Chapter 10: Complications of Pregnancy
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A patient with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this
medication is a
a. diuretic.
b. tocolytic.
c. anticonvulsant.
d. antihypertensive.
ANS: C
Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure
activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine
contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side
effect) of the anticonvulsant magnesium sulfate.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
2. Which clinical intervention is the only known cure for preeclampsia?
a. Magnesium sulfate
b. Delivery of the fetus
c. Antihypertensive medications
d. Administration of aspirin (ASA) every day of the pregnancy
ANS: B
Delivery of the infant is the only known intervention to halt the progression of preeclampsia. Magnesium sulfate is one of the
medications used to treat but not cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated
blood pressures in preeclampsia and eclampsia. Low doses of aspirin (81 mg/day) have been administered to women at high risk
for developing preeclampsia. This intervention appears to have little benefit.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
3. The clinic nurse is performing a prenatal assessment on a pregnant patient at risk for preeclampsia. Which clinical sign would not
present as a symptom of preeclampsia?
a. Edema
b. Proteinuria
c. Glucosuria
d. Hypertension
ANS: C
Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign noted by the pregnant patient is rapid
weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension. The first
indication of preeclampsia is usually an increase in the maternal blood pressure.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
a. Abdominal palpation
b. Venous sample of blood
c. Checking deep tendon reflexes
d. Auscultation of the heart and lungs
ANS: A
Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the
subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated.
Venous blood is checked frequently to observe for thrombocytopenia.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
5. A nurse is explaining to the nursing students working on the antepartum unit how to assess for edema. Which edema assessment
score indicates edema of the lower extremities, face, hands, and sacral area?
a. +1
b. +2
c. +3
d. +4
ANS: C
Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the
lower extremities. Marked edema of the lower extremities is +2 edema. Generalized massive edema (+4) includes the accumulation
of fluid in the peritoneal cavity.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
Copyright © 2019, Elsevier Inc. All Rights Reserved.
1
6. Which maternal condition always necessitates delivery by cesarean birth?
a. Partial abruptio placentae
b. Total placenta previa
c. Ectopic pregnancy
d. Eclampsia
ANS: B
In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal birth occurred. If the
patient has stable vital signs and the fetus is alive, a vaginal birth can be attempted. If the fetus has already expired, a vaginal birth
is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester.
Labor can be safely induced if the eclampsia is under control.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. Spontaneous termination of a pregnancy is considered to be an abortion if
a. the pregnancy is less than 20 weeks.
b. the fetus weighs less than 1000 g.
c. the products of conception are passed intact.
d. there is no evidence of intrauterine infection.
ANS: A
An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered
because some fetuses of an older age may have a low birth weight. A spontaneous abortion may be complete or incomplete. A
spontaneous abortion may be caused by many problems, one being intrauterine infection.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
8. An abortion when the fetus dies but is retained in the uterus is called
a. inevitable.
b. missed.
c. incomplete.
d. threatened.
ANS: B
A missed abortion refers to a dead fetus being retained in the uterus. An inevitable abortion means that the cervix is dilating with
the contractions. An incomplete abortion means that not all the products of conception were expelled. With a threatened abortion,
the patient has cramping and bleeding but not cervical dilation.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. A placenta previa when the placental edge just reaches the internal os is called
a. total.
b. partial.
c. low-lying.
d. marginal.
ANS: D
A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta
completely covers the os. With a partial previa, the lower border of the placenta is within 3 cm of the internal cervical os but does
not completely cover the os. A complete previa is termed total. The placenta completely covers the internal cervical os.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. Which finding would indicate concealed hemorrhage in abruptio placentae?
a. Bradycardia
b. Hard boardlike abdomen
c. Decrease in fundal height
d. Decrease in abdominal pain
ANS: B
Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta
and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. The patient will have
shock symptoms that include tachycardia. The fundal height will increase as bleeding occurs. Abdominal pain may increase
significantly.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
Copyright © 2019, Elsevier Inc. All Rights Reserved.
2
11. The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to
a. monitor uterine contractions.
b. assess fetal heart rate and maternal vital signs.
c. place clean disposable pads to collect any drainage.
d. perform a venipuncture for hemoglobin and hematocrit levels.
ANS: B
Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss
and its effect on the patient and fetus. Monitoring uterine contractions is important; however, not the top priority. It is important to
assess future bleeding, but the top priority is patient and fetal well-being. The most important assessment is to check patient and
fetal well-being. The blood levels can be obtained later.
DIF:
Cognitive Level: Application
12. A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is
based on the knowledge that these signs indicate
a. gastrointestinal upset.
b. effects of magnesium sulfate.
c. anxiety caused by hospitalization.
d. worsening disease and impending convulsion.
ANS: D
Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic
capsules and often warns that a convulsion is imminent. Gastrointestinal upset is not an indication as severe as the headache and
visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe
anxiety.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
13. Rh incompatibility can occur if the patient is Rh-negative and the
a. fetus is Rh-negative.
b. fetus is Rh-positive.
c. father is Rh-positive.
d. father and fetus are both Rh-negative.
ANS: B
For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive. If the fetus is Rh-negative, the blood
types are compatible and no problems should occur. The father’s Rh factor is a concern only as it relates to the possible Rh factor
of the fetus. If the fetus is Rh-negative, the blood type with the mother is compatible. The father’s blood type does not enter into the
problem.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
14. In which situation would a dilation and curettage (D&C) be indicated?
a. Complete abortion at 8 weeks
b. Incomplete abortion at 16 weeks
c. Threatened abortion at 6 weeks
d. Incomplete abortion at 10 weeks
ANS: D
D&C is carried out to remove the products of conception from the uterus and can be performed safely until week 14 of gestation. If
all the products of conception have been passed (complete abortion), a D&C is not necessary. If the pregnancy is still viable
(threatened abortion), a D&C is not indicated.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
15. Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?
a. Ovarian cyst 2 years ago
b. Recurrent pelvic infections
c. Use of oral contraceptives for 5 years
d. Heavy menstrual flow of 4 days’ duration
ANS: B
Infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for
implantation. Ovarian cysts do not cause scarring of the fallopian tubes. Oral contraceptives do not increase the risk for ectopic
pregnancies. Heavy menstrual flow of 4 days’ duration will not cause scarring of the fallopian tubes, which is the main risk factor
for ectopic pregnancies.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
Copyright © 2019, Elsevier Inc. All Rights Reserved.
3
16. Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
a. Blood pressure of 120/80 mm Hg
b. Complaint of frequent mild nausea
c. Fundal height measurement of 18 cm
d. History of bright red spotting for 1 day weeks ago
ANS: C
The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy.
A patient with a molar pregnancy may have early-onset, pregnancy-induced hypertension. Nausea increases in a molar pregnancy
because of the increased production of human chorionic gonadotropin (hCG). The history of bleeding is normally described as
being of a brownish color.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
17. Which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?
a. Determining cervical dilation and effacement
b. Monitoring FHR and maternal vital signs
c. Observing vaginal bleeding or leakage of amniotic fluid
d. Determining frequency, duration, and intensity of contractions
ANS: A
Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage. Monitoring FHR and
maternal vital signs is a necessary part of the assessment for this patient. Monitoring for bleeding and rupture of membranes is not
contraindicated with this patient. Monitoring contractions is not contraindicated with this patient.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
18. A laboratory finding indicative of DIC is one that shows
a. decreased fibrinogen.
b. increased platelets.
c. increased hematocrit.
d. decreased thromboplastin time.
ANS: A
DIC develops when the blood-clotting factor thromboplastin is released into the maternal bloodstream as a result of placental
bleeding. Thromboplastin activates widespread clotting, which uses the available fibrinogen, resulting in a decreased fibrinogen
level. The platelet count will decrease. The hematocrit may decrease if bleeding is pronounced. The thromboplastin time is
prolonged.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
19. Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of
medication?
a. Drowsiness
b. Urinary output of 20 mL/hour
c. Normal deep tendon reflexes
d. Respiratory rate of 10 to 12 breaths per minute
ANS: C
Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep
tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should
decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A
urinary output of 20 mL/hour is inadequate output. A respiratory rate of 10 to 12 breaths per minute is too slow and could be
indicative of magnesium toxicity.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
20. A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication,
which action should the nurse take?
a. Increase the patient’s IV fluids.
b. Administer calcium gluconate.
c. Vigorously stimulate the patient.
d. Instruct the patient to take deep breaths.
ANS: B
Calcium gluconate reverses the effects of magnesium sulfate. Increasing the patient’s IV fluids will not reverse the effects of the
medication. Stimulation will not increase the respirations. Deep breaths will not be successful in reversing the effects of the
magnesium sulfate.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
Copyright © 2019, Elsevier Inc. All Rights Reserved.
4
21. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following?
a. Hemorrhage is the primary concern.
b. She will be unable to conceive in the future.
c. Bed rest and analgesics are the recommended treatment.
d. A D&C will be performed to remove the products of conception.
ANS: A
Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, the patient’s fertility will decrease; however, she
will be able to achieve a future pregnancy. The recommended treatment is to remove the pregnancy before hemorrhage occurs. A
D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
22. A patient who was pregnant had a spontaneous abortion at approximately 4 weeks’ gestation. At the time of the miscarriage, it was
thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of
“crampy” abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is
negative. Vital signs reveal a temperature of 100°F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm),
and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?
a. Ectopic pregnancy
b. Uterine infection
c. Gestational trophoblastic disease
d. Endometriosis
ANS: B
The patient is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and
blood pressure and pulse manifesting as shock-trended vitals. Because the pregnancy test is negative, an undiagnosed ectopic
pregnancy and gestational trophoblastic disease are ruled out. There is no supportive evidence to indicate a clinical di agnosis of
endometriosis at this time; however, it is more likely that this is an infectious process that must be aggressively treated.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
23. A patient with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor
period, vital signs were normal. At birth, significant maternal hypertension is noted. When the patient is questioned, she relates that
there is history of heart disease in her family; but, that she has never been treated for hypertension. Blood pressure is treated in the
hospital setting and the patient is discharged. The patient returns at her scheduled 6-week checkup and is found to be hypertensive.
Which type of hypertension is the patient is exhibiting?
a. Pregnancy-induced hypertension (PIH)
b. Gestational hypertension
c. Preeclampsia superimposed on chronic hypertension
d. Undiagnosed chronic hypertension
ANS: D
Even though the patient has no documented prenatal care or medical history, she does relate a family history that is positive for
heart disease. Additionally, the patient’s blood pressure increased following birth and was treated in the hospital and resolved. Now
the patient appears at the 6-week checkup with hypertension. Typically, gestational hypertension resolves by the end of the 6-week
postpartum period. The fact that this has not resolved is suspicious for undiagnosed chronic hypertension. There is no evidence to
suggest that the patient was preeclamptic prior to the birth.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
24. A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is
delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing
HELLP syndrome?
a. Platelet count of 50,000/mcL
b. Liver enzyme levels within normal range
c. Negative for edema
d. No evidence of nausea or vomiting
ANS: A
HELLP syndrome is characterized by Hemolysis, Elevated Liver enzyme levels, and a Low platelet count. A platelet count of
50,000/mcL indicates thrombocytopenia.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Pathophysiology
Copyright © 2019, Elsevier Inc. All Rights Reserved.
5
25. As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of
traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive.
Based on this information, you anticipate that
a. immediate birth is required.
b. the patient should be transferred to the critical care unit for closer observation.
c. RhoGAM should be administered.
d. a tetanus shot should be administered.
ANS: A
A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication
and, because the patient is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore the patient should be
delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered,
because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time
because there is no evidence of penetrating trauma. The patient should be transferred to the obstetric area for birth, not the critical
care unit setting.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity: Medical Emergencies
26. A patient who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1
week later complaining that she is now in labor. The labor and birth nurse performs the following assessments. The vaginal exam is
deferred until the physician is in attendance. The patient is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130
bpm is noted. No contraction pattern is observed. The patient is then transferred to the antepartum unit for continued observation.
Several hours later, the patient complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height
of 34 cm. Muscle tone is no different from earlier in the hospital admission. The patient is placed on the EFM and no fetal heart
tones are observed. What does the nurse suspect is occurring?
a. Placental previa
b. Active labor has started
c. Placental abruption
d. Hidden placental abruption
ANS: D
The patient’s signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence
of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention
and imminent birth.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity: Medical Emergencies
27. What is the priority nursing intervention for the patient who has had an incomplete abortion?
a. Methylergonovine (Methergine), 0.2 mg IM
b. Preoperative teaching for surgery
c. Insertion of IV line for fluid replacement
d. Positioning of patient in left side-lying position
ANS: C
Initial treatment of an incomplete abortion should be focused on stabilizing the patient’s cardiovascular state. Methylergonovine
would be administered after surgical treatment, preoperative teaching is not a priority until the patient is stabilized, and the left
side-lying position provides no benefit to the patient in this situation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment: Management of Care
28. Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
a. Urine output of 30 mL in 1 hour
b. Blood pressure of 110/60 mm Hg
c. Bleeding at IV insertion site
d. Respiratory rate of 16 breaths per minute
ANS: C
DIC is a life-threatening defect in coagulation that may occur following abruptio placentae. DIC allows excess bleeding from any
vulnerable area such as IV sites, incisions, gums, or nose. A urine output of 30 mL in 1 hour, blood pressure of 110/60 mm Hg, and
respiratory rate of 16 breaths per minute are normal findings in a postpartum patient.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
29. Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?
a. Saturated perineal pad in 1 hour
b. Pain level 0 on a scale of 0 to 10
c. Cervical dilation at 2 cm
d. Fetal heart rate at 160 bpm
ANS: B
The classic sign of placenta previa is the sudden onset of painless uterine bleeding, whereas abruptio placentae results in abdominal
pain and uterine tenderness; heavy bleeding, cervical dilation, and fetal heart rate of 160 bpm could be associated with both
conditions.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Safe and Effective Care Environment: Management of Care
Copyright © 2019, Elsevier Inc. All Rights Reserved.
6
30. A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
a. 1800
b. 450
c. 900
d. 90
ANS: C
One g equals 1 mL of blood.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
31. Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?
a. Assessment of pain level
b. Administration of methotrexate
c. Administration of Rh immune globulin
d. Explanation of the common side effects of the treatment plan
ANS: B
The goal of medical management of an intact tube is to preserve the tube and improve the chance of future fertility. Methotrexate (a
folic acid antagonist) is used to inhibit cell division and stop growth of the embryo. Assessment of pain level, administration of Rh
immune globulin, and explaining common side effects of the treatment plan should be implemented in conjunction with or soon
after treatment with methotrexate has begun.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Safe and Effective Care Environment: Management of Care
32. Which finding in the exam of a patient with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion?
a. Presence of backache
b. Rise in hCG level
c. Clear fluid from vagina
d. Pelvic pressure
ANS: C
Clear fluid from the vagina indicates rupture of the membranes. Abortion is usually inevitable (cannot be stopped) when the
membranes rupture, the presence of backache and pelvic pressure are common symptoms in threatened abortion, and a rise in the
hCG level is consistent with a viable pregnancy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
33. What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
a. 1+ protein in urine
b. 2+ pitting edema in lower extremities
c. Urine output >100 mL/hour
d. Deep tendon reflexes +2
ANS: C
Rapid reduction of the edema associated with preeclampsia results in urinary output of 4 to 6 L/day as interstitial fluids shift back
to the circulatory system. 1+ protein in urine and 2+ pitting edema in lower extremities are signs of continuing preeclampsia. Deep
tendon reflexes are not a reliable sign, especially if the patient has been treated with magnesium.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
34. Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering
Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
a. direct Coombs test of twin A.
b. direct Coombs test of twin B.
c. indirect Coombs test of the mother.
d. transcutaneous bilirubin level for both twins.
ANS: C
Administration of RhoGAM is based on the results of the indirect Coombs test on the patient. A negative result confirms that the
mother has not been sensitized by the positive Rh factor of twin A and that RhoGAM is indicated. A direct Coombs test is a
diagnostic test used to determine maternal antibodies in fetal blood and to guide treatment of the newborn when Rh and ABO
incompatibilities occur. Transcutaneous bilirubin is a noninvasive measure to determine the level of bilirubin in a newborn.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
35. For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to
a. 6:30 AM on January 13.
b. 6:30 PM on January 13.
c. 6:30 PM on January 14.
d. 6:30 AM on January 15.
ANS: A
Rho(D) immune globulin (RhoGAM) must be administered within 72 hours after the birth of an Rh-positive infant. 6:30 PM on
January 13, 6:30 PM on January 14, and 6:30 AM on January 15 do not fall within the established timeframe.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
Copyright © 2019, Elsevier Inc. All Rights Reserved.
7
36. The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines
that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta
previa?
a. Female fetus, Mexican-American, primigravida
b. Male fetus, Asian-American, previous preterm birth
c. Male fetus, African-American, previous cesarean birth
d. Female fetus, European-American, previous spontaneous abortion
ANS: C
The rate of placenta previa is increasing. It is more common in older women, multiparous women, women who have had cesarean
births, and women who had suction curettage for an induced or spontaneous abortion. It is also more likely to recur if a woman has
had a placenta previa. African or Asian ethnicity also increases the risk. Cigarette smoking and cocaine use are personal habits that
add to a woman’s risk for a previa. Previa is more likely if the fetus is male. The Mexican-American primipara has no risk factors
for developing a placenta previa. The Asian-American multipara has two risk factors for developing a previa. The
African-American multipara has three risk factors for developing a previa. The European-American multigravida has one risk
factor for developing a placenta previa.
DIF: Cognitive Level: Synthesis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
37. A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium
sulfate. The laboratory technician reports that the patient’s magnesium level is 7.6 mg/dL. What is the nurse’s priority action?
a. Stop the infusion of magnesium.
b. Assess the patient’s respiratory rate.
c. Assess the patient’s deep tendon reflexes.
d. Notify the health care provider of the magnesium level.
ANS: B
The therapeutic serum level for magnesium is 4 to 8 mg/dL although it is elevated in terms of normal lab values. Adverse reactions
to magnesium sulfate usually occur if the serum level becomes too high. The most important is CNS depression, including
depression of the respiratory center. Magnesium is excreted solely by the kidneys, and the reduced urine output that often occurs in
preeclampsia allows magnesium to accumulate to toxic levels in the woman. Frequent assessment of serum magnesium levels, deep
tendon reflexes, respiratory rate, and oxygen saturation can identify CNS depression before it progresses to respiratory depression
or cardiac dysfunction. Monitoring urine output identifies oliguria that would allow magnesium to accumulate and reach excessive
levels. Discontinue magnesium if the respiratory rate is below 12 breaths per minute, a low pulse oximeter level (<95%) persists, or
deep tendon reflexes are absent. Additional magnesium will make the condition worse.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
38. Which factor is most important in diminishing maternal, fetal, and neonatal complications in a pregnant patient with diabetes?
a. Evaluation of retinopathy by an ophthalmologist
b. The patient’s stable emotional and psychological status
c. Degree of glycemic control before and during the pregnancy
d. Total protein excretion and creatinine clearance within normal limits
ANS: C
The occurrence of complications can be greatly diminished by maintaining normal blood glucose levels before and during the
pregnancy. Even nonpregnant diabetics should have an annual eye examination. Assessing a patient’s emotional status is helpful.
Coping with a pregnancy superimposed on preexisting diabetes can be very difficult for the whole family; however, it is not the top
priority. Baseline renal function is assessed with a 24-hour urine collection and does not diminish the patient’s risk for
complications.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
39. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?
a. Hypoglycemia
b. Hypercalcemia
c. Hypoinsulinemia
d. Hypobilirubinemia
ANS: A
The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize
excessive glucose from the mother. At birth, the maternal glucose supply stops, and the neonatal insulin exceeds the available
glucose, leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common
problems of the infant of a diabetic mother. Because fetal insulin production is accelerated during pregnancy, the neonate shows
hyperinsulinemia. Excess erythrocytes are broken down after birth, releasing large amounts of bilirubin into the neonate’s
circulation, which results in hyperbilirubinemia.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
Copyright © 2019, Elsevier Inc. All Rights Reserved.
8
40. Which factor is known to increase the risk of gestational diabetes mellitus?
a. Previous birth of large infant
b. Maternal age younger than 25 years
c. Underweight prior to pregnancy
d. Previous diagnosis of type 2 diabetes mellitus
ANS: A
Prior birth of a large infant suggests gestational diabetes mellitus. A patient younger than 25 is not at risk for gestational diabetes
mellitus. Obesity (>90 kg [198 lb]) creates a higher risk for gestational diabetes. The person with type 2 diabetes mellitus already is
a diabetic and will continue to be so after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs
are contraindicated during pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
41. Which disease process improves during pregnancy?
a. Epilepsy
b. Bell’s palsy
c. Rheumatoid arthritis
d. Systemic lupus erythematosus (SLE)
ANS: C
Although the reason is unclear, marked improvement is seen with rheumatoid arthritis in pregnancy. Unfortunately relapse occurs
within 36 months postpartum. With epilepsy, the effect of pregnancy is variable and unpredictable. Seizures may increase,
decrease, or remain the same. Bell’s palsy was thought to be the result of infection by a virus three times more common during
pregnancy and generally occurring in the third trimester. The patient with SLE can have a normal pregnancy but must be treated as
high risk because 50% of all births will be premature. Pregnancy can exacerbate SLE.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
42. Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is
a. varied depending on the stage of gestation.
b. increased throughout pregnancy and the postpartum period.
c. decreased throughout pregnancy and the postpartum period.
d. should not change because the fetus produces its own insulin.
ANS: A
Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. Insulin needs increase during the
second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs change
during pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
43. Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
a. Cardiomyopathy
b. Mitral valve prolapse
c. Rheumatic heart disease
d. Congenital heart disease
ANS: B
Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during
pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases will produce
pulmonary hypertension or endocarditis during pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
44. Which instructions should the nurse include when teaching a pregnant patient with Class II heart disease?
a. Advise her to gain at least 30 lb.
b. Instruct her to avoid strenuous activity.
c. Inform her of the need to limit fluid intake.
d. Explain the importance of a diet high in calcium.
ANS: B
Activity may need to be limited so that cardiac demand does not exceed cardiac capacity. Weight gain should be kept at a minimum
with heart disease. Iron and folic acid are important to prevent anemia. Fluid intake is necessary to prevent fluid deficits. Fluid
intake should not be limited during pregnancy. The patient may also be put on a diuretic.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
Copyright © 2019, Elsevier Inc. All Rights Reserved.
9
45. Anti-infective prophylaxis is indicated for a pregnant patient with a history of mitral valve stenosis related to rheumatic heart
disease because the patient is at risk of developing
a. hypertension.
b. postpartum infection.
c. bacterial endocarditis.
d. upper respiratory infections.
ANS: C
Because of vegetations on the leaflets of the mitral valve and the increased demands of pregnancy, the patient is at greater risk of
bacterial endocarditis. Pulmonary hypertension may occur with mitral valve stenosis, but anti-infective medications will not
prevent it from occurring. Women with cardiac problems must be observed for possible infections during the postpartum period but
are not given prophylactic antibiotics to prevent them. Women are not put on prophylactic antibiotics to prevent upper respiratory
infections.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
46. A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox.
What should the nurse tell her?
a. Her two children should be treated with acyclovir before she goes home from the
hospital.
b. The baby will acquire immunity from her and will not be susceptible to
chickenpox.
c. The children can visit their mother and baby in the hospital as planned but must
wear gowns and masks.
d. She must make arrangements to stay somewhere other than her home until the
children are no longer contagious.
ANS: D
Varicella (chickenpox) is highly contagious. Although the baby inherits immunity from the mother, it would not be safe to expose
either the mother or the baby. Acyclovir is used to treat varicella pneumonia. The baby is already born and has received the
immunity. If the mother never had chickenpox, she cannot transmit the immunity to the baby. Varicella infection occurring in a
newborn may be life-threatening.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
47. A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate?
a. Practice respiratory isolation.
b. Plan for retesting during the third trimester.
c. Discuss the recommendation to bottle feed her baby.
d. Anticipate administering the vaccination for hepatitis B as soon as possible.
ANS: B
A person who has a history of high-risk behaviors should be rescreened during the third trimester. Hepatitis B is transmitted
through blood. The first trimester is too early to discuss feeding methods with a woman in the high-risk category. The vaccine may
not have time to affect a person with high-risk behaviors.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
48. A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the
risks of this diagnosis?
a. “I know I will need to have an abortion as soon as possible.”
b. “Even though my test is positive, my baby might not be affected.”
c. “My baby is certain to have AIDS and die within the first year of life.”
d. “This pregnancy will probably decrease the chance that I will develop AIDS.”
ANS: B
The fetus is likely to test positive for HIV in the first 6 months, until the inherited immunity from the mother wears off. Many of
these babies will convert to HIV-negative status. With the newer drugs, the risk for infection of the fetus has decreased. Also, the
life span of an infected newborn has increased. The pregnancy will increase the chance of converting.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
49. Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely
cause this abnormality?
a. Rubella
b. Cytomegalovirus (CMV)
c. Syphilis
d. HIV
ANS: A
Transmission of congenital rubella causes serious complications in the fetus that may manifest as cataracts, cardiac defects,
microcephaly, deafness, intrauterine growth restriction (IUGR), and developmental delays.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
Copyright © 2019, Elsevier Inc. All Rights Reserved.
10
50. Which postpartum patient requires further assessment?
a. G4 P4 who has had four saturated pads during the last 12 hours
b. G1 P1 with Class II heart disease who complains of frequent coughing
c. G2 P2 with gestational diabetes whose fasting blood sugar level is 100 mg/dL
d. G3 P2 postcesarean patient who has active herpes lesions on the labia
ANS: B
Frequent coughing may be a sign of congestive heart failure in the postpartum patient with heart disease. Four saturated pads in a
4-hour period is acceptable postpartum blood loss, a fasting blood sugar is a normal value, and the patient with identified active
herpes does not require further assessment.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
51. The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse
determines that the patient understands the teaching when she makes which statement?
a. “I have to fast the night before the test.”
b. “I will drink a sugary solution containing 100 g of glucose.”
c. “I will have blood drawn at 1 hour after I drink the glucose solution.”
d. “I should keep track of my baby’s movements between now and the test.”
ANS: C
A GCT is administered between 24 and 28 weeks of gestation, often to low- and high-risk antepartum patients. Fasting is not
necessary for a GCT, and the woman is not required to follow any pretest dietary instructions. The woman should ingest 50 g of
oral glucose solution, and 1 hour later a blood sample is taken. Fetal surveillance with kick counts is an ongoing evaluation for
pregnant women; they should contact their health care provider if there is a noticeable decrease in fetal movement.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
52. The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent
outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
a. Ask the patient when she last had anything to eat or drink.
b. Take a culture of the lesions to verify the involved organism.
c. Ask the patient if she has had unprotected sex since her outbreak.
d. Use electronic fetal surveillance to determine a baseline fetal heart rate.
ANS: A
A cesarean birth is recommended for women with active lesions in the genital area, whether recurrent or primary, at the time of
labor. The patient’s dietary intake is needed to prepare for surgery. This patient is in active labor and the fetus is at risk for
infection if the membranes rupture. The health care provider needs to be notified, and a cesarean birth needs to be performed as
soon as possible. There is no need to validate the infection because the patient is well aware of the symptoms of an active infection.
Although transmission to sexual partners is valid information, it is not necessary information in an urgent situation such as depicted
in this scenario. Electronic fetal surveillance is the standard of care.
DIF: Cognitive Level: Synthesis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity
should the nurse monitor for? (Select all that apply.)
a. Cool, clammy skin
b. Altered sensorium
c. Pulse oximeter reading of 95%
d. Respiratory rate of less than 12 breaths per minute
e. Absence of deep tendon reflexes
ANS: B, D, E
Signs of magnesium toxicity include the following:
• Respiratory rate of less than 12 breaths per minute (hospitals may specify a rate <14 breaths per minute)
• Maternal pulse oximeter reading lower than 95%
• Absence of deep tendon reflexes
• Sweating, flushing
• Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented)
• Hypotension
• Serum magnesium value above the therapeutic range of 4 to 8 mg/dL
Cold, clammy skin and a pulse oximeter reading of 95% would not be signs of toxicity.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
Copyright © 2019, Elsevier Inc. All Rights Reserved.
11
2. The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby
are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential
complications and plan care accordingly. Significant risks include (Select all that apply.)
a. Breech presentation
b. Ectopic pregnancy
c. Birth defects
d. Venous thromboembolism
e. Postpartum anemia
ANS: C, D, E
Maternal complications associated with pregnancy include: Gestational diabetes, preeclampsia, venous thromboembolism,
Caesarean delivery, wound infection, respiratory complications, preterm birth, birth trauma and postpartum anemia. Obese women
also have an increased risk of spontaneous abortions and stillbirth. Complications for infants of obese mothers have an increased
risk of neural tube defects, hydrocephaly, cardiovascular defects, macrosomia, hypoglycemia, and birth injuries from shoulder
dystocia.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
COMPLETION
1. What is the value of the main line fluid rate for your patient, whose total fluid intake is ordered at 150 mL/hour and who is also
being given magnesium sulfate at 1 g/hour (1 g = 25 mL/hour) IV piggyback and pitocin at 15 mU/minute (l mU/minute = 1
mL/hour) IV piggyback. ______
ANS:
110
The rate of infusion of magnesium sulfate (25 mL/hour) and pitocin (15 mL/hour) equals 40 mL/hour. Subtracting the 40 mL from
the total ordered of 150 mL leaves 110 mL of main line fluid to be infused per hour.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
Copyright © 2019, Elsevier Inc. All Rights Reserved.
12