoglycemia during the first few hours post-birth.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Easy
24. A nurse is caring for a 40 weeks gestation neonate. The neonate is 12 hours
post-birth 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 neonates 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 neonates 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 neonates 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.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
25. A nurse is completing the initial assessment on a neonate of a mother with
type I diabetes. Important assessment areas for this neonate include which of the
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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 cardiac
anomalies.
b. Neonates of mothers with type I diabetes are at higher risk for RDS due to a
delay in surfactant production related to high maternal glucose levels.
c. Neonates of mothers with type I diabetes are usually large and are at risk for a
fractured clavicle.
d. Neonates of mothers with type I diabetes are at higher risk for neurological
damage and seizures due to neonatal hyperinsulinism.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level:
Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation
| Difficulty Level: Difficult
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 nurses 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 babys 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 skin
and mucus membranes, poor intake, concentrated urine or limited urine output,
and irritability. The newborn should also be kept warm while receiving
phototherapy. When an infant is under phototherapy, the temperature needs to
be monitored closely because the lights give off extra heat, but if the newborn is
in an open crib and undressed, hypothermia may occur. Hypomagnesia and
hypoglycemia are not related to phototherapy.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
27. The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at
26 weeks gestation, is providing discharge teaching. Emily is going to travel to
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 all
that apply):
a. In control
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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.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
28. A baby has just been admitted into the neonatal intensive care unit with a
diagnosis of intrauterine growth restriction (IUGR). Which of the following
maternal problems could have resulted in this complication? (Select all that
apply.)
a. Cholecystitis
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.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Antepartum Care | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
Fill-in-the-Blank
29. The perinatal nurse assessing a newborn for jaundice recalls that
__________ 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 newborns liver.
Conjugation is a process that converts the yellow lipid-soluble (nonexcretable)
bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Difficult
30. Providing information to parents about jaundice constitutes an important
component of the nurses 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.
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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 bloodbrain barrier, it can damage the cerebrum, causing a 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, and the function
of the surviving neurons.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
31. The NICU nurse recognizes that the infant who requires ventilation for
meconium aspiration syndrome is most often __________.
ANS: post-term
Meconium aspiration pneumonia occurs in 10% to 26% of all deliveries, and the
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.)
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Easy
32. The NICU nurses 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
gestation. The definition of premature is a neonate born between 32 and 34
weeks gestation. The definition of late premature is a neonate born between 34
and 37 weeks gestation.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis |
Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Difficult
33. Part of the assessment of a preterm infant includes obtaining an abdominal
girth 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 measure
and record frequent abdominal circumferences, auscultate bowel sounds before
every feeding, and observe the abdomen for distention (observable loops or
shiny skin indicating distention).
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Chapter 18. Well Women’s Health
1. Physical activity can lower a womans risk for (select all that apply):
a. Endometriosis
b. Depression
c. Colon cancer
d. Arthritis
ANS: b, c
According to the US Department of Health and Human Services, Office of
Womens Health, physical activity can lower a womans risk for heart disease,
type 2 diabetes, colon cancer, breast cancer, falls, and depression.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Health Promotion | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
2. During a routine physical of a 31-year-old non-Hispanic black woman, it was
noted that the womans BMI is 32, her only exercise is taking care of her two
children, her last Pap test was 2 years ago, and her last clinical breast exam was
2 years ago. Based on this information the woman (select all that apply):
a. Needs to be scheduled for a Pap test
b. Needs to be scheduled for a clinical breast exam
c. Is at risk for type 2 diabetes
d. Is at risk for depression
ANS: c, d
Recommended screenings for women ages 19 to 39 are clinical breast exams
and Pap test every 3 years. Obesity (a BMI of 30 or greater) places the woman at
risk for type 2 diabetes; decreased physical activity places the woman at risk of
depression.
KEY: Integrated Process: Nursing Process | Cognitive Level: Application and
Comprehension | Content Area: Health Promotion | Client Need: Health
Promotion and Maintenance | Difficulty Level: Hard
3. Excessive drinking places the woman at risk for (select all that apply):
a. Suicide
b. Stroke
c. Breast cancer
d. Menstrual disorders
ANS: a, b, c
Excessive drinking places a woman at risk for alcoholism, elevated blood
pressure, obesity, diabetes, stroke, breast cancer, suicide and accidents.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Health Promotion | Client Need: Reduction of Risk Potential |
Difficulty Level: Moderate
4. The womans health clinic nurse is providing information to a 21-year-old
woman who is being scheduled for a pelvic exam and Pap test. This information
should include (select all that apply):
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a. The Pap test is a diagnostic test for cervical cancer.
b. The woman should not use tampons or vaginal medication or engage in sexual
intercourse within 48 hours of the exam.
c. The best time to have a Pap test is 5 days after the menstrual period has
ended.
d. The woman should have a yearly Pap test.
ANS: 2, 3
The Pap test is a screening versus a diagnostic test. Women should not douche;
use tampons; use vaginal creams, spermicide foams, creams, or jellies; use
vaginal lubricants or moisturizers; use vaginal medications; or have sexual
intercourse for 48 hours prior to the exam. The best time to obtain a Pap test is 5
days after the period ends. Women ages 19 to 39 should have a Pap test every 3
years.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application
and Comprehension | Content Area: Diagnostic Tests | Client Need: Health
Promotion and Maintenance | Difficulty Level: Hard
5. A 60-year-old woman is scheduled for a dual-energy X-ray absorptiometry
scan (DXA). The womans health clinic nurse should provide the following
information:
a. DXA is a diagnostic test for osteoporosis.
b. DXA measures the bone density of the hip, spine, and forearm.
c. The T score is a comparison of the womans bone density with that of other
women her age.
d. Osteoporosis can cause a stooped posture.
ANS: a, b, d
Answers a, b, and d are true statements. A T-score is a comparison of the
womans bone density with that of a woman 30 years of age and the same race.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Diagnostic Tests | Client Need: Health Promotion and
Maintenance | Difficulty Level: Hard
6. Lesbians are at higher risk for breast, cervical, endometrial, and ovarian
cancer than heterosexual women due to (select all that apply):
a. A higher percentage of lesbians are smokers
b. Lesbians are less likely to have a Pap test
c. A higher percentage of lesbians are obese
d. Lesbians are less likely to exercise
ANS: a, b, c
Lesbians have higher rates of smoking, alcohol use, and obesity. They are also
less likely to follow the recommended frequency of health screening tests. These
behaviors place a woman at higher risk for breast and gynecological cancers.
KEY: Integrated Process: Knowledge | Cognitive Level: Analysis | Content Area:
Health Promotion | Client Need: Reduction of Risk Potential | Difficulty Level:
Hard
True/False
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7. Lesbian women are at a higher risk for heart disease than heterosexual
women.
ANS: True
The rates of smoking and obesity in lesbians are higher than those of
heterosexual women which places them at higher risk for heart disease.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level:
Application | Content Area: Health Promotion | Client Need: Reduction of Risk
Potential | Difficulty Level: Moderate
8. Which of the following women is at highest risk for osteoporosis?
a. A 70-year-old non-Hispanic white woman who has smoked for 50 years
b. A 70-year-old non-Hispanic black woman who is a heavy drinker
c. A 60-year-old Asian woman who takes steroids to treat SLE
d. A 70-year-old Hispanic woman who has had weight loss surgery
ANS: a
Each of the women has a risk factor for osteoporosis, but answer (a) has the
additional risk factor of being a non-Hispanic white woman.
KEY: Integrated Process: Critical Thinking | Cognitive Level: Synthesis | Content
Area: High Risk Behaviors | Client Need: Reduction of Risk Potential | Difficulty
Level: Hard
Multiple Choice
9. A 65-year-old woman is complaining of jaw pain, nausea, shortness of breath
without chest pain, and sweating. These are warning signs of:
a.. Heart attack
b. Stroke
c. Diabetes
d. Dental disease
ANS: a
Warning signs of heart attack in women are uncomfortable pressure, squeezing,
fullness, or pain in the center of the chest; pain or discomfort in one or both arms;
shortness of breath with or without chest discomfort; nausea; lightheadedness;
sweating.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level:
Assessment | Content Area: Physiological Adaptation | Client Need: Safe and
Effective Care Environment | Difficulty Level: Easy
10. Which of the following foods is highest in calcium?
a. An 8 oz. glass of milk
b. A 1.5 oz. piece of cheddar cheese
c. An 8 oz. container of plain, low-fat yogurt
d. A 3 oz. piece of salmon
ANS: c
Milk has 293 mg of calcium; cheddar cheese has 307 mg; yogurt has 415;
salmon has 181 mg.
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Chapter 19. Alterations in Women’s Health
1. Postoperative nursing care for a woman who had a total hysterectomy includes
(select all that apply):
a. Administering hormone replacement therapy as per MD orders
b. Informing the woman that she will experience small amounts of vaginal
bleeding for several days
c. Instructing the woman to use tampons
d. Instructing the woman to increase her ambulation to facilitate return of normal
intestinal peristalsis
ANS: b, d
Feedback
a. Hormone therapy is ordered for women who had a hysterectomy with salpingooophorectomy.
b. Women will experience a few days of vaginal bleeding.
c. Women should not put anything into the vagina until the area has healed.
d. Ambulation decreases the risk for deep vein thrombosis and also facilitates
intestinal peristalsis.
KEY: Integrated Process: Nursing Process | Cognitive Level: Application and
Comprehension | Content Area: Womens Health | Client Need: Safe and
Effective Care Environment | Difficulty Level: Hard
2. Menorrhagia may result from (select all that apply):
a. Anovulatory cycle
b. Metritis
c. Anorexia
d. Emotional distress
ANS: a, b
Metritis can be a cause of menorrhagia.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Womens Health | Client Need: Physiological Adaptation | Difficulty
Level: Moderate
3. Secondary amenorrhea results from (select all that apply):
a. Polycystic ovary syndrome
b. Diabetes
c. Metritis
d. Pregnancy
ANS: a, b, d
Nutritional disturbances such as anoxia and emotional distress can cause
secondary amenorrhea.
KEY: Integrated Process: Knowledge | Cognitive Level: Knowledge | Content
Area: Womens Health | Client Need: Physiological Adaptation | Difficulty Level:
Moderate
4. During a health visit, a 23-year-old patient shares with her health-care provider
that she has been experiencing a yellowish mucus vaginal discharge, pain during
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sexual intercourse, and burning on urination. A culture of the cervical epithelial
cells is obtained. Based on the patient information, the culture is obtained to
assist in the diagnosis of which of the following? (Select all that apply.)
a. Chlamydia
b. Gonorrhea
c. Genital herpes
d. Syphilis
ANS: a, b
These are symptoms that can be related to either chlamydia or gonorrhea.
Syphilis is diagnosed via blood test. Genital herpes has symptoms similar to the
flu, and the person usually has an itching or burning sensation in the genital or
anal area.
KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level:
Knowledge | Content Area: Diagnostic Tests | Client Need: Health Promotion and
Maintenance | Difficulty Level: Moderate
5. A woman who is receiving radiation therapy for treatment of stage I cervical
cancer is experiencing diarrhea. She contacts the oncology advice nurse. The
advice nurse recommends that the woman (select all that apply):
a. Eat five or six small meals a day instead of three large meals
b. Eat cooked vegetables instead of raw vegetables
c. Use baby wipes instead of toilet paper
d. Reduce fluid intake to four glasses of water
ANS: a, b, c
Radiation damages the cells of the intestines. Interventions are aimed at
decreasing stress on the intestines such as eating small, frequent meals and
foods low in fiber. Baby wipes help reduce irritation to the anal area. A person
should increase fluid intake to compensate for fluid loss caused by the diarrhea.
KEY: Integrated Process: Nursing Process | Cognitive Level: Synthesis | Content
Area: Health Promotion | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate
Multiple Choice
6. A primary topic for health promotion for a 25-year-old woman with a history of
polycystic ovary syndrome is (select the most important topic):
a. The adverse effects of cigarette smoking
b. The adverse effects of excessive alcohol consumption
c. Nutrition
d. Self-esteem issues
ANS: c
Women with PCOS are at higher risk for being obese. Obesity increases the
womans risk for type 2 diabetes. Obesity and type 2 diabetes increase the
womans risk for cardiovascular disease, hypertension, dyslipidemia, and
metabolic syndrome. It is also important to talk about self-esteem issues related
to hirsutism and the effects of smoking and drinking, but the long-term effects of
obesity are a greater risk to a woman with PCOS.
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KEY: Integrated Process: Teaching and Learning | Cognitive Level: Analysis |
Content Area: Womens Health | Client Need: Reduction of Risk Potential |
Difficulty Level: Hard
7. Which of the following is correct regarding endometriosis?
a. The physical symptoms of endometriosis can affect the womans mental
health.
b. The abnormal tissue bleeds into surrounding tissue during the secretory stage
of the menstrual cycle.
c. Endometriosis causes sterility.
d. Metronidazole is used to treat endometriosis.
ANS: a
Feedback
a. The physical symptoms can have an effect on the womans mental health. The
woman may experience anger and grief related to loss of fertility. The pain of
endometriosis can interfere with social activities, and dyspareunia can have an
effect on intimate relationships.
b. In endometriosis, there is an abnormal tissue response to the changes of
hormone levels of the menstrual cycle and the tissue breaks down and bleeds
into surrounding areas during the menstrual phase.
c. Endometriosis has an effect on fertility but does not cause sterility.
d. Metronidazole is used to treat trichomoniasis.
KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge |
Content Area: Womens Health | Client Need: Psychological Integrity | Difficulty
Level: Moderate
8. The daughter of an 85-year-old woman informs the doctor that her mother has
suddenly become disoriented/confused and that she is dizzy and having difficulty
with her balance. She is agitated and has fallen twice in the last 24 hours. The
patients blood pressure and VS are within normal limits. Her medications include
Synthroid, Lisinopril, and Crestor. Based on this data, the woman is most likely
experiencing:
a. Stroke
b. Beginning stages of dementia
c. Urinary tract infection
d. Adverse reaction to her medications
ANS: c
These are classic signs/symptoms of a UTI in older women.
9. A total hysterectomy is the removal of:
a. The uterus
b. The uterus and cervix
c. The uterus, cervix, fallopian tubes, and ovaries
d. The uterus, cervix, fallopian tubes, ovaries, upper portion of the vagina, and
lymph nodes
ANS: b Feedback
a. This is a supracervical hysterectomy.
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b. This constitutes a total hysterectomy.
c. This would be a salpingo-oophorectomy.
d. This is a radical hysterectomy.