Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 01: Maternity and Women’s Health Care Today
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A nurse educator is teaching a group of nursing students about the history of family-centered
maternity care. Which statement should the nurse include in the teaching session?
a. The Sheppard-Towner Act of 1921 promoted family-centered care.
b. Changes in pharmacologic management of labor prompted family-centered care.
c. Demands by physicians for family involvement in childbirth increased the practice
of family-centered care.
d. Parental requests that infants be allowed to remain with them rather than in a
nursery initiated the practice of family-centered care.
ANS: D
As research began to identify the benefits of early, extended parent–infant contact, parents
began to insist that the infant remain with them. This gradually developed into the practice of
rooming-in and finally to family-centered maternity care. The Sheppard-Towner Act provided
funds for state-managed programs for mothers and children but did not promote
family-centered care. The changes in pharmacologic management of labor were not a factor in
family-centered maternity care. Family-centered care was a request by parents, not physicians.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. Expectant parents ask a prenatal nurse educator, “Which setting for childbirth limits the
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amount of parent–infant interacUtionS?” N
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parents in order to assist them in choosing an appropriate birth setting?
a. Birth center
b. Home birth
c. Traditional hospital birth
d. Labor, birth, and recovery room
ANS: C
In the traditional hospital setting, the mother may see the infant for only short feeding periods,
and the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in
parent–infant contact. Home births allow the greatest amount of parent–infant contact. The
labor, birth, recovery, and postpartum room setting allows for increased parent–infant contact.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
3. Which statement best describes the advantage of a labor, birth, recovery, and postpartum
(LDRP) room?
a. The family is in a familiar environment.
b. They are less expensive than traditional hospital rooms.
c. The infant is removed to the nursery to allow the mother to rest.
d. The woman’s support system is encouraged to stay until discharge.
ANS: D
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Sleeping equipment is provided in a private room. A hospital setting is never a familiar
environment to new parents. An LDRP room is not less expensive than a traditional hospital
room. The baby remains with the mother at all times and is not removed to the nursery for
routine care or testing. The father or other designated members of the mother’s support system
are encouraged to stay at all times.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
4. Which nursing intervention is an independent function of the professional nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the patient perineal care
d. Providing wound care to a surgical incision
ANS: C
Nurses are now responsible for various independent functions, including teaching, counseling,
and intervening in nonmedical problems. Interventions initiated by the physician and carried
out by the nurse are called dependent functions. Administrating oral analgesics is a dependent
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic
studies is a dependent function. Providing wound care is a dependent function; however, the
physician prescribes the type of wound care through direct orders or protocol.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment
5. Which response by the nurse is the most therapeutic when the patient states, “I’m so afraid to
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have a cesarean birth”?
a. “Everything will be OK.”
b. “Don’t worry about it. It will be over soon.”
c. “What concerns you most about a cesarean birth?”
d. “The physician will be in later and you can talk to him.”
ANS: C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is
saying and asks for clarification, which is the most therapeutic response. The response,
“Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about
it. It will be over soon” will indicate that the patient’s feelings are not important. The
response, “The physician will be in later and you can talk to him” does not allow the patient to
verbalize her feelings when she wishes to do that.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
6. In which step of the nursing process does the nurse determine the appropriate interventions for
the identified nursing diagnosis?
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: A
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The third step in the nursing process involves planning care for problems that were identified
during assessment. The evaluation phase is determining whether the goals have been met.
During the assessment phase, data are collected. The intervention phase is when the plan of
care is carried out.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
7. Which goal is most appropriate for the collaborative problem of wound infection?
a. The patient will not exhibit further signs of infection.
b. Maintain the patient’s fluid intake at 1000 mL/8 hour.
c. The patient will have a temperature of 98.6F within 2 days.
d. Monitor the patient to detect therapeutic response to antibiotic therapy.
ANS: D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
interventions of monitoring or observing. Monitoring for complications such as further signs
of infection is an independent nursing role. Intake and output is an independent nursing role.
Monitoring a patient’s temperature is an independent nursing role.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
8. Which nursing intervention is written correctly?
a. Force fluids as necessary.
b. Observe interaction with the infant.
c. Encourage turning, coughing, and deep breathing.
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ANS: D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is
not specific; it does not state how much or how often. Encouraging the patient to turn, cough,
and breathe deeply is not detailed or specific. Observing interaction with the infant does not
state how often this procedure should be done. Assisting the patient to ambulate for 10
minutes within a certain timeframe is specific.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
9. The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which
response by the nurse would be the most therapeutic?
a. “You’re afraid to take the baby home?”
b. “Don’t you have a mother who can come and help?”
c. “You should read the literature I gave you before you leave.”
d. “I was scared when I took my first baby home, but everything worked out.”
ANS: A
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This response uses reflection to show concern and open communication. The other choices are
blocks to communication. Asking if the patient has a mother who can come and assist blocks
further communication with the patient. Telling the patient to read the literature before leaving
does not allow the patient to express her feelings further. Sharing your own birth experience is
inappropriate.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
10. The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
of 10. Which expected outcome is correctly stated for this problem?
a. Patient will state that pain is a 2 on a scale of 10.
b. Patient will have a reduction in pain after administration of the prescribed
analgesic.
c. Patient will state an absence of pain 1 hour after administration of the prescribed
analgesic.
d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
the prescribed analgesic.
ANS: D
The outcome should be patient-centered, measurable, realistic, and attainable and within a
specified timeframe. Patient stating that her pain is now 2 on a scale of 10 lacks a timeframe.
Patient having a reduction in pain after administration of the prescribed analgesic lacks a
measurement. Patient stating an absence of pain 1 hour after the administration of prescribed
analgesic is unrealistic.
DIF: Cognitive Level: ApplicN
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MSC: Patient Needs: Physiologic Integrity
11. Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical
changes
ANS: D
The nurse should determine which problem needs immediate attention. Risk for injury is the
problem that has the priority at this time because it is a safety problem. Risk for anxiety,
imbalanced nutrition, and altered family processes are not the priorities at this time.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
12. Regarding advanced roles of nursing, which statement related to clinical practice is the most
accurate?
a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital
setting.
b. Clinical nurse specialists (CNSs) provide primary care to obstetric patients.
c. Neonatal nurse practitioners provide emergency care in the postbirth setting to
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high-risk infants.
d. A certified nurse midwife (CNM) is not considered to be an advanced practice
nurse.
ANS: C
Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal
intensive care unit, as needed. FNPs do not participate in childbirth care; however, they can
take care of uncomplicated pregnancies and postbirth care outside of the hospital setting.
CNSs work in hospital settings but do not provide primary care services to patients. A CNM is
an advanced practice nurse who receives additional certification in the specific area of
midwifery.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Management of Care: Legal Rights and Responsibilities
13. Which statement is true regarding the shortage of nurses in the United States?
a. There are a larger proportion of younger nurses in the workforce as compared with
older nurses.
b. As a result of decreased RN-to-patient ratios, there is a decrease in patient
mortality in the clinical setting.
c. Nursing programs are turning away qualified applicants.
d. There are adequate classroom and clinical facilities for training RNs.
ANS: C
According to an Institute of Medicine (IOM) report, by the year 2020, 80% of new RNs
should hold baccalaureate degrees. Despite this need, baccalaureate and master’s programs are
turning away qualified applicants due to an insufficient number of faculty. There are a larger
proportion of older nurses inN
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nurse-to-patient ratios have resulted in decreased patient mortality in the clinical setting.
There are currently numerous limitations of both classroom and clinical facilities necessary to
train new nurses adequately.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion: Teaching/Learning
14. A hospital has achieved Magnet status. Which indicators would be consistent with this type of
certification?
a. There is stratification of communication in a directed manner between nursing
staff and administration.
b. There is increased job satisfaction of nurses, with a lower staff turnover rate.
c. Physicians are certified in their respective specialty areas.
d. All nurses have baccalaureate degrees and certification in their clinical specialty
area.
ANS: B
Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center)
in which hospitals apply based on designated criteria that consider nurse job satisfaction, staff
patterns, strength, quality of nursing staff, and open communication. It is not based on
physician status. Also, certification is not required for all nurses at this point. The expectation
with Magnet status is that nurses will continue to expand their knowledge by earning
additional degrees and certification.
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DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion: Teaching/Learning
15. Which of the following statements highlights the nurse’s role as a researcher?
a. Reading peer-reviewed journal articles
b. Working as a member of the interdisciplinary team to provide patient care
c. Helping patient to obtain home care postdischarge from the hospital
d. Delegating tasks to unlicensed personnel to allow for more teaching time with
patients
ANS: A
A nurse in a researcher role should look to improve her or his knowledge base by reading and
reviewing evidence-based practice information as found in peer-reviewed journals. Working
as a member of the interdisciplinary team to provide patient care indicates that the nurse is
working as a collaborator. Helping the patient to obtain home care postdischarge from the
hospital indicates that the nurse is working as a patient advocate. Delegating tasks to
unlicensed personnel in order to allow for more teaching time with patients indicates that the
nurse is working as a manager.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion: Teaching/Learning
16. Which patient could safely be cared for by a certified nurse-midwife?
a. Gravida 3, para 2, with no complications
b. Gravida 1, para 0, with mild hypertension
c. Gravida 2, para 1, with insulin-dependent diabetes
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ANS: A
A certified nurse-midwife (CNM) cares for women who are at low risk for complications. The
CNM would not care for a woman with hypertension. The CNM would not care for a woman
with insulin-dependent diabetes. The CNM would not care for a woman with borderline
pelvic measurements.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
17. A primipara patient asks about possible support options for her during the labor process. She
is apprehensive that her family members will not be prepared to assist her during this time.
Which option would be most effective for this patient?
a. Reassure the patient that the labor and birth staff consists of highly trained nurses
who are well educated to take care of laboring patients so that should be sufficient.
b. Encourage the patient to take prepared childbirth classes with her husband because
that should provide the best support by a family member.
c. Provide information to the patient about obtaining a doula during the labor process.
d. Tell the patient that this is a normal feeling based on fear of the unknown and that
it will subside once she starts the labor process.
ANS: C
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Providing information about a doula addresses the patient’s concern because the doula’s
designated role is to provide support during labor. Although it is true that labor and birth
nurses are trained in their specialty, the patient is voicing concern for support so her feelings
should not be minimized. Encouraging the patient to take prepared childbirth classes is also
important; however, it does not address the patient’s concern for support. Because this patient
is a primipara, it is normal to have some anxiety over the unknown process of the labor
experience but again this response minimizes the patient’s concern.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychologic Integrity
18. The nurse states to the newly pregnant patient, “Tell me how you feel about being pregnant.”
Which communication technique is the nurse using with this patient?
a. Clarifying
b. Paraphrasing
c. Reflection
d. Structuring
ANS: A
The nurse is attempting to follow up and check the accuracy of the patient’s message.
Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing
comprehension of what the patient has said. Structuring takes place when the nurse has set
guidelines or set priorities.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
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doula to the hospital during labor. What does the nurse think that this means?
a. The patient will have her grandmother as a support person.
b. The patient will bring a paid, trained labor support person with her during labor.
c. The patient will have a special video she will play during labor to assist with
relaxation.
d. The patient will have a bag that contains all the approved equipment that may help
with the labor process.
ANS: B
A doula is a trained labor support person who is employed by the mother to provide labor
support. She gives physical support such as massage, helps with relaxation, and provides
emotional support and advocacy throughout labor. A doula is usually not a relative of the
woman. A doula is a trained labor support person.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. In consideration of the historic evolution of maternity care, which treatment options were used
over the past century? (Select all that apply.)
a. During the nineteenth century, women of privilege were delivered by midwives in
a hospital setting.
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b. Granny midwives received their training through a period of apprenticeship.
c. The recognition of improved obstetric outcomes was related to increased usage of
hygienic practices.
d. A shift to hospital-based births occurred as a result of medical equipment designed
to facilitate birth.
e. The use of chloroform by midwives led to decreased pain during birth.
ANS: B, C, D
Training of granny midwives was done by apprenticeship as opposed to formal medical
school training. With the advent of usage of hygienic practices, improved health outcomes
were seen with regard to a decrease in sepsis. New equipment such as forceps enabled easier
birth. Women of privilege in the nineteenth century delivered at home, attended by a midwife.
Chloroform was used by physicians and was not available to midwives.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
2. Many communities now offer the availability of free-standing birth centers to provide care for
low-risk women during pregnancy, birth, and postpartum. When counseling the newly
pregnant patient regarding this option, the nurse should be aware that this type of care setting
includes which advantages? (Select all that apply.)
a. Staffing by lay midwives
b. Equipped for obstetric emergencies
c. Less expensive than acute care hospitals
d. Safe, homelike births in a familiar setting
e. Access to follow-up care for 6 weeks postpartum
ANS: C, D, E
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Patients who are at low risk and desire a safe, homelike birth are very satisfied with this type
of care setting. The new mother may return to the birth center for postpartum follow-up care,
breastfeeding assistance, and family planning information for 6 weeks postpartum. Because
birth centers do not incorporate advanced technologies into their services, costs are
significantly less than in a hospital setting. The major disadvantage of this care setting is that
these facilities are not equipped to handle obstetric emergencies. Should unforeseen
difficulties occur, the patient must be transported by ambulance to the nearest hospital. Birth
centers are usually staffed by certified nurse-midwives (CNMs).
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
3. The nurse is assessing a patient’s use of complementary and alternative therapies. Which
should the nurse document as an alternative or complementary therapy practice? (Select all
that apply.)
a. Practicing yoga daily
b. Drinking green tea in the morning
c. Taking omeprazole (Prilosec) once a day
d. Using aromatherapy during a relaxing bath
e. Wearing a lower back brace when lifting heavy objects
ANS: A, B, D
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Complementary and alternative (CAM) therapies can be defined as those systems, practices,
interventions, modalities, professions, therapies, applications, theories, and claims that are
currently not an integral part of the conventional medical system in North America. Yoga is
considered to be a mind–body alternative therapy. Green tea and aromatherapy are
biologically based complementary therapies. Prilosec and the use of a lower back brace would
be therapies consistent with those used by conventional medicine.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
4. The nurse is formulating a nursing care plan for a postpartum patient. Which actions by the
nurse indicate use of critical thinking skills when formulating the care plan? (Select all that
apply.)
a. Using a standardized postpartum care plan
b. Determining priorities for each diagnosis written
c. Writing interventions from a nursing diagnosis book
d. Reflecting and suspending judgment when writing the care plan
e. Clustering data during the assessment process according to normal versus
abnormal
ANS: B, D, E
Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes
reflective skepticism. Determining priorities, reflecting and suspending judgment, and
clustering data are actions that indicate the use of critical thinking. Using a standardized care
plan and writing interventions from a nursing diagnosis book do not show that reflection
about the patient’s individual care is being done.
DIF: Cognitive Level: ApplicN
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MSC: Patient Needs: Physiologic Integrity
5. The RN is delegating tasks to the unlicensed assistive personnel (UAP). Which tasks can the
nurse delegate? (Select all that apply.)
a. Teaching the patient about breast care
b. Assessment of a patient’s lochia and perineal area
c. Assisting a patient to the bathroom for the first time after birth
d. Vital signs on a postpartum patient who delivered the night before
e. Assisting a postpartum patient to take a shower on the second postpartum day
ANS: D, E
Nurses must be aware that they remain legally responsible for patient assessments and must
make the critical judgments necessary to ensure patient safety when delegating tasks to
unlicensed personnel. The nurse cannot delegate assessment, teaching, or evaluation. The two
tasks that the nurse can delegate are vital signs on a stable postpartum patient and assisting a
stable postpartum patient on the second postpartum day to take a shower.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
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Chapter 02: Social, Ethical, and Legal Issues
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. During which phase of the cycle of violence does the batterer become contrite and
remorseful?
a. Battering
b. Honeymoon
c. Tension-building
d. Increased drug taking
ANS: B
During the honeymoon phase, the battered person wants to believe that the battering will
never happen again, and the batterer will promise anything to get back into the home. During
the battering phase, violence actually occurs, and the victim feels powerless. During the
tension-building phase, the batterer becomes increasingly hostile, swears, threatens, throws
things, and pushes the battered person. Often, the batterer increases the use of drugs during
the tension-building phase.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
2. The United States ranks poorly in terms of worldwide infant mortality rates. Which factor has
the greatest impact on decreasing the mortality rate of infants?
a. Providing more women’s shelters G B.C M
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b. Ensuring early and adequatU
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c. Resolving all language and cultural differences
d. Enrolling pregnant women in the Medicaid program by their eighth month of
pregnancy
ANS: B
Because preterm infants form the largest category of those needing expensive intensive care,
early pregnancy intervention is essential for decreasing infant mortality. The women in
shelters have the same difficulties in obtaining health care as other poor people, particularly
lack of transportation and inconvenient clinic hours. Language and cultural differences are not
infant mortality issues but must be addressed to improve overall health care. Medicaid
provides health care for poor pregnant women, but the process may take weeks to take effect.
The eighth month is too late to apply and receive benefits for this pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. The nurse is planning a teaching session for staff on ethical theories. Which situation best
reflects the Deontologic theory?
a. Approving a physician-assisted suicide
b. Supporting the transplantation of fetal tissue and organs
c. Using experimental medications for the treatment of AIDS
d. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
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ANS: D
In the Deontologic theory, life must be maintained at all costs, regardless of quality of life.
Approving a physician-assisted suicide, supporting the transplantation of fetal tissue and
organs, and using experimental medications for the treatment of AIDS are examples of a
utilitarian model.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
4. Which step of the nursing process is being used when the nurse decides whether an ethical
dilemma exists?
a. Analysis
b. Planning
c. Evaluation
d. Assessment
ANS: A
When a nurse uses the collected data to determine whether an ethical dilemma exists, the data
are being analyzed. Planning is done after the data have been analyzed. Evaluation occurs
once the outcome has been achieved. Assessment is the data collection phase.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment: Coordinated Care
5. The nurse is interviewing a patient who is 6-weeks pregnant. The patient asks the nurse, “Why
is elective abortion considered such an ethical issue?” Which response by the nurse is most
appropriate?
a. Abortion requires third-pN
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b. The U.S. Supreme Court ruled that life begins at conception.
c. Abortion law is unclear about a woman’s constitutional rights.
d. There is a conflict between the rights of the woman and the rights of the fetus.
ANS: D
Elective abortion is an ethical dilemma because two opposing courses of action are available.
Abortion does not require third-party consent. The Supreme Court has not ruled on when life
begins. Abortion laws are clear concerning a woman’s constitutional rights.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
6. At the present time, which agency governs surrogate parenting?
a. State law
b. Federal law
c. Individual court decision
d. Protective child services
ANS: C
Each surrogacy case is decided individually in a court of law. Surrogate parenting is not
governed by either state or federal law. Protective child services do not make decisions related
to surrogacy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
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MSC: Patient Needs: Health Promotion and Maintenance
7. Which patient will most likely seek prenatal care?
a. A 15-year-old patient who tells her friends, “I just don’t believe that I am
pregnant”
b. A 28-year-old who is in her second pregnancy and abuses drugs and alcohol
c. A 20-year-old who is in her first pregnancy and has access to a free prenatal clinic
d. A 30-year-old who is in her fifth pregnancy and delivered her last infant at home
with the help of her mother and sister
ANS: C
The patient who acknowledges the pregnancy early, has access to health care, and has no
reason to avoid health care is most likely to seek prenatal care. Being in denial regarding the
pregnancy will prevent a patient from seeking health care. Patients who abuse substances are
less likely to seek health care. Some women see pregnancy and birth as a natural occurrence
and do not seek health care.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
8. A medical-surgical nurse is asked to float to a women’s health unit to care for patients who
are scheduled for therapeutic abortions. The nurse refuses to accept this assignment and
expresses her personal beliefs as being incongruent with this medical practice. The nursing
supervisor states that the unit is short-staffed and the nurse is familiar with caring for
postoperative patients. In consideration of legal and ethical practices, can the nursing
supervisor enforce this assignment?
a. The staff nurse has the responsibility of accepting any assignment that is made
while working for a healtN
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rights to enforce this assignment.
b. Because the unit is short-staffed, the staff nurse should accept the assignment to
provide care by benefit of her or his experience to patients who need care.
c. The staff nurse has expressed a legitimate concern based on his or her feelings; the
nursing supervisor does not have the authority to enforce this assignment.
d. The nursing supervisor should emphasize that this assignment requires care of a
surgical patient for which the staff nurse is adequately trained and should therefore
enforce the assignment.
ANS: C
The Nurse Practice Act allows nurses to refuse assignments that involve practices that they
have expressed as being opposed to their religious, cultural, ethical, and/or moral values.
Although the nursing supervisor has a right to arrange assignments, the supervisor, if made
aware of a potential bias or limitation, must act accordingly and accept the nurse’s position.
This should be upheld regardless of staffing limitations and independent of persuasive efforts
to make the nurse feel guilty for her or his stated beliefs.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe Effective Care: Ethical Practice/Assignment, Delegation and Supervision
9. With regard to an obstetric litigation case, a nurse working in labor and birth is found to be
negligent. Which intervention performed by the nurse indicates that a breach of duty has
occurred?
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a. The nurse did not document fetal heart tones (FHR) during the second stage of
labor.
b. The patient was only provided ice chips during the labor period, which lasted 8
hours.
c. The nurse allowed the patient to use the bathroom rather than a bedpan during the
first stage of labor.
d. The nurse asked family members to leave the room when she prepared to do a
pelvic exam on the patient.
ANS: A
A breach of duty has occurred when a nurse or health care provider fails to provide treatment
relative to the standard of care. In this case, documentation of FHR during the second stage of
labor is a recognized standard of care. Providing ice chips to laboring patients is within the
standard of care. The time period of 8 hours is not excessive. A patient without any risk
factors can use the bathroom and be ambulatory during the first stage of labor. Asking family
members to leave during a vaginal exam helps maintain patient privacy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities
10. A nurse is working with an active labor patient who is in preterm labor and has been
designated as high risk. The patient is very apprehensive and asks the nurse, “Is everything
going to be all right?” The nurse replies, “Yes, everything will be okay.” Following delivery
via an emergency cesarean birth, the newborn undergoes resuscitation and does not survive.
The patient is distraught over the outcome and blames the nurse for telling her that everything
would be okay. Which ethical principle did the nurse violate?
a. Autonomy
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b. Fidelity
c. Beneficence
d. Accountability
ANS: B
In this type of situation, the nurse (and/or health care provider) cannot make statements or
promises that cannot be kept. Telling the patient that everything will be okay is not based on
the accuracy of medical diagnosis and should not be conveyed to the patient. The other ethical
principles of autonomy (self-determination), beneficence (greatest good), and accountability
(accepting responsibility) do not apply in this situation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities
11. A nurse is working in the area of labor and birth. Her assignment is to take care of a gravida 1
para 0 woman who presents in early labor at term. Vaginal exam reflects the following: 2 cm,
cervix posterior, –1 station, and vertex with membranes intact. The patient asks the nurse if
she can break her water so that her labor can go faster. The nurse’s response, based on the
ethical principle of nonmaleficence, is which of the following?
a. Tell the patient that she will have to wait until she has progressed further on the
vaginal exam and then she will perform an amniotomy.
b. Have the patient write down her request and then call the physician for an order to
implement the amniotomy.
c. Instruct the patient that only a physician or certified midwife can perform this
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procedure.
d. Give the patient an enema to stimulate labor.
ANS: C
The ethical principle of nonmaleficence conveys the concept that one should avoid risk taking
or harm to others. The procedure of amniotomy is performed by a physician and/or certified
nurse midwife. It is not in the scope of practice of an RN, so option C validates that the nurse
is upholding this ethical principle. Options A and B are not within the scope of practice. The
use of an enema as a labor stimulant is no longer considered necessary during labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities
12. A nurse working in a labor and birth unit is asked to take care of two high-risk patients in the
labor and birth suite: a 34 weeks’ gestation 28-year-old gravida 3, para 2 in preterm labor and
a 40-year-old gravida 1, para 0 who is severely preeclamptic. The nurse refuses this
assignment telling the charge nurse that based on individual patient acuity, each patient should
have one-on-one care. Which ethical principle is the nurse advocating?
a. Accountability
b. Beneficence
c. Justice
d. Fidelity
ANS: B
In this situation, the patients are each exhibiting significant high-risk conditions and should
receive individual nursing care. The nurse is advocating the principle of beneficence in that
she is trying to do the “greatest good or the least harm” to improve patient outcomes. The
other ethical principles do noN
t aUpR
plS
yI
inNtG
hiT
s sBit.
uaCtiO
onM.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities
13. A charge nurse is working on a postpartum unit and discovers that one of the patients did not
receive AM care during her shift assessment. The charge nurse questions the nurse assigned to
provide care and finds out that the nurse thought “the patient should just do it by herself
because she will have to do this at home.” On further questioning of the nurse, it is determined
that the rest of her assigned patients were provided AM care. The assigned nurse has violated
which ethical principle?
a. Justice
b. Truth
c. Confidentiality
d. Autonomy
ANS: A
The ethical principle of justice indicates that all patients should be treated equally and fairly.
In this case, the charge nurse ascertained that the AM care was not equally applied to all the
nurse’s assigned patients. The other ethical principles do not apply to this situation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities
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14. A nurse is entering information on the patient’s electronic health record (EHR) and is called to
assist in an emergency situation with regard to another patient in the labor and birth suite. The
nurse rushes to the scene to assist; however, she leaves the chart open on the computer screen.
The emergent patient situation is resolved satisfactorily, and the nurse comes back to the
computer entry screen to complete charting. At the end of the shift, the nurse manager asks to
speak with the nurse and tells her that she is concerned with what happened today on the unit
because there was a breach in confidentiality. Which response by the nurse indicates that she
understands the nurse manager’s concerns?
a. The nurse acknowledges that she should have made sure that her patient was safe
before assisting with the emergency.
b. The nurse states that she should have logged out of the EHR prior to attending to
the emergency.
c. The nurse indicates that the unit was understaffed.
d. The nurse indicates that the she changed her password following the clinical
emergency to maintain confidentiality.
ANS: B
With the use of electronic health records, it is necessary to take all steps to maintain
confidentiality and limit access to nonhealth care personnel. In an emergent care situation, the
nurse should have logged out of the system to maintain confidentiality. Although it is
important to make sure that one’s patient is safe, there is no information here to suggest that
there were any safety issues applicable to her assigned patient. The staffing of the unit should
not affect confidentiality. Changing the password for logging in to a system is an option for
clinical practice but does not affect the situation as described.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe EffeN
ctivR
e CaI
re: L
ega
ghtsM
and Responsibilities
G Bl R.iC
U S N T
O
15. A nurse is admitting a patient to the labor and birth unit in early labor that was sent to the
facility following a checkup with her health care provider in the office. The patient is a
gravida 1, para 0, and is at term. No health issues are discerned from the initial assessment,
and the nurse prepares to initiate physician orders based on standard procedures. Which action
by the nurse manager is warranted in this situation?
a. No action is indicated because the nurse is acting within the scope of practice.
b. The nurse manager should intervene and ask the nurse to clarify admission orders
directly with the physician.
c. The nurse manager should review standard procedures with the nurse to validate
that orders are being carried out accurately.
d. The nurse manger should review the admission procedure with the nurse.
ANS: A
Standard procedures are often used in labor and birth settings because they are based on
physician-directed orders that apply to general admissions. The nurse is acting appropriately
since the patient was sent directly to the unit, by the health care provider. The nurse manager
does not have to intervene at this point. There is no additional need to review standard
procedures or the admission process with the nurse at this time. There is no evidence that the
nurse needs additional training and/or does not have the prerequisite knowledge to admit the
patient.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
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16. A nurse who works in the emergency department (ED) is assigned to a patient who is
experiencing heavy vaginal bleeding at 12 weeks’ gestation. An ultrasound has confirmed the
absence of a fetal heart rate, and the patient is scheduled for a dilation and evacuation of the
pregnancy. The nurse refuses to provide any further care for this patient based on moral
principles. What is the nurse manager’s initial response to the nurse?
a. “I recall you sharing that information in your interview. I will arrange for another
nurse to take report on this patient.”
b. “Because we are shorthanded today, you have to continue to provide care. There is
no one else available to provide care for this patient.”
c. “I understand your point of view. You were hired to work here in the ED so you
had to know this situation was possible.”
d. “Abandonment is a serious issue. I have to advise you to continue to provide care
for this patient.”
ANS: A
Nurses do not have to provide care if the care is in violation of their moral, ethical, or
religious principles. It is the responsibility of the nurse to share these views at the time of the
initial interview. Disclosing beliefs that would affect the care of patients at the point of care
and refusing to provide care is unethical on behalf of the nurse. The manager cannot force the
nurse to provide care if the nurse’s principles were shared at the time of the initial interview.
It is the manager’s responsibility to disclose the type of care delivered in the department at the
time of the interview. Threats of abandonment are unwarranted at this time.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
N R I G B.C M
17. The nurse is providing care to U
a paS
tienN
t whTo was jO
ust admitted to the labor and birth unit in
active labor at term. The patient informed the nurse, “I have not received any prenatal care
because I cannot afford to go to the doctor. And, this is my third baby, so I know what to
expect.” What is the nurse’s primary concern when developing the patient’s plan of care?
a. Low birth weight
b. Oligohydramnios
c. Gestational diabetes
d. Gestational hypertension
ANS: A
Due to adverse living conditions, poor health care, and inadequate nutrition, infants born to
low-income women are more likely to begin life with problems such as low birth weight.
Oligohydramnios is a condition where there is too little amniotic fluid and is not directly
correlated with poverty. While gestational diabetes and gestational hypertension are
associated with poverty, they can be seen during any pregnancy. This patient is in active labor
and the primary concern at this time is the fetus.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
18. A nurse is reviewing evidence-based teaching and learning principles. Which situation is most
conducive to learning with patients of other cultures?
a. An auditorium is being used as a classroom for 300 students.
b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
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c. A class is composed of students of various ages and educational backgrounds.
d. An Asian nurse provides nutritional information to a group of pregnant Asian
women.
ANS: D
A patient’s culture influences the learning process; thus a situation that is most conducive to
learning is one in which the teacher has knowledge and understanding of the patient’s cultural
beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher
cannot see nonverbal cues from the students to ensure understanding. The ability to
understand the language in which teaching is done determines how much the patient learns.
Patients for whom English is not their primary language may not understand idioms, nuances,
slang terms, informal usage of words, or medical terms. The teacher should be fluent in the
language of the student. Developmental levels and educational levels influence how a person
learns best. For the teacher to present the information in the best way, the class should be at
the same level.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
19. The nurse is teaching a parenting class to new parents. Which statement should the nurse
include in the teaching session about the characteristics of a healthy family?
a. Adults agree on the majority of basic parenting principles.
b. The parents and children have rigid assignments for all the family tasks.
c. Young families assume total responsibility for the parenting tasks, refusing any
assistance.
d. The family is overwhelmed by the significant changes that occur as a result of
childbirth.
ANS: A
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Adults in a healthy family communicate with each other, so there is minimal discord in areas
such as discipline and sleep schedules. Healthy families remain flexible in their role
assignments. Members of a healthy family accept assistance without feeling guilty. Healthy
families can tolerate irregular sleep and meal schedules, which are common during the months
after childbirth.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
20. A patient who is 6 months pregnant has sought medical attention, saying she fell down the
stairs. Which scenario would cause an emergency department nurse to suspect that the woman
has been battered?
a. She avoids making eye contact and is hesitant to answer questions.
b. The woman and her partner are having an argument that is loud and hostile.
c. The woman has injuries on various parts of her body that are in different stages of
healing.
d. Examination reveals a fractured arm and fresh bruises. Her husband asks her about
her pain.
ANS: C
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The battered woman often has multiple injuries in various stages of healing. It is more normal
for the woman to have a flat affect. A loud and hostile argument is not always an indication of
battering. Often the batterer will be attentive and refuse to leave the woman’s bedside.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
21. Which situation is most representative of an extended family?
a. It includes adoptive children.
b. It is headed by a single-parent.
c. It contains children from previous marriages.
d. It is composed of children, parents, and grandparents living in the same house.
ANS: D
An extended family is defined as a family having members from three generations living
under the same roof. A family with adoptive children is a nuclear family. A single-parent
family is headed by a single parent. A blended family is one that contains children from
previous marriages.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
22. The nurse is reviewing the principles of family-centered care with a primiparous patient.
Which patient statement will the nurse need to correct?
a. “Remaining focused on my family will help benefit me and my baby.”
b. “Most of the time, childbirth is uncomplicated and a healthy event for the family.”
c. “Because childbirth is normal, after my baby’s birth our family dynamics will not
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change.”
d. “With correct information, I am able to make decisions regarding my health care
while I am pregnant.”
ANS: C
The birth of an infant alters family relationships and structures; family dynamics will change
with the birth of an infant. Childbirth is usually a normal and healthy event. Given
professional support and guidance, the pregnant woman is able to make decisions about her
prenatal care. Maintaining a focus on family or other support can benefit a woman as she
seeks to maintain her health throughout pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
23. Which issue is a major concern among members of lower socioeconomic groups?
a. Practicing preventive health care
b. Meeting health needs as they occur
c. Maintaining an optimistic view of life
d. Maintaining group health insurance for their families
ANS: B
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Because of their economic uncertainty, lower socioeconomic groups place more emphasis on
meeting the needs of the present rather than on future goals. Lower socioeconomic groups
may value health care but generally cannot afford preventive health care. They may struggle
for basic needs and often do not see a way to improve their situation. It is difficult to maintain
optimism. Lower socioeconomic groups usually do not have group health insurance.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
24. While teaching an Asian patient regarding prenatal care, the nurse notes that the patient
refuses to make eye contact. Which is the most likely cause for this behavior?
a. A submissive attitude
b. Lack of understanding
c. Embarrassment about the subject
d. Cultural beliefs about eye contact
ANS: D
The nurse must understand that making eye contact means different things in different
cultures. The nurse should have a basic understanding of normal responses of various cultures
within her community. Asians believe that eye contact shows disrespect, not submission.
Many Asian women may nod and smile during patient teaching; however, this does not
indicate understanding. They are responding that they heard you; therefore validation of
information is important. Concerns regarding modesty are more common among Muslim
women.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
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25. The nurse in labor and birth is caring for a Muslim patient during the active phase of labor.
The nurse notes that the patient quickly draws away when touched. Which intervention should
the nurse implement?
a. Ask the charge nurse to reassign you to another patient.
b. Assume that she does not like you and decrease your time with her.
c. Continue to touch her as much as you need to while providing care.
d. Limit touching to a minimum because physical contact may not be acceptable in
her culture.
ANS: D
Touching is an important component of communication in various cultures; however, if the
patient appears to find it offensive, the nurse should respect her cultural beliefs and limit
touching her. Asking the charge nurse to reassign you could be offensive to the patient. A
Muslim’s response to touch does not reflect like or dislike. By continuing to touch her, the
nurse is showing disrespect for the patient’s cultural beliefs.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
26. Which patient may require more help and understanding when integrating the newborn into
the family?
a. A primipara from an upper income family
b. A primipara who comes from a large family
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c. A multipara (gravida 2) who has a supportive husband and mother
d. A multipara (gravida 6) who has two children younger than 3 years
ANS: D
Pregnancy tasks are more complex for the multipara (gravida 6), and she may need special
assistance to integrate the infant into the family structure. A primipara from an upper income
family has the financial resources to assist her with daily care of the home. This leaves her
free to concentrate on the newborn’s needs. The primipara with a large support system has
help available to her. The multipara (gravida 2) who has a supportive husband and mother has
a support system to assist with integrating the infant into the family structure.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
27.
A patient arrives to the clinic 2 hours late for her prenatal appointment. This is the third time
she has been late. What is the nurse’s best action in response to this patient’s tardiness?
a. Ask the patient if she has a way to tell the time.
b. Ask the patient if she is deliberately being late for her appointments.
c. Determine if the patient wants this baby and if this is her way of acting out.
d. Determine if the patient arrives after the start time for other types of appointments.
ANS: D
Time orientation is viewed differently by other cultures. Native Americans, Middle
Easterners, Hispanics, and American Eskimos tend to emphasize the moment rather than the
future. This causes conflicts in the health care setting, in which tests or appointments are
scheduled at particular times. If a woman does not place the same importance on keeping
appointments, she may encounter anger and frustration in the health care setting. Asking if she
has a way to tell time does noNt U
geRt S
toIthNeGpT
otB
en.tiC
alOroMot of the problem. Asking if she is
deliberately late is inconsiderate and nontherapeutic. Although her action may be an
acting-out behavior, there are other considerations that must be considered first.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The clinic nurse often cares for patients who are considering an abortion. Which
responsibilities does this nurse have in regard to this issue? (Select all that apply.)
a. Informing the patient about pro-life options
b. Informing the patient about pro-choice support groups
c. Being informed about abortion from a legal standpoint
d. Being informed about abortion from an ethical standpoint
e. Recognizing that this issue may result in confusion for the patient
ANS: C, D, E
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Nurses have several responsibilities while caring for patients who request a termination of
pregnancy. First, the nurse must be informed about the complexity of the abortion issue from
a legal and an ethical standpoint and know the regulations and laws in their state. Second, the
nurse must recognize that for many patients abortion is an ethical dilemma that results in
confusion, ambivalence, and personal distress. Informing the patient regarding pro-life options
or pro-choice support groups would not be appropriate because it is the patient’s decision and
these interventions show bias on the nurse’s part.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
2. A couple asks the nurse about the procedure for surrogate parenting. Which correct responses
should the nurse provide for this couple? (Select all that apply.)
a. Donated embryos can be implanted into the surrogate mother.
b. The surrogate mother needs to have carried one previous birth to term.
c. You both need to be infertile to be eligible for surrogate parenting.
d. Conception can take place outside the surrogate mother’s body and then implanted.
e. The surrogate mother can be inseminated artificially with sperm from the intended
father.
ANS: A, D, E
In surrogate parenting, conception may take place outside the body using ova and sperm from
the couple that wishes to become parents. These embryos are then implanted into the
surrogate mother, or the surrogate mother may be inseminated artificially with sperm from the
intended father. Donated embryos may also be implanted into a surrogate mother. The couple
does not need to be infertile. The surrogate parent does not need to have previously carried a
pregnancy to term.
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DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
3. Which actions by the nurse indicate compliance with the Health Insurance Portability and
Accountability Act (HIPAA)? (Select all that apply.)
a. The nurse posts an update about a patient on Facebook.
b. The nurse gives the report to the oncoming nurse in a private area.
c. The nurse gives information about the patient’s status over the phone to the
patient’s friend.
d. The nurse logs off any computer screen showing patient data before leaving the
computer unattended.
e. The nurse puts any documentation with the patient’s information in the shred bin at
the hospital before leaving for the day.
ANS: B, D, E
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HIPAA regulations provide consumers with significant power over their records, including
the right to see and correct their records, the application of civil and criminal penalties for
violations of privacy standards, and protection against deliberate or inadvertent misuse or
disclosure. Discussions about a patient with other professionals should be restricted to those
who need to know and should occur in a private location. Nurses must take care to avoid
violating patient confidentiality when using electronic patient data formats. For example,
nurses must promptly log off terminals when finished so that unauthorized individuals cannot
gain access to the system. Shredding documentation with patient identifiers should be done
before leaving the hospital. Discussing a patient’s status in any online forum is a violation of
HIPAA. Giving information to a patient’s friend over the phone, without the patient’s consent,
is a violation of HIPAA.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
4. In some Middle Eastern and African cultures, female genital mutilation (female cutting) is a
prerequisite for marriage. Women who now live in North America need care from nurses who
are knowledgeable about the procedure and comfortable with the abnormal appearance of
their genitalia. When caring for this patient, the nurse can formulate a diagnosis with the
understanding that the patient may be at risk for which of the following? (Select all that
apply.)
a. Infection
b. Laceration
c. Hemorrhage
d. Obstructed labor
e. Increased signs of pain response
ANS: A, B, C, D
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The patient is at risk for infection, laceration, hemorrhage, and obstructed labor. Female
genital mutilation, cutting, or circumcision involves removal of some or all of the external
female genitalia. The labia majora are often stitched together over the vaginal and urethral
openings as part of this practice. Enlargement of the vaginal opening may be performed
before or during the birth. The woman is unlikely to give any verbal or nonverbal signs of
pain. This lack of response does not indicate lack of pain. In fact, pelvic examinations are
likely to be very painful because the introitus is so small, and inelastic scar tissue makes the
area especially sensitive. A pediatric speculum may be necessary, and the patient should be
made as comfortable as possible.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Psychosocial Integrity
5. A Vietnamese patient who speaks little English is admitted to the labor and birth unit in early
labor. The nurse plans to use an interpreter during an initial assessment. Which should the
nurse plan to implement with regard to using an interpreter? (Select all that apply.)
a. Face the interpreter when speaking.
b. Listen carefully to what the patient says.
c. Speak slowly and smile when appropriate.
d. Plan to use a male interpreter, even if a female interpreter is available.
e. Ask the interpreter to explain exactly what is said as much as possible, instead of
paraphrasing.
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ANS: B, C, E
The nurse planning to use an interpreter should listen carefully to what the patient says.
The nurse should speak slowly and smile when appropriate. Ask the interpreter to explain
exactly what is said instead of paraphrasing. It is preferable to use a trained female
interpreter when one is available instead of a male interpreter. The nurse should directly face
the patient when speaking.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
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Chapter 03: Reproductive Anatomy and Physiology
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A postpartum patient who has had a vaginal birth asks the nurse, “I was wondering if my
cervix will return to its previous shape before I had the baby?” Which is the best response by
the nurse?
a. The cervix will now have a slit-like shape.
b. The cervix will be round and smooth after healing occurs.
c. The cervix will remain 50% effaced now that you have had a baby.
d. The cervix will be slightly dilated to 2 cm for about 6 months.
ANS: A
After vaginal birth, the external os has an irregular slit-like shape and may have tags of scar
tissue. The external os of a childless woman is round and smooth; however, after a vaginal
birth it will be round and smooth. During labor, the cervix effaces (thins) and dilates (opens)
to allow passage of the fetus. Once the baby is born, the cervix will close and return to close
to 100% effacement.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
2. The school nurse is conducting health education classes for a group of adolescents. Which
statement best describes a secondary sexual characteristic?
a. Maturation of ova
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b. Production of sperm
c. Female breast development
d. Secretion of gonadotropin-releasing hormone
ANS: C
A secondary sexual characteristic is one not directly related to reproduction, such as
development of the characteristic female body form. Maturation of ova is directly related to
reproduction and is a primary sexual characteristic. Production of sperm is directly related to
reproduction and is a primary sexual characteristic. Secretion of hormones is directly related
to reproduction and is a primary sexual characteristic.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
3. Which 16-year-old female patient is most likely to experience secondary amenorrhea?
a. 5 ft 2 in, 130 lb
b. 5 ft 9 in, 180 lb
c. 5 ft 7 in, 96 lb
d. 5 ft 4 in, 125 lb
ANS: C
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Due to her height and low body weight, this adolescent is at risk of developing secondary
amenorrhea. Secondary amenorrhea occurs in women who are thin and have a low percentage
of body fat. Fat is necessary to make the sex hormones that stimulate ovulation and
menstruation. The other patients are of sufficient height and weight to promote sex hormone
production.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which characteristic best describes the levator ani?
a. Division of the fallopian tube
b. Collection of three pairs of muscles
c. Imaginary line that divides the true pelvis and false pelvis
d. Basin-shaped structure at the lower end of the spine
ANS: B
The levator ani is a collection of three pairs of muscles that support internal pelvic structures
and resist increases in intraabdominal pressure. The fallopian tube divisions are the interstitial
portion, isthmus, ampulla, and infundibulum. The linea terminalis is the imaginary line that
divides the false from the true pelvis. The basin-shaped structure at the lower end of the spine
is the bony pelvis.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
5. The nurse is describing the size and shape of the nonpregnant uterus to a patient. Which is an
accurate description?
a. The nonpregnant uterus iN
s tU
heRsSizIeN
anGdTsB
ha.
pC
e oOfM
a pear.
b. The nonpregnant uterus is the size and shape of a cantaloupe.
c. The nonpregnant uterus is the size and shape of a grapefruit.
d. The non-pregnant uterus is the size and shape of a large orange.
ANS: A
The nonpregnant uterus is about 7.5  5  2.5 cm, which is close to the size and shape of a
pear. A cantaloupe would be too large and is the wrong shape for the uterus. A grapefruit is
too large for the nonpregnant uterus; the uterus is larger at the upper end and tapers down. An
orange may be the appropriate size, but it is not the appropriate shape.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
6. If a woman’s menstrual cycle began on June 2, on which date should ovulation mostly likely
have occurred?
a. June 10
b. June 16
c. June 29
d. July 5
ANS: B
NURSINGTB.COM
June 16 would be 18 days into the cycle; ovulation should have occurred at this point. June 10
would just be 8 days into the cycle and too early for ovulation. Ovulation occurs about 12 to
14 days after the beginning of the next menstrual period in a 28-day cycle; ovulation normally
occurs about 14 days before the beginning of the next period. June 29 is at the end of the
cycle. July 5 would be 27 days into the cycle and about time for the next period.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. A patient states, “My breasts are so small. I don’t think I will be able to breastfeed my baby.”
Which is the nurse’s best response?
a. “It may be difficult but you should try anyway.”
b. “You can always supplement with formula.”
c. “All women have about the same amount of glandular tissue necessary to secrete
milk.”
d. “The ability to produce breast milk depends on increased levels of estrogen and
progesterone.”
ANS: C
All women have 15 to 20 lobes arranged around and behind the nipple and areola. These
lobes, not the size of the breast, are responsible for milk production. The size of the breasts
does not ensure success or failure in breastfeeding. Supplementation decreases the production
of breast milk by decreasing stimulation. Stimulation of the breast, not the size of the breast,
brings about milk production. Increased levels of estrogen decrease the production of milk by
affecting prolactin.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: PhysiologNicUIR
ntS
egI
ritN
y GTB.COM
8.
The nurse is explaining the function of the male’s cremaster muscle to a group of nursing
students. Which statement accurately describes the function of the cremaster muscle?
a. Assists with transporting sperm
b. Aids in temperature control of the testicles
c. Aids in voluntary control of excretion of urine
d. Entraps blood in the penis to produce an erection
ANS: B
One cremaster muscle is attached to each testicle. Its function is to bring the testicle closer to
the body to warm it or allow it to fall away from the body to cool it, thus promoting normal
sperm production. Seminal fluid assists with transporting sperm. The urinary meatus aids in
controlling the excretion of urine. Entrapment of the blood in the penis is a result of the
spongy tissue.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. A newly pregnant patient asks the nurse, “What is a false pelvis?” Which statement by the
nurse will best explain this anatomy to the patient?
a. It is the total anterior portion of the pelvis.
b. It is considered to be the lower portion of the pelvis.
c. It provides support for the internal organs and the upper part of the body.
NURSINGTB.COM
d. It is the narrowest part of the pelvis through which a fetus will pass during birth.
ANS: C
The linea terminalis, also called the pelvic brim or iliopectineal line, is an imaginary line that
divides the upper, or false, pelvis from the lower, or true, pelvis. The false pelvis provides
support for the internal organs and upper part of the body. The false pelvis is the upper
portion, not the total anterior portion. The lower portion of the pelvis is the true pelvis, which
is most important during childbirth because it has the narrowest portion through which the
fetus will pass during childbirth.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. The clinic nurse is reviewing breastfeeding with a pregnant patient. Which hormone will the
nurse explain is responsible for milk production after the birth of the placenta?
a. Pitocin
b. Prolactin
c. Estrogen
d. Progesterone
ANS: B
During pregnancy, high levels of estrogen and progesterone produced by the placenta
stimulate growth of the alveoli and ductal system to prepare them for lactation. Prolactin
secretion by the anterior pituitary gland stimulates milk production during pregnancy;
however, this effect is inhibited by estrogen and progesterone produced by the placenta.
Inhibiting effects of estrogen and progesterone stop when the placenta is expelled after birth,
and active milk production occurs in response to the infant’s suckling while breastfeeding.
Pitocin is the hormone that cN
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DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
11. Which hormonal effect is noted during the menstrual cycle?
a. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) secretion rise
during the ovulatory phase.
b. A negative feedback mechanism is exhibited by the anterior pituitary gland and
ovaries.
c. The posterior pituitary gland secretes LH.
d. Estrogen secretion enhances FSH secretion.
ANS: A
Levels of LH and FSH rise dramatically during the ovulatory phase and are known as the LH
surge prior to ovulation. A positive feedback mechanism occurs with regard to the menstrual
cycle. The anterior pituitary gland secretes LH. Estrogen secretion minimizes FSH secretion.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential/System-Specific Assessments
12. A female patient who has gone through puberty and started menstruating without any
problems has developed cessation of periods after 2 years of normal cycles. Which finding
would indicate a possible cause for this occurrence?
a. Lag in development of secondary sexual characteristics
NURSINGTB.COM
b. Overproduction of androgenic hormones
c. Negative pregnancy test
d. Clinical diagnosis of primary amenorrhea
ANS: B
An overproduction of androgenic hormones may cause the development of secondary
amenorrhea. This patient has progressed through puberty, which would indicate that there is
no problem with the development of secondary sexual characteristics. If the patient had a
positive pregnancy test, then menstruation would stop. These signs and symptoms indicate the
occurrence of secondary amenorrhea.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
13. On speculum examination of the cervix, it is found to be round and smooth. These findings
suggest that the patient
a. is a multipara.
b. has had previous vaginal deliveries.
c. is nulliparous.
d. is a gravida 1, para 0.
ANS: C
These findings indicate that the patient has never been pregnant and she would be classified as
nulliparous. The other findings indicate that the patient is a multipara, has had vaginal
deliveries, or is a gravida 1, para 0. These all refer to a patient with a positive history of
pregnancy.
DIF: Cognitive Level: ApplicN
ationR I GOBB
NursM
Process Step: Assessment
U S and
N Maintenance:
TJ:.C
O ingTechniques
MSC: Patient Needs: Health Promotion
of Physical Assessment
14. Which statement with regard to reproductive anatomy and physiology is inaccurate?
a. Female patients who are past puberty and sexually active can become pregnant
even if they have not had a menstrual cycle.
b. Puberty symptoms are more prominent in males than females.
c. Females enter puberty earlier than their male counterparts.
d. Secondary sexual characteristics develop during puberty.
ANS: B
Puberty symptoms are less prominent in developing males than females. The other statements
are correct.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
15. The nurse is reviewing normal female development with a mother of a 10-year-old daughter.
The mother states, “I noticed that my daughter developed breast buds about a year ago. When
do you think she will start her menstrual cycle?” What is the nurse’s best response?
a. “In about a year.”
b. “Likely any time now.”
c. “Does your daughter know what to expect?”
d. “It is impossible to predict when she will start her cycle.”
NURSINGTB.COM
ANS: A
Menarche occurs about 2 to 2.5 years after breast development. Asking the mother if her
daughter knows what to expect is a vague response that does not answer the mother’s
question.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
16. The middle school nurse is reviewing the phases of the endometrial cycle with a group of
female students. Which statement by a student will the nurse need to correct?
a. “The proliferative phase occurs when the ovum is maturing.”
b. “The expulsion phase occurs when the ovum is discharged from the ovary.”
c. “The secretory phase occurs during the second half of the menstrual cycle.”
d. “The menstrual phase occurs after the levels of estrogen and progesterone fall.”
ANS: B
The menstrual cycle has only three phases: proliferative, secretory, and menstrual.
Occurrences of each of the three phases have been described. There is no expulsion phase in
the menstrual cycle.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A young female patient comes to the health unit at school to discuss her irregular periods. In
providing education regarding the female reproductive cycle, the nurse describes the regular
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and recurrent changes related to
and thOeSuterine endometrium. Although this is
generally referred to as the menstrual cycle, the ovarian cycle includes which phases? (Select
all that apply.)
a. Follicular
b. Ovulatory
c. Luteal
d. Proliferative
e. Secretory
ANS: A, B, C
The follicular phase is the period during which the ovum matures. It begins on day 1 and ends
around day 14. The ovulatory phase occurs near the middle of the cycle, about 2 days before
ovulation. After ovulation and under the influence of the luteinizing hormone, the luteal phase
corresponds with the last 12 days of the menstrual cycle. The proliferative and secretory
phases are part of the endometrial cycle. The proliferative phase takes place during the first
half of the ovarian cycle when the ovum matures. The secretory phase occurs during the
second half of the cycle when the uterus is prepared to accept the fertilized ovum. These are
followed by the menstrual phase if fertilization does not occur.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
2. The school nurse is conducting health education classes for a group of adolescent girls. Select
the actions of the estrogen hormone that the nurse should include in the lessons. (Select all
that apply.)
a. Stimulates contractions during birth
b. Relaxes pelvic ligaments during pregnancy
c. Stimulates the endometrium before ovulation
d. Stimulates growth of uterus during pregnancy
e. Stimulates the let-down reflex during breastfeeding
ANS: B, C, D
The hormone estrogen relaxes pelvic ligaments during pregnancy, stimulates the endometrium
before ovulation, and stimulates the growth of the uterus during pregnancy. Oxytocin
stimulates contractions during pregnancy and stimulates the let-down reflex during
breastfeeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
COMPLETION
1. Delayed onset of menstruation or primary amenorrhea is considered if the girl’s periods have
not begun by which age in years? Record your answer in a whole number. _
ANS:
16
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primBa.
ryCamMenorrhea if the girl’s periods have not
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begun within 2 years after the onset
or by age 16, or if the girl is more
than 1 year older than her mother or sisters were when their menarche occurred.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Chapter 04: Hereditary and Environmental Influences on Childbearing
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A clinic nurse is planning a teaching session for childbearing-age female patients. Which
information should the nurse include in the teaching session with regard to avoiding exposing
a fetus to teratogens?
a. Eliminate use of acne medications.
b. Immunizations should be updated during the first trimester of pregnancy.
c. Use of saunas and hot tubs during pregnancy should be during the winter months
only.
d. Alcoholic beverages can be consumed in the first and third trimesters of
pregnancy.
ANS: A
Elimination of nontherapeutic drugs is the best action to avoid teratogen exposure. Acne
medication is not essential during pregnancy. Immunizations for diseases such as rubella are
contraindicated during pregnancy. Use of saunas and hot tubs are not recommended because
maternal hyperthermia is a significant teratogen. Alcohol is an environmental substance
known to be teratogenic and should not be consumed during pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. The parents of a child with a karyotype of 47,XY,+21 ask the nurse what this means. Which is
N R I G B.C M
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the most accurate response by U
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a. This karyotype is for a normal male.
b. This karyotype is for a normal female.
c. This karyotype is for a male with Down syndrome.
d. This karyotype is for a female with Turner’s syndrome.
ANS: C
This child is male because his sex chromosomes are XY. He has one extra copy of
chromosome 21 (for a total of 47, instead of 46), resulting in Down syndrome. A normal
female would have 46 chromosomes and XX for the sex chromosomes. A normal male would
have 46 chromosomes. A female with Turner’s syndrome would have 45 chromosomes; the
sex chromosome would have just one X.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. People who have two copies of the same abnormal autosomal dominant gene are generally
a. mildly affected with the disorder.
b. infertile and unable to transmit the gene.
c. carriers of the trait but not affected with the disorder.
d. more severely affected by the disorder than people with one copy of the gene.
ANS: D
NURSINGTB.COM
People who have two copies of an abnormal gene are usually more severely affected by the
disorder because they have no normal gene to compensate and maintain normal function.
Those mildly affected with the disorder will have only one copy of the abnormal gene.
Infertility may or may not be caused by chromosomal defects. A carrier of a trait has one
recessive gene.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. An infant is born with blood type AB. The father is type A and the mother is type B. The
father asks why the baby has a blood type different from that of the parents. The nurse’s
answer should be based on the knowledge that
a. both A and B blood types are dominant.
b. types A and B are recessive when linked together.
c. the baby has a mutation of the parents’ blood types.
d. type A is recessive and links more easily with type B.
ANS: A
Types A and B are equally dominant, and the baby can thus inherit one from each parent.
Both types A and B are dominant, not recessive. The infant has inherited both blood types
from the parents and this is not a mutation. Both blood types A and B are equally dominant.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
5. Which statement regarding multifactorial disorders is correct?
a. They may not be evident until later in life.
b. They are usually present N
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c. The disorders are characterized by multiple defects.
d. Secondary defects are rarely associated with them.
ANS: B
Multifactorial disorders result from an interaction between a person’s genetic susceptibility
and environmental conditions that favor development of the defect. They are characteristically
present and detectable at birth. They are usually single isolated defects, although the primary
defect may cause secondary defects. Secondary defects can occur with multifactorial
disorders.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
6. Which information should the nurse include when discussing the prenatal diagnosis of genetic
disorders with an expectant couple?
a. The diagnosis may be slow and could be inconclusive.
b. A comprehensive evaluation will result in an accurate diagnosis.
c. Common disorders can be quickly diagnosed through blood tests.
d. Diagnosis can be obtained promptly through most hospital laboratories.
ANS: A
NURSINGTB.COM
Even the best efforts at diagnosis do not always yield the information needed to counsel the
patient. The process may require many visits over several weeks. Some tests must be sent to
special laboratories, which take additional time. Despite a comprehensive evaluation, a
diagnosis may never be established. At this time there are no rapid result blood tests available
to diagnose genetic disorders. Some tests must be sent to a special laboratory, which requires
a longer waiting period for results.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
7. A patient tells the nurse at a prenatal interview that she has quit smoking, and only has one
glass of wine with dinner. Which response by the nurse will be most helpful in promoting a
lifestyle change?
a. “Those few things won’t cause any trouble. Good for you.”
b. “You need to do a lot better than that. You are still hurting your baby.”
c. “Here are some pamphlets for you to study. They will help you to find more ways
to improve.”
d. “You have made some good progress toward having a healthy baby. Let’s talk
about the changes you have made.”
ANS: D
Praising her for making positive changes is an effective technique for motivating a patient.
She still has risk factors to alter for optimal outcome, and a gentle maneuver to help her see
these for herself will be most likely to succeed. Alcohol consumption is still a major risk
factor and needs to be addressed in a positive, nonjudgmental manner. The statement, “You
need to do a lot better” is belittling to the patient; she will be less likely to confide in the
nurse. The nurse is not acknowledging the efforts that the patient has already accomplished by
NmR
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B.CtoMbe praised to motivate the patient to
offering pamphlets; those accoU
plS
ishm
ts need O
continue.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
8. A 35-year-old patient has an amniocentesis performed to identify whether her baby has a
chromosomal defect. Which statement indicates that the patient understands the situation?
a. “The doctor will tell me if I should have an abortion when the test results come
back.”
b. “When all the lab results come back, my husband and I will make a decision about
the pregnancy.”
c. “My mother must not find out about all this testing. If she does, she will think I’m
having an abortion.”
d. “I know there are support groups for parents who have a baby with birth defects,
but we have plenty of insurance to cover what we need.”
ANS: B
NURSINGTB.COM
The final decision about genetic testing and the future of the pregnancy lies with the patient.
The patient will involve only those people whom she chooses. An amniocentesis is done to
detect chromosomal defects; many women have this done to prepare and educate themselves
for the baby’s arrival. The woman should also be assured that her care is confidential.
Insurance will help cover expenses; however, a child with birth defects also takes a toll on the
emotional, physical, and social aspects of the parents’ lives. Support groups are extremely
important for parents of a baby with birth defects.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
9. Which characteristic is related to Down syndrome?
a. Up-slanting eyes
b. Abnormal genitalia
c. Bleeding tendency
d. Edema of extremities
ANS: A
Up-slanting eyes, wide short fingers, and low-set ears are often seen in infants with Down
syndrome. Bleeding tendency, edema of extremities, and abnormal genitalia are not
characteristics of Down syndrome.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. Which question posed by the nurse will most likely promote the sharing of sensitive
information during a genetic counseling interview?
a. “What kind of defects or N
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to.
ruCnOinMthe family?”
b. “How many people in your family are mentally retarded or handicapped?”
c. “Did you know that you can always have an abortion if the fetus is abnormal?”
d. “Are there any members of your family who have learning or developmental
problems?”
ANS: D
The nurse should probe gently using layperson-oriented terminology, such as learning
problems rather than defects or diseases. Some individuals may not be aware of which
diseases are genetically linked and may not answer the question accurately. “How many
people in your family are mentally retarded or handicapped?” assumes that there are genetic
problems that resulted in retardation in the family. Some individuals may find these terms
offensive. “Did you know that you can always have an abortion if the fetus is abnormal?” is
taking the decision away from the parents. They are seeking counseling to prevent problems,
not to find out what to do if there is a problem.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
11. Testing for the cause of anomalies in a stillborn infant is underway. The mother angrily asks
the nurse how long these tests are going to take. The nurse should understand that this mother
is
a. exhibiting normal grief behavior.
b. trying to place blame on someone.
NURSINGTB.COM
c. being impatient and unreasonable.
d. feeling guilty and blaming herself.
ANS: A
Grief after a fetal loss may initially be expressed as anger. The mother is not placing blame;
she is in the anger stage of the grieving process. The mother is not being impatient or
unreasonable. The mother is expressing anger as an initial stage of grief, not blaming herself
or feeling guilty.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
12. While obtaining a genetic history from a female patient, you note that there is a family history
of a genetic disease on the maternal side; however, no evidence of symptomatology in the
patient or the patient’s children, two girls. Which observation can you make related to genetic
expression?
a. Autosomal dominant expression is observed.
b. X-linked dominant trait is observed.
c. More information is needed to determine the answer.
d. Autosomal recessive expression is observed and both the children will be carriers
of the disease process.
ANS: C
Because we have no information about the father and/or paternal side, the other stated options
do not apply. If an autosomal dominant expression were present in the family history, the
patient would be symptomatic. X-linked recessive traits are more common than X-linked
dominant traits and, again, the patient and children are not symptomatic. Although an
RaSyIbN
autosomal recessive expressiN
onUm
eG
prT
esB
en.t,CwOeMcannot predict that the children will be
carriers. There is a 25% chance of being affected.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Physiologic Integrity: Pathophysiology
13. A couple is undergoing genetic counseling and are very concerned about the possibility of
having a child with a birth defect as a result of a strong family history on both sides of the
family. Which statement made by the nurse is evidence of therapeutic communication?
a. “It is important to ask other members of your family for any information they can
provide that will help obtain more insight into the health history.”
b. “Given what you have told me, there is little that anyone can do to improve
outcomes.”
c. “Although you may feel that you have no options, I can’t really discuss these
matters as only the physician can provide you with information.”
d. “Do you have all your forms filled out correctly? This will make the review easier
to accomplish. ”
ANS: A
NURSINGTB.COM
Having as much information as possible will help analyze potential health outcomes. It also
shows that the nurse is taking the patients’ concerns seriously. Telling the patients that there is
little anyone can do does not provide any comfort or hope and is therefore self-defeating.
Although the patients may have limited options based on their genetic and medical history, it
is important to provide support and not defer all communication to the physician. The nurse
must be able to provide support and counseling to patients. It is important to have completed
forms, but asking patients about them does not address their psychological concerns.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity: Therapeutic Communication
14. A patient presents with curly hair and blue eyes. These findings are consistent with
a. phenotype.
b. genotype.
c. dominant alleles.
d. recessive traits.
ANS: A
Curly hair is considered to be a dominant trait, whereas blue eyes are considered to be a
recessive trait. Observation of characteristics is noted as phenotype. Genotype identifies the
genetic makeup of traits.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
15. The nurse is working with a patient to obtain information necessary for genetic counseling.
Which tool will be used to obtain this information?
NURSINGTB.COM
a. Braden scale
b. Genogram
c. Chorionic villus sampling (CVS)
d. Serum protein electrophoresis
ANS: B
When obtaining information with regard to genetic counseling, it is important to obtain a
family history using a genogram or pedigree as the clinical tool. The use of this diagram
provides information for maternal and paternal histories and allows for the interpretation of
significance based on findings of age, death, and medical history. A Braden scale is used to
assess problems with skin leading to potential breakdown. CVS is a diagnostic procedure used
during pregnancy to obtain genetic information about the fetus. Serum protein electrophoresis
is a lab test used to determine immunoglobulin levels.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
16. The nurse receives report on an infant whose analysis indicates 47 total chromosomes, with
the abnormality noted at chromosome 21. Which additional assessments will the nurse include
when evaluating the infant?
a. Cleft palate
b. Protruding tongue
c. Extra fingers or toes (polydactyly)
d. Intellectual developmental delay
NURSINGTB.COM
ANS: B
Trisomy 21 is associated with a number of notable physical characteristics, including wide-set
eyes, flat bridge of the nose, protruding tongue, short neck, small chin, poor muscle tone, and
space between the great and second toes. An infant with trisomy 21 tends to be short in stature
and developmentally delayed, but two characteristics will become more noticeable as the child
gets older. Cleft palate and polydactyly are more common with trisomy 13.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
17. The patient indicates to the clinic nurse that she is trying to become pregnant. The clinic nurse
reviews the patient’s chart and notes the following laboratory values: Blood type O−, RPR
nonreactive, rubella non-immune, HCT 35%. Which laboratory value is most concerning to
the nurse?
a. HCT 35%
b. Blood type O−
c. RPR nonreactive
d. Rubella non-immune
ANS: D
Rubella non-immune indicates that the patient does not have immunity against rubella and is
therefore susceptible to the infection. Exposure to rubella, or German measles, in the first
trimester is associated with fetal congenital anomalies. The patient requires a rubella
immunization and must not become pregnant within the next 28 days. Although a HCT of
35% is low, women of childbearing age may have mild anemia associated with menstruation.
A blood type of O− indicates that the patient will require Rho GAM; however, it is not of
concern in the preconceptionNpU
erR
ioS
d.IANnGoT
nrB
ea.cC
tivOeMRPR indicates that the patient has not
been exposed to syphilis.
DIF: Cognitive Level: Synthesis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The clinic nurse is reviewing charts on prenatal patients. Which patient histories indicate that
a referral to a genetic counselor is warranted? (Select all that apply.)
a. A father who is aged 35
b. A patient having a first baby at age 30
c. A family history of unexplained stillbirths
d. A patient with a family history of birth defects
e. A patient who is a carrier of an X-linked disorder
ANS: C, D, E
Reasons for a referral to a genetic counselor include family history of unexplained stillbirths,
family history of birth defects, and a woman who is a carrier of an X-linked disorder.
Pregnant women who will be 35 years of age or older when the infant is born and men who
father children after age 40 constitute reasons for referral to a genetic counselor. The patient
who is 30 and the father who is aged 35 would not warrant a referral to a genetic counselor.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
NURSINGTB.COM
MSC: Patient Needs: Health Promotion and Maintenance
2. The nurse is teaching prenatal patients about avoiding substances or conditions that can harm
the fetus. Which should the nurse include in the teaching session? (Select all that apply.)
a. Elimination of use of alcohol
b. Avoidance of supplemental folic acid replacement
c. Stabilization of blood glucose levels in a diabetic patient with insulin
d. Avoidance of nonurgent radiologic procedures during the pregnancy
e. Avoidance of maternal hyperthermia to temperatures of 37.8C (100F) or higher
ANS: A, C, D, E
The best action is for the pregnant woman to eliminate use of nontherapeutic drugs and
substances such as alcohol. A woman who has diabetes should try to keep her blood glucose
levels normal and stable before and during pregnancy for the best possible fetal outcomes.
Nonurgent radiologic procedures may be done during the first 2 weeks after the menstrual
period begins, before ovulation occurs. Exposure to temperatures of 37.8C (100F) or higher
is not advised for the pregnant patient. Folic acid supplements should be taken. All women of
childbearing age should take at least 0.4 mg (400 mcg) of folic acid daily before and after
conception because this has been found to reduce the incidence of neural tube defects by 50%
to 70%.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
3. The nurse is explaining genetics to a group of nursing students. Which are autosomal
recessive disorders that the nurse should discuss during the teaching session? (Select all that
apply.)
NURSINGTB.COM
a. Hemophilia
b. Cystic fibrosis
c. Sickle cell disease
d. Turner’s syndrome
e. Phenylketonuria (PKU) disease
ANS: B, C, E
Cystic fibrosis, sickle cell disease, and PKU disease are autosomal recessive disorders.
Hemophilia and Turner’s syndrome are X-linked genetic disorders.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
COMPLETION
1. Two healthy parents who carry the same abnormal autosomal recessive gene have what
percentage chance of having a child affected with the disorder caused by this gene? Record
your answer as a whole number.
%
ANS:
25
NURSINGTB.COM
Two healthy parents who carry the same abnormal autosomal recessive gene have a 25%
chance of having a child affected with the disorder caused by this gene. Unaffected parents are
carriers of the abnormal autosomal recessive trait. Children of carriers have a 25% (1 in 4)
chance of receiving both copies of the defective gene and thus having the disorder.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
NURSINGTB.COM
Chapter 05: Conception and Prenatal Development
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. An expectant father asks the nurse, “Which part of the mature sperm contains the male
chromosome?” What is the correct response by the nurse?
a. X-bearing sperm
b. The tail of the sperm
c. The head of the sperm
d. The middle portion of the sperm
ANS: C
The head of the sperm contains the male chromosomes that will join the chromosomes of the
ovum. If an X-bearing sperm fertilizes the ovum, the baby will be female. The tail of the
sperm helps propel the sperm toward the ovum. The middle portion of the sperm supplies
energy for the tail’s whip-like action.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
2. One of the assessments performed in the birth room is checking the umbilical cord for blood
vessels. Which finding is considered to be within normal limits?
a. One artery and one vein
b. Two veins and one artery
c. Two arteries and one vein
NURSINGTB.C M
O
d. Two arteries and two veins
ANS: C
The umbilical cord contains two arteries and one vein to transport blood between the fetus and
the placenta. Any option other than two arteries and one vein is considered abnormal and
requires further assessment. Two veins and one artery is abnormal and may indicate an
anomaly. Two arteries instead is a normal finding; this infant would require further
assessment for anomalies due to the finding of two veins.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. What is the purpose of the ovum’s zona pellucida?
a. Prevents multiple sperm from fertilizing the ovum
b. Stimulates the ovum to begin mitotic cell division
c. Allows the 46 chromosomes from each gamete to merge
d. Makes a pathway for more than one sperm to reach the ovum
ANS: A
Fertilization causes the zona pellucida to change its chemical composition so that multiple
sperm cannot fertilize the ovum. Mitotic cell division begins when the nuclei of the sperm and
ovum unite. Each gamete (sperm and ovum) has only 23 chromosomes; there will be 46
chromosomes when they merge. Once sperm has entered the ovum, the zona pellucida
changes to prevent other sperm from entering.
NURSINGTB.COM
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
4. The nurse is explaining the process of cell division during the preembryonic period to a group
of nursing students. Which statement best describes the characteristics of the morula?
a. Fertilized ovum before mitosis begins
b. Double layer of cells that becomes the placenta
c. Flattened, disk-shaped layer of cells within a fluid-filled sphere
d. Solid ball composed of the first cells formed after fertilization
ANS: D
The morula is so named because it resembles a mulberry. It is a solid ball of 12 to 16 cells that
develops after fertilization. The fertilized ovum is called the zygote. The placenta is formed
from two layers of cells—the trophoblast, which is the other portion of the fertilized ovum,
and the decidua, which is the portion of the uterus where implantation occurs. The flattened,
disk-shaped layer of cells is the embryonic disk; it will develop into the body.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
5. The upper uterus is the best place for the fertilized ovum to implant due to which anatomical
adaptation?
a. Maternal blood flow is lower.
b. Placenta attaches most firmly.
c. Uterine endometrium is softer.
d. Developing baby is best nourished.
ANS: D
NURSINGTB.COM
The uterine fundus is richly supplied with blood and has the thickest endometrium, both of
which promote optimum nourishment of the fetus. The blood supply is rich in the fundus,
which allows for optimal nourishment of the fetus. If the placenta attaches too deeply, it does
not easily detach. Softness is not a concern with implantation; attachment and nourishment are
the major concerns.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
6. Some of the embryo’s intestines remain within the umbilical cord during the embryonic
period because the
a. intestines need this time to grow until week 15.
b. nutrient content of the blood is higher in this location.
c. abdomen is too small to contain all the organs while they are developing.
d. umbilical cord is much larger at this time than it will be at the end of pregnancy.
ANS: C
NURSINGTB.COM
The abdominal contents grow more rapidly than the abdominal cavity, so part of their
development takes place in the umbilical cord. By 10 weeks, the abdomen is large enough to
contain them. The intestines remain within the umbilical cord only until about week 10. Blood
supply is adequate in all areas; intestines stay in the umbilical cord for about 10 weeks
because they are growing faster than the abdomen. Intestines begin their development within
the umbilical cord, but only because the liver and kidneys occupy most of the abdominal
cavity, not because of the size of the umbilical cord.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. A patient who is 16 weeks pregnant with her first baby asks how long it will be before she
feels the baby move. Which is the nurse’s best answer?
a. “You should have felt the baby move by now.”
b. “The baby is moving, but you can’t feel it yet.”
c. “Some babies are quiet and you don’t feel them move.”
d. “Within the next month you should start to feel fluttering sensations.”
ANS: D
Maternal perception of fetal movement (quickening) usually begins between 17 and 20 weeks
after conception. Because this is her first pregnancy, movement is felt toward the later part of
the 17 to 20 weeks. “The baby is moving, but you can’t feel it yet” may be alarming to the
woman. “Some babies are quiet and you don’t feel them move” is a true statement; the fetus’
movements are not strong enough to be felt until 17 to 20 weeks; however, this statement does
not answer the woman’s concern. Fetal movement should be felt between 17 and 20 weeks; if
movement is not perceptible by the end of that time, further assessment will be necessary.
DIF: Cognitive Level: ApplicN
atU
ionRSINGOT
BB
J:.C
NuOrsM
ing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
8. Which statement best describes the changes that occur during the fetal period of development?
a. Maturation of organ systems
b. Development of basic organ systems
c. Resistance of organs to damage from external agents
d. Development of placental oxygen–carbon dioxide exchange
ANS: A
During the fetal period, the body systems grow in size and mature in function to allow
independent existence after birth. Basic organ systems are developed during the embryonic
period. The organs are always at risk for damage from external sources; however, the older
the fetus, the more resistant will be the organs. The greatest risk is when the organs are
developing. The placental system is complete by week 12, but that is not the best description
of the fetal period.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
9. An expectant mother says to the nurse, “When my sister’s baby was born, it was covered in a
cheese-like coating. What is the purpose of this coating?” The correct response by the nurse is
to explain that the purpose of vernix caseosa is to
a. regulate fetal temperature.
NURSINGTB.COM
b. protect the fetal skin from amniotic fluid.
c. promote normal peripheral nervous system development.
d. allow the transport of oxygen and nutrients across the amnion.
ANS: B
Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the
skin without the protection of the vernix caseosa. The amniotic fluid aids in maintaining fetal
temperature. Normal peripheral nervous system development is dependent on the nutritional
intake of the mother. The amnion is the inner membrane that surrounds the fetus. It is not
involved in the oxygen and nutrient exchange.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
10. An expectant mother, diagnosed with oligohydramnios, asks the nurse what this condition
means for the baby. Which statement should the nurse provide for the patient?
a. Oligohydramnios can cause poor fetal lung development.
b. Oligohydramnios means that the fetus is excreting excessive urine.
c. Oligohydramnios could mean that the fetus has a gastrointestinal blockage.
d. Oligohydramnios is associated with fetal central nervous system abnormalities.
ANS: A
Because an abnormally small amount of amniotic fluid restricts normal lung development, the
fetus may have poor fetal lung development. Oligohydramnios may be caused by a decrease
in urine secretion. Excessive amniotic fluid production may occur when the gastrointestinal
tract prevents normal ingestion of amniotic fluid. Excessive amniotic fluid production may
occur when the fetus has a central nervous system abnormality.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
11. The nurse is conducting a staff in-service on multifetal pregnancy. Which statement regarding
dizygotic twin development should the nurse include in the teaching session?
a. Dizygotic twins arise from two fertilized ova and are the same sex.
b. Dizygotic twins arise from a single fertilized ovum and are always of the same sex.
c. Dizygotic twins arise from two fertilized ova and may be the same sex or different
sexes.
d. Dizygotic twins arise from a single fertilized ovum and may be the same sex or
different sexes.
ANS: C
Dizygotic twins arise from two ova that are fertilized by different sperm. They may be the
same or different gender, and they may not have similar physical traits. Monozygotic twins
are always the same sex. A single fertilized ovum that produces twins is called monozygotic.
Dizygotic twins are from two fertilized ova and may or may not be the same sex.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
12. An infant is diagnosed with fetal anemia. Which information would support this clinical
diagnosis?
a. Presence of excess maternal hormones
NURSINGTB.COM
b. Maternal blood type O-negative, Rh-negative, and infant blood type O-negative,
Rh-negative
c. Passive immunity
d. Rh-negative mother and Rh-positive baby
ANS: C
Passive immunity provides temporary protection to the baby based on the transfer of maternal
antibodies. Maternal hormones would not lead to a clinical diagnosis of fetal anemia. These
blood types and Rh factors are the same; therefore, no antibodies will be created. In this
situation, an Rh-negative mother and Rh-positive baby will result in stimulation of antibodies
that will stimulate a reaction leading to hemolysis.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
13. The nurse is explaining the function of the placenta to a pregnant patient. Which statement
indicates to the nurse that further clarification is necessary?
a. “My baby gets oxygen from the placenta.”
b. “The placenta functions to help excrete waste products.”
c. “The nourishment that I take in passes through the placenta.”
d. “The placenta helps maintain a stable temperature for my baby.”
ANS: D
Amniotic fluid and not the placenta helps with thermoregulation. The remaining statements
are correct regarding placental function.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health PrN
omoRtionIandGMaB
in.
teC
nancMe
U S N T
O
14. The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score
of 9, the nurse notes two vessels in the umbilical cord. What is the nurse’s next action?
a. Assess for other abnormalities of the infant.
b. Note the assessment finding in the infant’s chart.
c. Notify the health care provider of the assessment finding.
d. Call for the neonatal resuscitation team to attend the infant immediately.
ANS: A
The normal finding in the umbilical cord is two arteries and one vein. Two vessels may
indicate other fetal anomalies. Notation of the finding is the appropriate next step when the
finding is expected. The health care provider will need to be notified; however, the infant is
the nurse’s primary concern and must be assessed for abnormalities first. The initial Apgar
score is 9, indicating no signs of distress or need of resuscitation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
15. A pregnant patient asks the nurse how her baby gets oxygen to breathe. What is the nurse’s
best response?
a. “Oxygen-rich blood is delivered through the umbilical vein to the baby.”
b. “Take lots of deep breaths because the baby gets all of its oxygen from you.”
c. “You don’t need to be concerned about your baby getting enough oxygen.”
d. “The baby’s lungs are not mature enough to actually breathe, so don’t worry.”
NURSINGTB.COM
Foundations of
n Murray Test Bank
ANS: A
Oxygen-rich blood travels from the mother’s circulatory system to the placenta and from the
placenta to the umbilical vein (veins carry blood to the heart). From the vein, most of the
oxygenated blood travels to the fetal liver or the inferior vena cava. Taking deep breaths can
temporarily increase oxygenation but can also lead to increased carbon dioxide retention and
dizziness. The patient is asking a normal fetal developmental question often asked by
pregnant women. Fetal lungs reach maturity by 37 weeks of gestation, but fetal breathing
movements are common. Oxygen transport across lung tissue occurs with the first breath.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which physical characteristics decrease as the fetus nears term? (Select all that apply.)
a. Vernix caseosa
b. Lanugo
c. Port wine stain
d. Brown fat
e. Eyebrows or head hair
ANS: A, B
Both vernix caseosa and lanugo decrease as the fetus reaches term. Port wine stain is a
birthmark and, if present, will be exhibited at or shortly after birth. Brown fat in the fetus will
be maintained in order to maintain core temperature. Eyebrows and head hair increase as the
fetus nears term.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment
2. Along with gas exchange and nutrient transfer, the placenta produces many hormones
necessary for normal pregnancy, including which of the following? (Select all that apply.)
a. Insulin
b. Estrogen
c. Progesterone
d. Testosterone
e. Human chorionic gonadotropin (hCG)
ANS: B, C, E
HCG causes the corpus luteum to persist and produce the necessary estrogens and
progesterone for the first 6 to 8 weeks. Estrogens cause enlargement of the woman’s uterus
and breasts and growth of the ductal system in the breasts and, as term approaches, plays a
role in the initiation of labor. Progesterone causes the endometrium to change, providing early
nourishment. Progesterone also protects against spontaneous abortion by suppressing maternal
reactions to fetal antigens and reduces unnecessary uterine contractions. Other hormones
produced by the placenta include hCT, hCA, and a number of growth factors. Insulin and
testosterone are not secreted by the placenta.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
3. The nurse is planning a prenatal class on fetal development. Which characteristics of prenatal
development should the nurse include for a fetus of 24 weeks, based on fertilization age?
(Select all that apply.)
a. Ear cartilage firm
b. Skin wrinkled and red
c. Testes descending toward the inguinal rings
d. Surfactant production nears mature levels
e. Fetal movement becoming progressively more noticeable
ANS: B, C, E
A fetus of 24 weeks, based on fertilization age, will have wrinkled and red skin, testes
descending toward inguinal rings, and the fetal movement becoming progressively more
noticeable. Surfactant production nearing the mature levels does not occur until 32 weeks and
ear cartilage is not firm until 38 weeks.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
4. The nurse is explaining fetal circulation to a group of nursing students. Which information
should be included in the teaching session? (Select all that apply.)
a. After birth the ductus venosus remains open, but the other shunts close.
b. The foramen ovale shunts blood from the right atrium to the left atrium.
c. The ductus venosus shunts blood from the liver to the inferior vena cava.
d. The ductus arteriosus shunts blood from the right ventricle to the left ventricle.
ANS: B, C
The foramen ovale shunts oxN
ygUeR
naS
teI
dN
bG
loT
odBf.
roC
mOtM
he right atrium to the left atrium, bypassing
the lungs. The ductus venosus shunts oxygenated blood from the liver to the inferior vena
cava. All shunts close after birth. The ductus arteriosus shunts blood from the right ventricle
to the aorta.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
5. A nurse is conducting prenatal education classes for a group of expectant parents. Which
information should the nurse include in her discussion of the purpose of amniotic fluid?
(Select all that apply.)
a. Cushions the fetus
b. Protects the skin of the fetus
c. Provides nourishment for the fetus
d. Allows for buoyancy for fetal movement
e. Maintains a stable temperature for the fetus
ANS: A, D, E
The amniotic fluid provides cushioning for the fetus against impacts to the maternal abdomen.
It provides a stable temperature and allows room and buoyancy for fetal movement. Vernix
caseosa, the cheeselike coating on the fetus, provides skin protection. The placenta provides
nourishment for the fetus.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 06: Maternal Adaptations to Pregnancy
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. During vital sign assessment of a pregnant patient in her third trimester, the patient complains of
feeling faint, dizzy, and agitated. Which nursing intervention is most appropriate?
a. Have the patient stand up and retake her blood pressure.
b. Have the patient sit down and hold her arm in a dependent position.
c. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
d. Have the patient lie supine for 5 minutes and recheck her blood pressure on both
arms.
ANS: C
Blood pressure is affected by positioning during pregnancy. The supine position may cause
occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral
recumbent position alleviates pressure on the blood vessels and quickly corrects supine
hypotension. Pressures are significantly higher when the patient is standing. This would cause
an increase in systolic and diastolic pressures. The arm should be supported at the same level
of the heart. The supine position may cause occlusion of the vena cava and descending aorta,
creating hypotension.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
2. A pregnant woman has come to the emergency department with complaints of nasal
N R I G B.C M
congestion and epistaxis. WhicU
h isStheNcorT
rect inteOrpretation of these symptoms by the health
care provider?
a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone.
b. These conditions are abnormal. Refer the patient to an ear, nose, and throat
specialist.
c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and
epistaxis are within normal limits.
d. Estrogen causes increased blood supply to the mucous membranes and can result
in congestion and nosebleeds.
ANS: D
As capillaries become engorged, the upper respiratory tract is affected by the subsequent
edema and hyperemia, which causes these conditions, seen commonly during pregnancy.
Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy.
Progesterone levels increase during pregnancy. The patient should be reassured that these
symptoms are within normal limits. No referral is needed at this time. Relaxation of the
smooth muscles in the respiratory tract is affected by progesterone.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
3. While providing education to a primiparous patient regarding the normal changes of
pregnancy, what is an important information for the nurse to share regarding Braxton Hicks
contractions?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
These contractions may indicate preterm labor.
These are contractions that never cause any discomfort.
Braxton Hicks contractions only start during the third trimester.
These occur throughout pregnancy, but you may not feel them until the third
trimester.
ANS: D
Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks
contractions. During the first two trimesters, the contractions are infrequent and usually not
felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm
labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester.
Braxton Hicks contractions occur throughout the whole pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
4. What is the physiologic reason for vascular volume increasing by 40% to 60% during
pregnancy?
a. Prevents maternal and fetal dehydration
b. Eliminates metabolic wastes of the mother
c. Provides adequate perfusion of the placenta
d. Compensates for decreased renal plasma flow
ANS: C
The primary function of increased vascular volume is to transport oxygen and nutrients to the
fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for
the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal
excretion is one purpose of thNeUinRcS
reI
asN
edGvTaB
sc.
ulC
arOvM
olume. Renal plasma flow increases
during pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
5. Physiologic anemia often occurs during pregnancy due to
a. inadequate intake of iron.
b. the fetus establishing iron stores.
c. dilution of hemoglobin concentration.
d. decreased production of erythrocytes.
ANS: C
When blood volume expansion is more pronounced and occurs earlier than the increase in red
blood cells, the woman will have physiologic anemia, which is the result of dilution of
hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may
lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may
occur when the fetus pulls stored iron from the maternal system. There is increased production
of erythrocytes during pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. Which finding is a positive sign of pregnancy?
a. Amenorrhea
NURSINGTB.COM
b. Breast changes
c. Fetal movement felt by the woman
d. Visualization of fetus by ultrasound
ANS: D
The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the
fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive
sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a
presumptive sign of pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. A patient in her first trimester complains of nausea and vomiting. The patient asks, “Why is
this happening?” What is the nurse’s best response?
a. “It is due to an increase in gastric motility.”
b. “It may be due to changes in hormones.”
c. “It is related to an increase in glucose levels.”
d. “It is caused by a decrease in gastric secretions.”
ANS: B
Nausea and vomiting are believed to be caused by increased levels of hormones, decreased
gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose
levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause
of nausea and vomiting.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: PhysiologNic IR
ntegI
rity G B.C M
U S N T
O
8. The patient has just learned that she is pregnant and overhears the gynecologist saying that she
has a positive Chadwick’s sign. When the patient asks the nurse what this means, how would
the nurse respond?
a. “Chadwick’s sign signifies an increased risk of blood clots in pregnant women
because of a congestion of blood.”
b. “That sign means the cervix has softened as the result of tissue changes that
naturally occur with pregnancy.”
c. “This means that a mucus plug has formed in the cervical canal to help protect you
from uterine infection.”
d. “This sign occurs normally in pregnancy, when estrogen causes increased blood
flow in the area of the cervix.”
ANS: D
Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting
in the characteristic bluish purple color that extends to include the vagina and labia. This
discoloration, referred to as Chadwick’s sign, is one of the earliest signs of pregnancy.
Although Chadwick’s sign occurs with hyperemia (congestion with blood), the sign does not
signify an increased risk of blood clots. The softening of the cervix is called Goodell’s sign,
not Chadwick’s sign. Although the formation of a mucus plug protects from infection, it is not
called Chadwick’s sign.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Health Promotion and Maintenance
9. An expected change during pregnancy is a darkly pigmented vertical midabdominal line. The
nurse recognizes this alteration as
a. epulis.
b. linea nigra.
c. melasma.
d. striae gravidarum.
ANS: B
The linea nigra is a dark pigmented line from the fundus to the symphysis pubis. Epulis refers
to gingival hypertrophy. Melasma is a different kind of dark pigmentation that occurs on the
face. Striae gravidarum (stretch marks) are lines caused by lineal tears that occur in
connective tissue during periods of rapid growth.
DIF: Cognitive Level: Knowledge
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. What is the best explanation that the nurse can provide to a patient who is concerned that she
has “pseudoanemia” of pregnancy?
a. Have her write down her concerns and tell her that you will ask the physician to
respond once the lab results have been evaluated.
b. Tell her that this is a benign self-limiting condition that can be easily corrected by
switching to a high-iron diet.
c. Inform her that because of the pregnancy, her blood volume has increased, leading
to a substantial dilution effect on her serum blood levels, and that most women
experience this condition.
d. Contact the physician andNgUeR
t aSpIreNscGrT
ipB
tio.nCfoOrM
iron pills to correct this condition.
ANS: C
Providing factual information based on physiologic mechanisms is the best option. Although
having the patient write down her concerns is reasonable, the nurse should not refer this
conversation to the physician but rather address the patient’s specific concerns. Switching to a
high-iron diet will not correct this condition. This physiologic pattern occurs during
pregnancy as a result of hemodilution from excess blood volume. Iron medication is not
indicated for correction of this condition. There is no need to contact the physician for a
prescription.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
11. Which physiologic finding is consistent with normal pregnancy?
a. Systemic vascular resistance increases as blood pressure decreases.
b. Cardiac output increases during pregnancy.
c. Blood pressure remains consistent independent of position changes.
d. Maternal vasoconstriction occurs in response to increased metabolism.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Cardiac output increases during pregnancy as a result of increased stroke volume and heart
rate. Systemic vascular resistance decreases while blood pressure remains the same. Maternal
blood pressure changes in response to patient positioning. In response to increased
metabolism, maternal vasodilation is seen during pregnancy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
12. A pregnant woman complains of frequent heartburn. The patient states that she has never had
these symptoms before and wonders why this is happening now. The most appropriate
response by the nurse is to
a. examine her dietary intake pattern and tell her to avoid certain foods.
b. tell her that this is a normal finding during early pregnancy and will resolve as she
gets closer to term.
c. explain to the patient that physiologic changes caused by the pregnancy make her
more likely to experience these types of symptoms.
d. refer her to her health care provider for additional testing because this is an
abnormal finding.
ANS: C
The presentation of heartburn is a normal abnormal finding that can occur in pregnant woman
because of relaxation of the lower esophageal sphincter as a result of the physiologic effects
of pregnancy. Although foods may contribute to the heartburn, the patient is asking why this
presentation is occurring, so the nurse should address the cause first. It is independent of
gestation. There is no need to refer to the physician at this time because this is a normal
abnormal finding. There is no evidence of complications ensuing from this presentation.
DIF: Cognitive Level: AnalysN
isURSINGOT
BB
J:.C
NuOrsM
ing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
13. Which physiologic adaptation of pregnancy may lead to increased constipation during the
pregnancy?
a. Increased emptying time in the intestines
b. Abdominal distention and bloating
c. Decreased absorption of water
d. Decreased motility in the intestines
ANS: D
Decreased motility in the intestines leading to increased water absorption would cause
constipation. Increased emptying time in the intestines leads to increased nutrient absorption.
Abdominal distention and bloating are a result of increased emptying time in the intestines.
Decreased absorption of water would not cause constipation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
14. Which physiologic findings related to gallbladder function may lead to the development of
gallstones during pregnancy?
a. Decrease in alkaline phosphatase levels compared with nonpregnant women
b. Increase in albumin and total protein as a result of hemodilution
c. Hypertonicity of gallbladder tissue
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Prolonged emptying time
ANS: D
Prolonged emptying time is seen during pregnancy and may lead to the development of
gallstones. In pregnancy, there is a twofold to fourfold time increase in alkaline phosphatase
levels as compared with those in nonpregnant woman. During pregnancy, a decrease in
albumin level and total protein is seen as a result of hemodilution. Gallbladder tissue becomes
hypotonic during pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
15. Which of these findings would indicate a potential complication related to renal function
during pregnancy?
a. Increase in glomerular filtration rate (GFR)
b. Increase in serum creatinine level
c. Decrease in blood urea nitrogen (BUN)
d. Mild proteinuria
ANS: B
With pregnancy, one would expect the serum creatinine and BUN levels to decrease. An
elevation in the serum creatinine level should be investigated. With pregnancy, the GFR
increases because of increased renal blood flow and is thus a normal expected finding. A
decrease in the blood urea nitrogen level and mild proteinuria is expected findings in
pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: PhysiologNic IR
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16. A pregnant woman notices that she is beginning to develop dark skin patches on her face. She
denies using any different type of facial products as a cleansing solution or makeup. What
would the priority nursing intervention be in response to this situation?
a. Refer the patient to a dermatologist for further examination.
b. Ask the patient if she has been eating different types of foods.
c. Take a culture swab and send to the lab for culture and sensitivity (C&S).
d. Let the patient know that this is a common finding that occurs during pregnancy.
ANS: D
This condition is known as chloasma or melasma (mask of pregnancy) and is a result of
pigmentation changes relative to hormones. It can be exacerbated by exposure to the sun.
There is no need to refer to a dermatologist. Intake of foods is not associated with
exacerbation of this process. There is no need for a C&S to be taken. The patient should be
assured that this is a normal finding of pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
17. A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is
tired, and her breasts are sore all of the time. The patient’s urine test is positive for hCG. What
is the correct nursing action related to this information?
a. Ask the patient if she has had any nausea or vomiting in the morning.
b. Schedule the patient to be seen by a health care provider within the next 4 weeks.
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Send the patient to the maternity screening area of the clinic for a routine
ultrasound.
d. Determine if there are any factors that might prohibit her from seeking medical
care.
ANS: D
The patient has presumptive and probable indications of pregnancy. However, she has not
sought out health care until late in the first or early in the second trimester. The nurse must
assess for barriers to seeking health care, physical or emotional, because regular prenatal care
is key to a positive pregnancy outcome. Asking if the patient has nausea or vomiting will only
add to the list of presumptive signs of pregnancy, and this information will not add to the
assessment data to determine whether the patient is pregnant. The patient needs to see a health
care provider before the next 4 weeks because she is late in seeking early prenatal care.
Ultrasound testing must be prescribed by a health care provider.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
18. Which comment made by a patient in her first trimester indicates ambivalent feelings?
a. “My body is changing so quickly.”
b. “I haven’t felt well since this pregnancy began.”
c. “I’m concerned about the amount of weight I’ve gained.”
d. “I wanted to become pregnant, but I’m scared about being a mother.”
ANS: D
Ambivalence refers to conflicting feelings. Expressing a concern about being a mother
indicates possible ambivalent feelings. Not feeling well since the pregnancy began does not
RoSmIaN
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confirm the pregnancy when she is stating
the rapid changes to her body. She is not expressing conflicting feelings. By expressing
concerns over gaining weight, which is normal, the woman is trying to confirm the pregnancy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
19. A patient who is 7 months pregnant states, “I’m worried that something will happen to my
baby.” Which is the nurse’s best response?
a. “Your baby is doing fine.”
b. “Tell me about your concerns.”
c. “There is nothing to worry about.”
d. “The doctor is taking good care of you and your baby.”
ANS: B
Encouraging the patient to discuss her feelings is the best approach. The nurse should not
disregard or belittle the patient’s feelings. Responding that your baby is doing fine disregards
the patient’s feelings and treats them as unimportant. Responding that there is nothing to
worry about does not answer the patient’s concerns. Saying that the doctor is taking good care
of you and your baby is belittling the patient’s concerns.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
20. What is the term for the step in maternal role attainment that relates to the woman giving up
certain aspects of her previous life?
a. Fantasy
b. Grief work
c. Role playing
d. Looking for a fit
ANS: B
The woman experiences sadness as she realizes that she must give up certain aspects of her
previous self and that she can never go back. This is called grief work. Fantasies allow the
woman to try on a variety of possibilities or behaviors. This usually deals with how the child
will look and the characteristics of the child. Role playing involves searching for opportunities
to provide care for infants in the presence of another person. Looking for a fit is when the
woman observes the behaviors of mothers and compares them with her own expectations.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
21. An expectant patient in her third trimester reports that she developed a strong tie to her baby
from the beginning and now is really in tune to her baby’s temperament. The nurse interprets
this as the development of which maternal task of pregnancy?
a. Learning to give of herself
b. Developing attachment with the baby
c. Securing acceptance of the baby by others
d. Seeking safe passage for herself and her baby
ANS: B
Developing a strong tie in theNfU
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trI
imNeG
stT
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ndCpO
roMgressing to be in tune is the process of
commitment, attachment, and interconnection with the infant. This stage begins in the first
trimester and continues throughout the neonatal period. Learning to give of herself is the task
that occurs during pregnancy as the woman allows her body to give space to the fetus. She
continues with giving to others in the form of food and presents. Securing acceptance of the
baby is a process that continues throughout pregnancy as the woman reworks relationships.
Seeking safe passage is the task that ends with birth. During this task, the woman seeks health
care and carries out cultural practices.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
22. Which situation best describes a man trying on fathering behaviors?
a. Reading books on newborn care
b. Spending more time with his siblings
c. Coaching a little league baseball team
d. Exhibiting physical symptoms related to pregnancy
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Coaching a little league baseball team shows interaction with children and assuming the
behavior and role of a father. This best describes a man trying on the role of being a father.
Men do not normally read information that is provided in advance. The nurse should be
prepared to present information after the baby is born, when it is more relevant. The man will
normally seek closer ties with his father. Exhibiting physical symptoms related to pregnancy
is called couvade.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
23. A 36-year-old divorcee with a successful modeling career finds out that her 18-year-old
daughter is expecting her first child. Which is a major factor in determining how this woman
will respond to becoming a grandmother?
a. Her age
b. Her career
c. Being divorced
d. Age of the daughter
ANS: A
Age is a major factor in determining the emotional response of prospective grandparents.
Young grandparents may not be happy with the stereotype of grandparents as being old.
Career responsibilities may have demands that make the grandparents not as accessible but are
not a major factor in determining the woman’s response to becoming a grandmother. Being
divorced is not a major factor that determines the adaptation of grandparents. The age of the
daughter is not a major factor that determines the adaptation of grandparents. The age of the
grandparent is a major factor.
DIF: Cognitive Level: UndersN
taU
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inS
gINGOT
BB
J:.C
NuOrsM
ing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
24. Which comment made by a new mother to her own mother is most likely to encourage the
grandmother’s participation in the infant’s care?
a. “Could you help me with the housework today?”
b. “The baby is spitting up a lot. What should I do?”
c. “I know you are busy, so I’ll get John’s mother to help me.”
d. “The baby has a stomachache. I’ll call the nurse to find out what to do.”
ANS: B
Looking to the grandmother for advice encourages her to become involved in the care of the
infant. Housework does not encourage the grandmother to participate in the infant’s care.
Getting John’s mother to help and calling the nurse about advice excludes the grandmother.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
25. Which comment made by a new mother exhibits understanding of her toddler’s response to a
new sibling?
a. “I can’t believe he is sucking his thumb again.”
b. “He is being difficult and I don’t have time to deal with him.”
c. “When we brought the baby home, we made Michael stop sleeping in the crib.”
d. “My husband is going to stay with the baby so I can take Michael to the park
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
tomorrow.”
ANS: D
It is important for a mother to seek time alone with her toddler to reassure him that he is
loved. It is normal for a child to regress when a new sibling is introduced into the home. The
toddler may have feelings of jealousy and resentment toward the new baby taking attention
away from him. Frequent reassurance of parental love and affection is important. Changes in
sleeping arrangements should be made several weeks before the birth so the child does not
feel displaced by the new baby.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
26. An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe
for the baby. What information should the nurse provide?
a. Intercourse is safe until the third trimester.
b. Safer sex practices should be used once the membranes rupture.
c. Intercourse should be avoided if any spotting from the vagina occurs afterward.
d. Intercourse and orgasm are often contraindicated if a history of or signs of preterm
labor are present.
ANS: D
Uterine contractions that accompany orgasm can stimulate labor and would be problematic if
the woman is at risk for or has a history of preterm labor. Intercourse can continue as long as
the pregnancy is progressing normally. Rupture of the membranes may require abstaining
from intercourse. Safer sex practices are always recommended. Some spotting can normally
occur as a result of the increased fragility and vascularity of the cervix and vagina during
pregnancy.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
27. A pregnant patient comes into the medical clinic stating that her family and friends are telling
her that she is always talking about the pregnancy and nothing else. She is concerned that
something is wrong with her. What psychological behavior is she exhibiting?
a. Antepartum obsession
b. Ambivalence
c. Uncertainty
d. Introversion
ANS: D
The patient is exhibiting behaviors associated with introversion and/or narcissism. These are
normal findings during pregnancy as long as they do not become obsessive to the exclusion of
everything else. The patient is talking about the pregnancy but there is no evidence that it is
affecting her perception of reality and/or ability to perform ADLs. It is normal for pregnant
women to focus on the self as being of prime importance in their life initially during the
pregnancy. Some women may feel ambivalent about their pregnancy, which is a normal
reaction. However, this patient’s behavior does not support this finding. Some women react
with uncertainty at the news of being pregnant, which is a normal reaction. However, this
patient’s behavior does not support this finding.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
28. A patient relates a story of how her boyfriend is feeling her aches and pains associated with
her pregnancy. She is concerned that her boyfriend is making fun of her concerns. How would
you respond to this patient statement?
a. Tell her not to worry because it is natural for her boyfriend to make her feel better
by identifying with her pregnancy.
b. Refer the patient to a psychologist for counseling to deal with this problem because
it is clearly upsetting her.
c. Explain that her boyfriend may be experiencing couvade syndrome and that this is
a normal finding seen with male partners.
d. Ask the patient specifically to define her concerns related to her relationship with
her boyfriend and suggest methods to stop this type of behavior by her significant
other.
ANS: C
Provide factual information that will help reduce stress and modify acceptance. Telling her
not to worry does not address the possibility that her boyfriend may be experiencing couvade
syndrome. The patient is expressing concern but does not have all the facts related to couvade
syndrome and requires education, rather than referral. Couvade syndrome is not an abnormal
condition and should be treated with acceptance and understanding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
MULTIPLE RESPONSE
NURSINGTB.COM
1. The nurse is assessing a patient in her 37th week of pregnancy for the psychological responses
commonly experienced as birth nears. Which psychological responses should the nurse expect
to evaluate? (Select all that apply.)
a. The patient is excited to see her baby.
b. The patient has not started to prepare the nursery for the new baby.
c. The patient expresses concern about how to know if labor has started.
d. The patient and her spouse are concerned about getting to the birth center in time.
e. The patient and her spouse have not discussed how they will share household
tasks.
ANS: A, C, D
As birth nears, the expectant patient will express a desire to see the baby. Most pregnant
patients are concerned with their ability to determine when they are in labor. Many couples
are anxious about getting to the birth facility in time for the birth. As birth nears, a nesting
behavior occurs, which means getting the nursery ready. Not preparing the nursery at this
stage is not a response that the nurse should expect to assess. Negotiation of tasks is done
during this stage. Discussion regarding the division of household chores is not a response that
the nurse should expect to assess at this stage.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Psychosocial Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
2. The nurse is teaching a pregnant patient about signs of possible pregnancy complications.
Which should the nurse include in the teaching plan? (Select all that apply.)
a. Report watery vaginal discharge.
b. Report puffiness of the face or around the eyes.
c. Report any bloody show when you go into labor.
d. Report visual disturbances, such as spots before the eyes.
e. Report any dependent edema that occurs at the end of the day.
ANS: A, B, D
Watery vaginal discharge could mean that the membranes have ruptured. Puffiness of the face
or around the eyes and visual disturbances may indicate preeclampsia or eclampsia. These
three signs should be reported. Bloody show as labor starts may mean the mucus plug has
been expelled. One of the earliest signs of labor may be bloody show, which consists of the
mucus plug and a small amount of blood. This is a normal occurrence. Up to 70% of women
have dependent edema during pregnancy. This is not a sign of a pregnancy complication.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. Which findings are presumptive signs of pregnancy? (Select all that apply.)
a. Quickening
b. Amenorrhea
c. Ballottement
d. Goodell’s sign
e. Chadwick’s sign
ANS: A, B, E
Quickening, amenorrhea, andNC
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presumptive signs of pregnancy.
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Ballottement and Goodell’s sign are probable signs of pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
COMPLETION
1. The capacity of the uterus in a term pregnancy is how many times its prepregnant capacity?
Record your answer as a whole number.
times
ANS:
500
The prepregnant capacity of the uterus is about 10 mL, and it reaches 5000 mL (5 L) by the
end of the pregnancy, which reflects a 500-fold increase.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 07: Antepartum Assessment, Care, and Education
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which suggestion is most helpful for the pregnant patient who is experiencing heartburn?
a. Drink plenty of fluids at bedtime.
b. Eat only three meals a day so the stomach is empty between meals.
c. Drink coffee or orange juice immediately on arising in the morning.
d. Use Tums or Rolaids to obtain relief, as directed by the health care provider.
ANS: D
Antacids high in calcium (e.g., Tums, Rolaids) can provide temporary relief. Fluids
overstretch the stomach and may precipitate reflux when lying down. Instruct the patient to
eat five or six small meals per day rather than three full meals. Coffee and orange juice
stimulate acid formation in the stomach and may need to be eliminated from the diet.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
2. What is the rationale for a woman in her first trimester of pregnancy to expect to visit her
health care provider every 4 weeks?
a. Problems can be eliminated.
b. She develops trust in the health care team.
c. Her questions about labor can be answered.
d. The conditions of the expectant mother and fetus can be monitored.
ANS: D
N R I G B.C M
U S N T
O
This routine allows for monitoring maternal health and fetal growth and ensures that problems
will be identified early. All problems cannot be eliminated because of prenatal visits;
however, they can be identified early. Developing a trusting relationship should be established
during these visits, but that is not the primary reason. Most women do not have questions
concerning labor until the last trimester of the pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. Which advice to the patient is one of the most effective methods for preventing venous stasis?
a. Sit with the legs crossed.
b. Rest often with the feet elevated.
c. Sleep with the foot of the bed elevated.
d. Wear elastic stockings in the afternoon.
ANS: B
Elevating the feet and legs improves venous return and prevents venous stasis. Sitting with the
legs crossed will decrease circulation in the legs and increase venous stasis. Elevating the legs
at night may cause pressure on the diaphragm and increase breathing problems. Elastic
stockings should be applied before lowering the legs in the morning.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
4. What is the gravida and para for a patient who delivered triplets 2 years ago and is now
pregnant again?
a. 2, 3
b. 1, 2
c. 2, 1
d. 1, 3
ANS: C
She has had two pregnancies (gravida 2); para refers to the outcome of the pregnancy rather
than the number of infants from that pregnancy. She is pregnant now, so that would make her
a gravida 2. She is para 1 because she had one pregnancy that progressed to the age of
viability.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
5. A patient, gravida 2, para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is
palpated 3 cm below the umbilicus. This finding is
a. appropriate for gestational age.
b. a sign of impending complications.
c. lower than normal for gestational age.
d. higher than normal for gestational age.
ANS: C
By 20 weeks, the fundus should reach the umbilicus. The fundus should be at the umbilicus at
20 weeks, so 3 cm below the umbilicus is an inappropriate height and needs further
assessment. This is lower thaN
nU
exRpS
ecI
teN
dG
atTthBi.
s dCaO
teM
. It may be a complication, but it may also
be because of incorrect dating of the pregnancy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
6. Which complaint made by a patient at 35 weeks of gestation requires additional assessment?
a. Abdominal pain
b. Ankle edema in the afternoon
c. Backache with prolonged standing
d. Shortness of breath when climbing stairs
ANS: A
Abdominal pain at 35 weeks gestation may indicate preeclampsia, or abruptio placentae.
Ankle edema in the afternoon is a normal finding at this stage of the pregnancy. Backaches
while standing is a normal finding in the later stages of pregnancy. Shortness of breath is an
expected finding at 35 weeks.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What
should the nurse’s assessment include?
a. Palpation of the lumbar spine
b. Exercise pattern and duration
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Observation of posture and body mechanics
d. Ability to sleep for at least 6 hours uninterrupted
ANS: C
Correct posture and body mechanics can reduce lower back pain caused by increasing
lordosis. Pregnancy should not cause alterations in the spine. Any assessment for
malformation should be done early in pregnancy. Certain exercises can help relieve back pain.
Rest is important for overall well-being; however, the primary concern related to back pain is
a thorough evaluation of posture and body mechanics.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
8. Which laboratory result would be a cause for concern if exhibited by a patient at her first
prenatal visit during the second month of her pregnancy?
a. Rubella titer, 1:6
b. Platelets, 300,000/mm3
c. White blood cell count, 6000/mm3
d. Hematocrit 38%, hemoglobin 13 g/dL
ANS: A
A rubella titer of less than 1:8 indicates a lack of immunity to rubella, a viral infection that has
the potential to cause teratogenic effects on fetal development. Arrangements should be made
to administer the rubella vaccine after birth during the postpartum period because
administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women
receiving the vaccine during the postpartum period should be cautioned to avoid pregnancy
for 3 months. The lab values for WBCs, platelets, and hematocrit/hemoglobin are within the
NoUmReSn.INGTB.COM
expected range for pregnant w
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. A patient in her third trimester of pregnancy is asking about safe travel. Which statement
should the nurse provide regarding safe travel during pregnancy?
a. “Only travel by car during pregnancy.”
b. “Avoid use of the seat belt during the third trimester.”
c. “You can travel by plane until your 38th week of gestation.”
d. “If you are traveling by car stop to walk every 1 to 2 hours.”
ANS: D
Car travel is safe during normal pregnancies. Suggest that the woman stop to walk every 1 to
2 hours so she can empty her bladder. Walking also helps decrease the risk of thrombosis that
is elevated during pregnancy. Seat belts should be worn throughout the pregnancy. Instruct the
woman to fasten the seat belt snugly, with the lap belt under her abdomen and across her
thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her
uterus. Travel by plane is generally safe up to 36 weeks if there are no complications of the
pregnancy, so only traveling by car is an inaccurate statement.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. When a pregnant woman develops ptyalism, which guidance should the nurse provide?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a. Chew gum or suck on lozenges between meals.
b. Eat nutritious meals that provide adequate amounts of essential vitamins and
minerals.
c. Take short walks to stimulate circulation in the legs and elevate the legs
periodically.
d. Use pillows to support the abdomen and back during sleep.
ANS: A
Some women experience ptyalism, or excessive salivation. The cause of ptyalism may be
decreased swallowing associated with nausea or stimulation of the salivary glands by the
ingestion of starch. Small frequent meals and use of chewing gum and oral lozenges offer
limited relief for some women. All other options include recommendations for pregnant
women; however, they do not address ptyalism.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Basic Care and Comfort
11. When documenting a patient encounter, which term will the nurse use to describe the woman
who is in the 28th week of her first pregnancy?
a. Multigravida
b. Multipara
c. Nullipara
d. Primigravida
ANS: D
A primigravida is a woman pregnant for the first time. A multigravida has been pregnant more
than once. A nullipara is a woman who has never been pregnant or has not completed a
pregnancy of 20 weeks or moNreU. R
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deMlivered one pregnancy of at least 20
NG
weeks. A multipara has delivered two or more pregnancies of at least 20 weeks.
DIF: Cognitive Level: Knowledge
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
12. You are performing assessments for an obstetric patient who is 5 months pregnant with her
third child. Which finding would cause you to suspect that the patient was at risk?
a. Patient states that she doesn’t feel any Braxton Hicks contractions like she had in
her prior pregnancies.
b. Fundal height is below the umbilicus.
c. Cervical changes, such as Goodell’s sign and Chadwick’s sign, are present.
d. She has increased vaginal secretions.
ANS: B
Based on gestational age (20 weeks), the fundal height should be at the umbilicus. This
finding is abnormal and warrants further investigation about potential risk. With subsequent
pregnancies, multiparas may not perceive Braxton Hicks contractions as being evident
compared with their initial pregnancy. Cervical changes such as Goodell’s and Chadwick’s
signs should be present and are considered a normal finding. Increased vaginal secretions are
normal during pregnancy as a result of increased vascularity.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
13. Determine the obstetric history of a patient in her fifth pregnancy who has had two
spontaneous abortions in the first trimester, one infant at 32 weeks’ gestation, and one infant
at 38 weeks’ gestation.
a. G5 T1 P2 A2 L 2
b. G5 T1 P1 A1 L2
c. G5 T0 P2 A2 L2
d. G5 T1 P1 A2 L2
ANS: D
This patient is in her fifth pregnancy, which is G5, she had one viable term infant (between 38
and 42 weeks’ gestation), which is T1, she had one viable preterm infant (between 20 and 37
weeks’ gestation), which is P1, two spontaneous abortions (before 20 weeks’ gestation),
which is A2, and she has two living children, which is L2.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
14. Use Nägele’s rule to determine the EDD (estimated day of birth) for a patient whose last
menstrual period started on April 12.
a. February 19
b. January 19
c. January 21
d. February 7
ANS: B
Nägele’s rule subtracts 3 months from the month of the last menstrual period (month 4 – 3 =
January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days =
April 19), so the correct answNeU
r iR
sS
JaI
nuNaG
ryT1B
9.
ofCtO
heMfollowing calendar year.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
15. Which of the patient health behaviors in the first trimester would the nurse identify as a risk
factor in pregnancy?
a. Sexual intercourse two or three times weekly
b. Moderate exercise for 30 minutes daily
c. Working 40 hours a week as a secretary in a travel agency
d. Relaxing in a hot tub for 30 minutes a day, several days a week
ANS: D
Pregnant women should avoid activities that might cause hyperthermia. Maternal
hyperthermia, particularly during the first trimester, may be associated with fetal anomalies.
She should not be in a hot tub for more than 10 minutes at less than 100F. Sexual intercourse
is generally safe for the healthy pregnant woman; moderate exercise during pregnancy can
strengthen muscles, reduce backache and stress, and provide a feeling of well-being; working
during pregnancy is acceptable as long as the woman is not continually on her feet or exposed
to environmental toxins and industrial hazards.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
16. A patient who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse
will explain that smoking during pregnancy increases the risk of which condition?
a. Congenital anomalies
b. Death before or after birth
c. Neonatal hypoglycemia
d. Neonatal withdrawal syndrome
ANS: B
Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight,
abruptio placentae, placenta previa, preterm birth, perinatal mortality, and SIDS. Smoking
does not appear to cause congenital anomalies, hypoglycemia, or withdrawal syndrome.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
17. A patient with an IUD in place has a positive pregnancy test. When planning care, the nurse
will base decisions on which anticipated action?
a. A therapeutic abortion will need to be scheduled since fetal damage is inevitable.
b. Hormonal analyses will be done to determine the underlying cause of the
false-positive test result.
c. The IUD will need to be removed to avoid complications such as miscarriage or
infection.
d. The IUD will need to remain in place to avoid injuring the fetus.
ANS: C
Pregnancy with an intrauterine device (IUD) in place is unusual; however, it can occur and
cause complications such as spontaneous abortion and infection. A therapeutic abortion is not
indicated unless infection occNuU
rsR
. SINGTB.COM
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
18.
The health care provider reports that the primigravida’s fundus can be palpated at the
umbilicus. Which priority question will the nurse include in the patient’s assessment?
a. “Have you noticed that it is easier for you to breathe now?”
b. “Would you like to hear the baby’s heartbeat for the first time?”
c. “Have you felt a fluttering sensation in your lower pelvic area yet?”
d. “Have you recently developed any unusual cravings, such as for chalk or dirt?”
ANS: C
Quickening is the first maternal sensation of fetal movement and is often described as a
fluttering sensation. Quickening is detected at approximately 20 weeks in the primigravida
and as early as 16 weeks in the multigravida. The fundus is at the umbilicus at 20 weeks’
gestation. Lightening is associated with descent of the fetal head into the maternal pelvis and
is associated with improved lung expansion. Lightening occurs approximately 2 weeks before
birth in the primipara. Fetal heart tones can be detected by Doppler as early as 9 to 12 weeks
of gestation. Pica is the craving for nonnutritive substances such as chalk, dirt, clay, or sand. It
can develop at any time during pregnancy. It can be associated with malnutrition and the
health care provider should monitor the patient’s hematocrit/hemoglobin, zinc, and iron
levels.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
19. The nurse is scheduling the next appointment for a healthy primigravida currently at 28 weeks
gestation. When will the nurse schedule the next prenatal visit?
a. 1 week
b. 2 weeks
c. 3 weeks
d. 4 weeks
ANS: B
From 29 to 36 weeks, routine prenatal assessment is every 2 weeks. If the pregnancy is high
risk, the patient will see the health care provider more frequently.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
20. Which information is covered by early pregnancy classes offered in the first and second
trimesters?
a. Methods of pain relief
b. The phases and stages of labor
c. Coping with common discomforts of pregnancy
d. Prebirth and postbirth care of a patient having a cesarean birth
ANS: C
Early pregnancy classes focus on the first two trimesters and cover information on adapting to
pregnancy, dealing with early discomforts, and understanding what to expect in the months
ahead. Methods of pain reliefNareRdisI
cussGed B
in.aCchiM
ldbirth preparation class. The phases and
U
S
N
T
O
stages of labor are usually covered in a childbirth preparation class. Cesarean birth preparation
classes discuss prebirth and postbirth of a patient having a cesarean birth.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
21. Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow
abdominal breathing in early labor and rapid chest breathing in advanced labor?
a. Bradley
b. Lamaze
c. Leboyer
d. Dick-Read
ANS: D
The Dick-Read method helps prevent the fear-tension-pain cycle by using slow abdominal
breathing in early labor and rapid chest breathing in advanced labor. The Lamaze method
involves concentration and conditioning to help the woman respond to contractions with
relaxation to decrease pain. Viewing childbirth as a traumatic experience, the Leboyer method
uses decreased light and noise to help the newborn adapt to extrauterine life more easily. The
Bradley method teaches women to use abdominal muscles to increase relaxation and breath
control; it emphasizes avoidance of all medications and interventions.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
22. Which type of cutaneous stimulation involves massage of the abdomen?
a. Imagery
b. Effleurage
c. Mental stimulation
d. Thermal stimulation
ANS: B
Effleurage is massage usually performed on the abdomen during contractions. Imagery
exercises enhance relaxation by teaching the woman to imagine herself in a relaxing setting.
Mental stimulation is a group of methods to decrease pain by increasing mental stimulation.
Thermal stimulation decreases pain by using applications of heat and cold.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
23. What does a birth plan help the parents accomplish?
a. Avoidance of an episiotomy
b. Determining the outcome of the birth
c. Assuming complete control of the situation
d. Taking an active part in planning the birth experience
ANS: D
The birth plan helps the woman and her partner look at the available options and plan the birth
experience to meet their personal needs. A birth plan cannot dictate the need for or avoidance
of an episiotomy. The outcome of the birth is not an absolute determinant. A birth plan does
not assume complete control of the situation; it allows for expanding communication. Parents
who prepare a birth plan shouNldUbReSeI
duNcG
atT
edBth.aC
t fOleM
xibility is essential as each labor and
delivery is unique and may present unexpected complications.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
24. A relaxation technique that can be used during the childbirth experience to decrease maternal
pain perception is
a. using increased environmental stimulation as a method of distraction.
b. restricting family and friends from visiting during the labor period to keep the
patient focused on breathing techniques.
c. medicating the patient frequently to reduce pain perception.
d. assisting the patient in breathing methods aimed at taking control of pain
perception based on the contraction pattern.
ANS: D
Relaxation techniques are aimed at incorporating mind and body activities to maintain control
over pain. Additional environmental stimuli may have the opposite effect and increase patient
anxiety, which will affect pain perception. Restricting visitors may have the opposite effect,
leading to increased anxiety because of isolation. Medicating a patient may not decrease pain
perception but may place the patient at risk for adverse reactions and/or complications of
pregnancy related to medications.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity: Therapeutic Communication
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
25. Which technique would provide the best pain relief for a pregnant woman with an occiput
posterior position?
a. Neuromuscular disassociation
b. Effleurage
c. Psychoprophylaxis
d. Sacral pressure
ANS: D
The use of sacral pressure may provide relief for patients who are experiencing back labor.
The presentation of the fetus in a posterior position indicates this. Neuromuscular dissociation
is used as a conditioned response to affect pain relief based on the mother tensing one group
of muscles and focusing on releasing tension in the rest of her body. Effleurage is the process
of using circular massage to effect pain relief. Psychoprophylaxis is another name for the
Lamaze method of prepared childbirth.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity: Sensory Perceptual Alterations
26. The labor nurse is reviewing breathing techniques with a primiparous patient admitted for
induction of labor. When is the best time to encourage the laboring patient to use slow, deep
chest breathing with contractions?
a. During labor, when she can no longer talk through contractions
b. During the first stage of labor, when the contractions are 3 to 4 minutes apart
c. Between contractions, during the transitional phase of the first stage of labor
d. Between her efforts to push to facilitate relaxation between contractions
ANS: A
NURSINGTB.COM
Focused breathing techniques should not be used in labor until they are actually needed,
which is usually when the woman can no longer walk and talk during a contraction. If
breathing techniques are used too early, the woman tends to move through the different
techniques too quickly, and she may stop using them. In addition, the use of the more complex
breathing patterns in latent labor may increase fatigue. Women should be encouraged to adapt
the techniques to their own comfort and needs. Breathing deeply between contractions or
pushing can increase the possibility of carbon dioxide retention and make the patient dizzy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
27. In a prenatal education class, the nurse is reviewing the importance of using relaxation
techniques during labor. Which patient statement will the nurse need to correct?
a. “We will practice relaxation techniques only in a quiet setting so I can focus.”
b. “Relaxation is important during labor because it will help me conserve my
energy.”
c. “If I relax in between contractions, my baby will get more oxygen during labor.”
d. “My partner and I will practice relaxation throughout the remainder of my
pregnancy.”
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Relaxation exercises must be practiced frequently to be useful during labor. Couples begin
practice sessions in a quiet, comfortable setting. Later, they practice in other places that
simulate the noise and unfamiliar setting of the hospital. The ability to relax during labor is an
important component of coping effectively with childbirth. Relaxation conserves energy,
decreases oxygen use, and enhances other pain relief techniques. Women learn exercises to
help them recognize and release tension. The labor partner assists the woman by providing
feedback during exercise sessions and labor.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A pregnant patient reports that she works in a long-term care setting and is concerned about
the impending flu season. She asks about receiving the flu vaccine. As the nurse, you are
aware that some immunizations are safe to administer during pregnancy, whereas others are
not. Which vaccines could this patient receive? (Select all that apply.)
a. Tetanus
b. Varicella
c. Influenza
d. Hepatitis A and B
e. Measles, mumps, rubella (MMR)
ANS: A, C, D
Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe
to administer to women who have a risk for contracting or developing the disease.
Immunizations with live viruN
sU
vaR
ccSinIeN
sG
suT
chBa.
sC
MOMMR, varicella (chickenpox), or smallpox are
contraindicated during pregnancy because of the possible teratogenic effects on the fetus.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
2. The nurse is planning care for a patient in her first trimester of pregnancy. The patient is
experiencing nausea and vomiting. Which interventions should the nurse plan to share with
this patient? (Select all that apply.)
a. Suck on hard candy.
b. Take prenatal vitamins in the morning.
c. Try some herbal tea to relieve the nausea.
d. Drink fluids frequently but separate from meals.
e. Eat crackers or dry cereal before arising in the morning.
ANS: A, D, E
A patient experiencing nausea and vomiting should be taught to suck on hard candy, drink
fluids frequently but separately from meals, and eat crackers, dry toast, or dry cereal before
arising in the morning. Prenatal vitamins should be taken at bedtime because they may
increase nausea if taken in the morning. Before taking herbal tea, the patient should check
with her health care provider.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
3. Which factors contribute to the presence of edema in the pregnant patient? (Select all that
apply.)
a. Diet consisting of processed foods
b. Hemoconcentration
c. Increase in colloid osmotic pressure
d. Last trimester of pregnancy
e. Decreased venous return
ANS: A, D, E
Processed foods, which are high in sodium content, can contribute to edema formation. As the
pregnancy progresses, because of the weight of the uterus, compression takes place, leading to
decreased venous return and an increase in edema formation. A decrease in colloid osmotic
pressure would contribute to edema formation and fluid shifting. Hemodilution would also
lead to edema formation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation
4. The prenatal nurse educator is teaching couples the technique of applying sacral pressure
during labor. Which should be included in the teaching session? (Select all that apply.)
a. The technique can be combined with heat to the area.
b. A jiggling motion should be used while applying the pressure.
c. Tennis balls may be used to apply the pressure to the sacral area.
d. The pressure against the sacrum should be intermittent during the contraction.
e. The hand may be moved slowly or remain positioned directly over the sacrum.
ANS: A, C, E
Sacral pressure can be combiN
neUdRwSitI
hN
thG
erT
mB
al.sC
tim
OuMlation to increase effectiveness.
The hand may be moved slowly over the area or remain positioned directly over the sacrum,
but pressure should be continuous and firm throughout the contraction. Care should be taken
not to jiggle the woman, which may be irritating.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
COMPLETION
1. Calculate the estimated date of birth (EDD) in October using Nägele’s rule for a patient whose
last normal menstrual period (LNMP) began on January 1. Record your answer as a whole
number.
ANS:
8
Nägele’s rule is often used to establish the EDD. This method involves subtracting 3 months
from the date that the LNMP began, adding 7 days, and then correcting the year, if
appropriate. Subtracting 3 months from January 1 gives you the month of October and adding
7 days = October 8.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Chapter 08: Nutrition for Childbearing
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. When planning a healthy diet with a pregnant patient, what should the nurse’s first action be?
a. Teach the patient about MyPlate.
b. Review the patient’s current dietary intake.
c. Instruct the patient to limit the intake of fatty foods.
d. Caution the patient to avoid large doses of vitamins, especially those that are
fat-soluble.
ANS: B
The first action should be to assess the patient’s current dietary pattern and practices because
instruction should be geared to what she already knows and does. Teaching the food guide
MyPlate is important but not the first action when planning a diet with a pregnant patient.
Limiting intake of fatty foods is important in a pregnant patient’s diet; however, not the first
action. Caution regarding about excessive fat-soluble vitamins is important; however, not the
first action.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
2. The nurse is meeting with a patient with an elevated BMI regarding an optimal diet for
pregnancy. Which major source of nutrients should be a significant component of this
patient’s diet?
NURSINGTB.COM
a. Fats
b. Fiber
c. Simple sugars
d. Complex carbohydrates
ANS: D
Complex carbohydrates supply the pregnant woman with vitamins, minerals, and fiber. Fats
provide 9 calories in each gram, in contrast to carbohydrates and proteins, which provide only
4 calories in each gram. Fiber is supplied primarily by complex carbohydrates. The most
common simple carbohydrate is table sugar, which is a source of energy but does not provide
any nutrients.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
3. In order to increase the absorption of iron by a pregnant patient, which beverage should an
iron preparation be given with?
a. Tea
b. Milk
c. Coffee
d. Orange juice
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Vitamin C source may increase the absorption of iron and would be the optimal choice.
Tannin in the tea reduces the absorption of iron. The calcium and phosphorus in milk decrease
iron absorption. Decreased intake of caffeine is recommended during pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
4. When should iron supplementation during a normal pregnancy begin?
a. Before pregnancy
b. In the first trimester
c. In the third trimester
d. In the second trimester
ANS: D
Vitamin supplements should be prescribed in the second trimester, when the need for iron is
increased. Healthy young women do not usually need iron supplementation for their diets.
Morning sickness in the first trimester increases the routine side effects of iron supplements.
The iron supplements may continue to be prescribed in the third trimester and during the
postpartum period.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
5. A patient in her fifth month of pregnancy asks the nurse, “How many more calories should I
be eating daily?” What is the correct response by the nurse?
a. 180 more calories a day
b. 340 more calories a day
c. 452 more calories a day NURSINGTB.COM
d. 500 more calories a day
ANS: B
The increased nutritional needs of pregnancy can be met with an additional 340 calories per
day. 180 calories are not enough to meet the increased nutritional needs of pregnancy. 452
calories are more than the recommended calories for pregnancy at this gestation. A patient in
her third trimester would increase her energy intake by 452 calories per day. 500 calories are
more than the recommended calories for pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
6. A pregnant patient’s diet may not meet her need for folate. Which food choice is an excellent
source of this nutrient?
a. Chicken
b. Cheese
c. Potatoes
d. Green leafy vegetables
ANS: D
Sources of folate include green leafy vegetables, whole grains, fruits, liver, dried peas, and
beans. Chicken is a good source of protein, but poor in folate. Cheese is an excellent source of
calcium, but poor in folate. Potatoes contain carbohydrates and vitamins but are poor in folate.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
7. A pregnant patient asks the nurse if she can double her prenatal vitamin dose because she does
not like to eat vegetables. What is the nurse’s response regarding the danger of taking
excessive vitamins?
a. Increases caloric intake
b. Has toxic effects on the fetus
c. Increases absorption of all vitamins
d. Promotes development of pregnancy-induced hypertension (PIH)
ANS: B
The use of vitamin supplements in addition to food may increase the intake of some nutrients
to doses much higher than the recommended amounts. Overdoses of some vitamins have been
linked to fetal defects. Vitamin supplements do not contain calories. Vitamin supplements do
not have better absorption than natural vitamins and minerals. There is no relationship
between vitamin supplements and PIH.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
8. The nurse is conducting a prenatal nutrition education class for a group of nursing students.
Which statement best describes the condition known as pica?
a. Iron-deficiency anemia
b. Intolerance to milk products
c. Ingestion of nonfood substances
d. Episodes of anorexia and vomiting
ANS: C
NURSINGTB.COM
The practice of eating substances not normally thought of as food is called pica. Clay, dirt,
and solid laundry starch are the substances most commonly ingested. Pica may produce
iron-deficiency anemia if proper nutrition is decreased. Intolerance to milk products is termed
lactose intolerance. Pica is not related to anorexia and vomiting.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
9. Which effect is a common response to both smoking and cocaine use in the pregnant patient?
a. Vasoconstriction
b. Increased appetite
c. Increased metabolism
d. Changes in insulin metabolism
ANS: A
Both smoking and cocaine use cause vasoconstriction, which results in impaired placental
blood flow to the fetus. Smoking and cocaine use do not increase appetite, change insulin
metabolism, or increase metabolism.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance: Physiologic Integrity
10. Which is the most important reason for evaluating the pattern of weight gain in pregnancy?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
Prevents excessive adipose tissue deposits
Determines cultural influences on the woman’s diet
Assesses the need to limit caloric intake in obese women
Identifies potential nutritional problems or complications of pregnancy
ANS: D
Deviations from the recommended pattern of weight gain may indicate nutritional problems or
developing complications. Excessive adipose tissue may occur with excess weight gain but is
not the reason for monitoring the weight gain pattern. The pattern of weight gain is not
affected by cultural influences. It is important to monitor the pattern of weight gain for the
developing complications.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
11. A pregnant patient would like to know which foods, other than dairy products, contain the
most calcium. Which food group would the nurse recommend?
a. Legumes
b. Lean meat
c. Whole grains
d. Yellow vegetables
ANS: A
Although dairy products contain the greatest amount of calcium, it can also be found in
legumes, nuts, dried fruits, and some dark green leafy vegetables. Lean meats are rich in
protein and phosphorus. Whole grains are rich in zinc and magnesium. Yellow vegetables are
rich in vitamin A.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. To determine cultural influences on a patient’s diet, what is the nurse’s primary action?
a. Evaluate the patient’s weight gain during pregnancy.
b. Assess the socioeconomic status of the patient.
c. Discuss the four food groups with the patient.
d. Identify the food preferences and methods of food preparation common to the
patient’s culture.
ANS: D
Understanding the patient’s food preferences and how she prepares food will assist the nurse
in determining whether the patient’s culture is adversely affecting her nutritional intake.
Evaluating a patient’s weight gain during pregnancy should be included for all patients, not
just for those who are culturally different. The socioeconomic status of the patients may alter
the nutritional intake, but not the cultural influence. Teaching the food groups to the patient
should come after assessing food preferences.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
13. In teaching a pregnant adolescent about nutrition, what should the nurse include in the care
plan?
a. Determine the weight gain needed to meet adolescent growth and add 35 lb.
NURSINGTB.COM
b. Suggest that she does not eat at fast food restaurants to avoid foods of poor
nutritional value.
c. Realize that most adolescents are unwilling to make dietary changes during
pregnancy.
d. Emphasize the need to eliminate common teen snack foods because they are too
high in fat and sodium.
ANS: A
Adolescents should gain in the upper range of the recommended weight gain. They also need
to gain weight that would be expected for their own normal growth. Adolescents are willing to
make changes; however, they still need to be like their peers. Eliminating fast foods will make
her appear different from her peers. She should be taught to choose foods that add needed
nutrients. Changes in the diet should be kept at a minimum and snacks should be included.
Snack foods can be included in moderation and other foods added to make up for the lost
nutrients.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
14. The traditional diet of Asian women includes little meat and few dairy products and may be
low in calcium and iron. The nurse can assist a patient increase her intake of these foods by
which action?
a. Suggest that she eat more tofu, bok choy, and broccoli.
b. Suggest that she eat more hot foods during pregnancy.
c. Emphasize the need for increased milk intake during pregnancy.
d. Tell her husband that she must increase her intake of fruits and vegetables for the
baby’s sake.
ANS: A
NURSINGTB.COM
The diet should be improved by increasing foods acceptable to the woman. These foods are
common in the Asian diet and are good sources of calcium and iron. Pregnancy is considered
hot; therefore the woman would eat cold foods. Because milk products are not part of this
woman’s diet, it should be respected and other alternatives offered. Also, lactose intolerance
is common. Fruits and vegetables are cold foods and should be included in the diet. In regard
to the family dynamics, however, the husband does not dictate to the wife in this culture.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
15. Which patient would require additional calories and nutrients?
a. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy
b. An 18-year-old female who delivered a 7-lb baby and is bottle feeding
c. A 23-year-old female who had a cesarean birth and is bottle feeding
d. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding
ANS: D
A patient who is breastfeeding will require more calories and nutrients than women who are
pregnant. The type of birth has no impact on nutrient intake. A patient who is bottle-feeding
does not require additional calories.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Physiologic Integrity: Basic Care and Comfort
16. A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as
possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be
of concern at her 6-week postpartum checkup?
a. Patient has lost 30 lb during the 6-week period prior to her scheduled checkup.
b. Patient states that she is eating healthy and limiting intake of processed foods.
c. Patient relates increased consumption of fruits and vegetables in her diet postbirth.
d. Patient has resumed her usual exercise pattern of walking around the neighborhood
for 10 minutes each night.
ANS: A
Although a certain amount of weight loss is expected in the postpartum period, the fact that
the reported weight loss is double the amount of weight gained during the pregnancy places
the patient at risk for malnutrition. Further inquiry is needed. Limiting the intake of processed
foods is a healthy dietary alternative to decreasing sodium intake. Increases in fruits and
vegetables are a healthy dietary alternative to decrease possible occurrence of hypertension.
An exercise program is part of a healthy nutrition approach.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
17. Which clinical finding is associated with inadequate maternal weight gain during pregnancy?
a. Prolonged labor
b. Preeclampsia
c. Gestational diabetes
d. Low-birth-weight infant
I G B.C M
ANS: D
NURS N T
O
Inadequate maternal weight gain during pregnancy can manifest in the birth of a
low-birth-weight infant. Prolonged labor and gestational diabetes are associated with excess
weight gain during pregnancy. Preeclampsia is based on maternal hypertension, proteinuria,
and edema states.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
18. A pregnant patient arrives for her first prenatal visit at the clinic. She informs the nurse that
she has been taking an additional 400 mcg of folic acid prior to becoming pregnant. Based on
the patient’s history, she has reached 8 weeks’ gestation. Which recommendation would the
nurse provide regarding folic acid supplementation?
a. Have the patient continue to take 400 mcg folic acid throughout her pregnancy.
b. Tell the patient that she no longer has to take additional folic acid because it will
be included in her prenatal vitamins.
c. Have the patient increase her folic acid intake to 1000 mcg throughout the rest of
her pregnancy.
d. Schedule the patient to go for an AFP (alpha-fetoprotein) test.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Prenatal vitamins include adequate folic acid supplementation, so patients should not take
additional supplementation as long as they continue their prenatal vitamins. During
pregnancy, the recommendation is to increase the folic acid intake to 600 mcg. 1000 mcg of
folic acid would be an excessive dose. The AFP test should be done at 15 to 18 weeks’
gestation. This is not clinically indicated because the patient is at 8 weeks’ gestation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
19.
Which patient is most at risk for a low-birth-weight infant?
22-year-old, 60 inches tall, normal prepregnant weight
18-year-old, 64 inches tall, body mass index is <18.5
30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm
35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb
a.
b.
c.
d.
ANS: B
The patient who has a low prepregnancy weight is associated with preterm labor and
low-birth-weight infants. Women who are underweight should gain more during pregnancy to
meet the needs of pregnancy as well as their own need to gain weight; patients who have a
normal prepregnancy weight, who start pregnancy overweight, or who have a history of
excessive weight gain in pregnancy are not at risk for low-birth-weight infants.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
20. Changes in the diet of the pregnant patient who has phenylketonuria would include
a. adding foods high in vitamin C.
b. eliminating drinks contaiN
niU
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spIaN
rtaGmTeB
. .COM
c. restricting protein intake to <20 g a day.
d. increasing caloric intake to at least 1800 cal/day.
ANS: B
Use of aspartame by women with phenylketonuria can result in fetal brain damage because
these women lack the enzyme to metabolize aspartame. Adding vitamin C, restricting protein,
and increasing caloric intake are not necessary for the pregnant patient with phenylketonuria.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
21. When explaining the recommended weight gain to your patient, the nurse’s teaching should
include which statement?
a. “All pregnant women need to gain a minimum of 25 to 35 lb.”
b. “The fetus, amniotic fluid, and placenta require 15 lb of weight gain.”
c. “Weight gain in pregnancy is based on the patient’s prepregnant body mass index.”
d. “More weight should be gained in the first and second trimesters and less in the
third.”
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Recommendations for weight gain in pregnancy are based on the woman’s prepregnancy
weight for her height (body mass index). Depending on the prepregnant weight,
recommendation for weight gain may be more or less than 25 to 35 lb. The combination of the
fetus, amniotic fluid, and placenta averages about 11 lb in the patient who has a normal BMI.
Less weight should be gained in the first trimester, when the fetus needs fewer nutrients for
growth, and more in the third trimester, when fetal growth is accelerated.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
22. Which patient has correctly increased her caloric intake from her recommended pregnancy
intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months?
a. From 1800 to 2200 calories per day
b. From 2000 to 2500 calories per day
c. From 2200 to 2530 calories per day
d. From 2500 to 2730 calories per day
ANS: C
The increased calories necessary for breastfeeding are 500, with 330 calories coming from
increased caloric intake and 170 calories from maternal stores. An increase of 230 calories is
insufficient for breastfeeding. An increase of 400 and 500 calories is above the recommended
amount.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
23. A pregnant woman of normal weight enters her 13th week of pregnancy. If the patient eats
and exercises as directed, whN
atUwRilS
l tI
heNnGuT
rsB
e.
anC
tiO
ciM
pate as the ongoing weight gain for the
remaining trimesters?
a. 0.3 lb every week
b. 1 lb every week
c. 1.8 lb every week
d. 2 lb every week
ANS: B
After the first 12 weeks (first trimester), the pregnant woman should gain 0.35 to 0.5 kg (0.8
to 1 lb) per week for the remainder of the pregnancy.
DIF: Cognitive Level: Knowledge
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
24. A patient with a BMI of 32 has a positive pregnancy test. What is the maximum number of
pounds that the nurse will advise the patient gain during the pregnancy?
a. 20 lb
b. 25 lb
c. 28 lb
d. 40 lb
ANS: A
The weight gain for obese women is 5 to 9 kg (11 to 20 lb). A BMI of 30 or higher
categorizes the patient as obese. The other options refer to minimal or maximal weight gain
for patients in other BMI categories.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
25. A pregnant patient with significant iron-deficiency anemia is prescribed iron supplements.
The patient explains to the nurse that she cannot take iron because it makes her nauseous.
What is the best response by the nurse?
a. “Iron will be absorbed more readily if taken with orange juice.”
b. “It is important to take this drug regardless of this side effect.”
c. “Taking the drug with milk may decrease your symptoms.”
d. “Try taking the iron at bedtime on an empty stomach.”
ANS: D
Iron taken at bedtime may be easier to tolerate. All the answers are true statements; however,
only the option that states that iron taken at bedtime may be easier to tolerate addresses both
optimal absorption of iron and alleviation of nausea, which will not be noticeable during
sleep. It is true that taking iron with milk will decrease the symptoms; however, it will also
decrease absorption.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Pharmacologic Therapies
26. Which guidance related to a healthy diet during pregnancy will the nurse provide to a patient
d.
in her 1st trimester?
a. “Every day you need to have at least 6 ounces of protein from sources such as
meat, fish, eggs, beans, nuts, soybean products, and tofu.”
b. “High-dose vitamin A supplements will promote optimal vision while preventing a
common cause of blindneNssUiR
nS
neIoN
naG
teT
s.B
” .COM
c. “Meals such as sushi with a cold deli salad made with raw sprouts combine
high-fiber foods with protein sources to meet multiple nutritional needs.”
“Vitamin and mineral supplements can meet your nutrient needs if you have
inadequate intake because of nausea or a sensation of fullness.”
ANS: A
Protein sources include meat, poultry, fish, eggs, legumes (e.g., beans, peas, lentils), nuts, and
soybean products such as tofu. Pregnant women need 6 to 6.5 oz of protein daily. Vitamin A
can cause fetal anomalies of the bones, urinary tract, and central nervous system when taken
in high doses. Pregnant women should avoid raw fish and foods such as cold deli salads and
raw sprouts. Supplements do not generally contain protein and calories and may lack many
necessary nutrients; therefore they cannot serve as food substitutes.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
27. For the pregnant patient who is a vegan, what combination of foods will the nurse advise to
meet the nutritional needs for all essential amino acids?
a. Eggs and beans
b. Fruits and vegetables
c. Grains and legumes
d. Vitamin and mineral supplements
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Combining incomplete plant proteins with other plant foods that have complementary amino
acids allows intake of all essential amino acids. Dishes that contain grains (e.g., wheat, rice,
corn) and legumes (e.g., garbanzo, navy, kidney, or pinto beans, peas, peanuts) are
combinations that provide complete proteins. Eggs are not consumed by vegans. Fruits and
vegetables alone will not provide the essential amino acids. Vitamin and mineral supplements
do not provide amino acids.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
28. A pregnant patient has lactose intolerance. Which recommendation will the nurse provide to
best help the patient meet dietary needs for calcium?
a. Add foods such as nuts, dried fruit, and broccoli to the diet.
b. Consume dairy products but take an over-the-counter anti-gas product.
c. Increase the intake of dark leafy vegetables, such as spinach and chard.
d. Use powdered milk instead of liquid forms of milk.
ANS: A
Calcium is present in legumes, nuts, dried fruits, and broccoli, so these foods can be added to
increase calcium intake. Although dark leafy vegetables contain calcium, they also contain
oxalates that decrease the availability of calcium. Powdered milk contains lactase, similar to
the nondehydrated varieties. Milk products should be avoided by patients with lactose
intolerance. Adequate calcium may be obtained from food and supplements. Some patients
may be able to tolerate lactose free dairy products.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
29. The nurse is reviewing a list of foods high in folic acid with a patient who is considering
becoming pregnant. The nurse determines that the patient understands the teaching when the
patient states she will include which list of foods in her diet?
a. Peaches, yogurt, and tofu
b. Strawberries, milk, and tuna
c. Asparagus, lemonade, and chicken breast
d. Spinach, orange juice, and fortified bran flakes
ANS: D
Prepregnant, the recommendation for folic acid is 800 mcg. Foods high in folic acid are dark
green leafy vegetables, legumes (beans, peanuts), orange juice, asparagus, spinach, and
fortified cereal and pasta. In the United States, folic acid is added to orange juice and
wheat-based products.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
30. A patient at 8 weeks’ gestation complains to the nurse, “I feel sick almost every morning. And
I throw up at least two or three times a week.” What is the nurse’s best guidance for this
patient?
a. “Do you like cheese?”
b. “Try eating four meals a day instead of three meals a day.”
c. “Try eating peanut butter on whole wheat bread right before going to bed.”
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. “If you can eat enough throughout the day, you don’t have to worry about being
sick.”
ANS: C
Eating a bedtime protein snack helps maintain glucose levels throughout the night. Cheese is
high in fat and can aggravate nausea. Small and frequent meals is the optimal
recommendation. Four meals a day would not be ideal for a patient experiencing nausea, she
needs to eat more frequently. Consumption is not the patient’s stated concern—it is the nausea
and vomiting.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is teaching a patient taking prenatal vitamins how to avoid constipation. Which
should the nurse plan to include in the teaching session? (Select all that apply.)
a. Advise taking a daily laxative for constipation.
b. Recommend a diet high in fruits and vegetables.
c. Encourage an increase in fluid consumption during the day.
d. Increase the intake of whole grains and whole grain products.
e. Suggest increasing the intake of dairy products, especially cheeses.
ANS: B, C, D
Common sources of dietary fiber include fruits and vegetables (with skins when possible—
apples, strawberries, pears, carrots, corn, potatoes with skins, and broccoli), whole
grains, and whole grain products—whole wheat bread, bran muffins, bran cereals, oatmeal,
Nasta
RS. In
IN
G sed
B.C
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brown rice, and whole wheat pU
creaT
intaO
ke of fluids can help prevent constipation. A
pregnant patient should not take a daily laxative unless prescribed by her health care provider.
Increased intake of dairy products, especially cheese, may increase constipation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. The nurse is teaching a breastfeeding patient about substances to avoid while she is
breastfeeding. Which substances should the nurse include in the teaching session? (Select all
that apply.)
a. Caffeine
b. Alcohol
c. Omega-6 fatty acids
d. Appetite suppressants
e. Polyunsaturated omega-3 fatty acids
ANS: A, B, D
NURSINGTB.COM
Foods high in caffeine should be limited. Infants of mothers who drink more than two or three
cups of caffeinated coffee or the equivalent each day may be irritable or have trouble sleeping.
Although the relaxing effect of alcohol was once thought to be helpful to the nursing mother,
the deleterious effects of alcohol are too important to consider this suggestion appropriate
today. An occasional single glass of an alcoholic beverage may not be harmful, but larger
amounts may interfere with the milk-ejection reflex and may be harmful to the infant. Nursing
mothers should avoid appetite suppressants, which may pass into the milk and harm the
infant. The long-chain polyunsaturated omega-3 and omega-6 fatty acids are present in human
milk. Therefore they should be included in the mother’s diet during lactation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
3. The nurse is advising a lactose-intolerant pregnant patient about calcium intake. Which
calcium sources are approximately equivalent to 1 cup of milk? (Select all that apply.)
a.
cup yogurt
b. 1 cup of sherbet
c.
oz of hard cheese
d.
cups of ice cream
e.
cup of low-fat cottage cheese
ANS: A, C, D
Calcium sources approximately equivalent to 1 cup of milk include
cup yogurt,
ounce of hard cheese, and
cups of ice cream. It takes 3 cups of sherbet and
cups of
low-fat cottage cheese to equal the calcium equivalent of 1 cup of milk.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
4. The nurse is teaching a pregnant patient about food safety during pregnancy and lactation.
Which statements by the patient indicate she understood the teaching? (Select all that apply.)
a. “I will limit my intake of shrimp to 12 oz a week.”
b. “I will avoid the soft cheeses made with unpasteurized milk.”
c. “I plan to continue to pack my bologna sandwich for lunch.”
d. “I am glad I can still go to the sushi bar during my pregnancy.”
e. “I will not eat any swordfish or shark while I am pregnant or nursing.”
ANS: A, B, E
Statements that indicate the patient understood the teaching are limiting shrimp to 12 oz a
week, avoiding soft cheeses, and not eating any swordfish. A bologna sandwich should be
avoided unless it is reheated until steaming hot. Raw or undercooked fish should be avoided.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 09: Assessing the Fetus
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the
results. What is the nurse’s most appropriate response?
a. “The test results are within normal limits.”
b. “Immediate birth by cesarean birth is being considered.”
c. “Further testing will be performed to determine the meaning of this score.”
d. “An obstetric specialist will evaluate the results of this profile and, within the next
week, will inform you of your options regarding birth.”
ANS: A
The normal biophysical score ranges from 8 to 10 points if the amniotic fluid volume is
adequate. A normal score allows conservative treatment of high-risk patients. Birth can be
delayed if fetal well-being is an issue. Scores less than 4 would be investigated, and birth
could be initiated sooner than planned. This score is within normal range, and no further
testing is required at this time. The results of the biophysical profile are usually available
immediately after the procedure is performed.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
2. Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the
fetus?
NURSINGTB.COM
a. Biophysical profile
b. Multiple-marker screening
c. Lecithin-to-sphingomyelin ratio
d. Blood type and crossmatch of maternal and fetal serum
ANS: B
Maternal serum can be analyzed for abnormal levels of alpha-fetoprotein (AFP), human
chorionic gonadotropin (hCG), inhibin A, and estriol. The multiple-marker screening may
predict chromosomal defects in the fetus. The biophysical profile is used to evaluate fetal
status during the antepartum period. Five variables are used; however, none are concerned
with chromosomal problems. The lecithin-to-sphingomyelin ratio is used to determine fetal
lung maturity. The blood type and crossmatch will not predict chromosomal defects in the
fetus.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
3. The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an
indication for fetal diagnostic procedures if present in the health history?
a. Maternal diabetes
b. Weight gain of 25 lb
c. Maternal age older than 30 years
d. Previous infant weighing more than 3000 g at birth
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: A
Diabetes is a risk factor in pregnancy because of possible impairment of placental perfusion.
Excessive weight gain is an indication for testing. Normal weight gain is 25 to 35 lb. A
maternal age older than 35 years is an indication for testing. Having had another infant
weighing more than 4000 g is an indication for testing.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
4. What point in the pregnancy is the most accurate time to determine gestational age through
ultrasound?
a. First trimester
b. Second trimester
c. Third trimester
d. No difference in accuracy among the trimesters
ANS: A
Gestational age determination by ultrasonography is increasingly less accurate after the first
trimester. Gestational age determination is best done in the first trimester. There is a
difference in trimesters when doing a gestational age ultrasonography.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
5. The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to
determine whether the fetus has which condition?
a. Hemophilia
NURSINGTB.COM
b. Sickle cell anemia
c. A neural tube defect
d. Abnormal lecithin-to-sphingomyelin ratio
ANS: C
An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter the
maternal serum. Hemophilia is a genetic defect and is best detected with chromosomal
studies, such as chorionic villus sampling or amniocentesis. Sickle cell anemia is a genetic
defect and is best detected with chromosomal studies such as chorionic villus sampling or
amniocentesis. L/S ratios are determined with an amniocentesis and are usually performed in
the third trimester.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. When is the earliest interval that chorionic villus sampling (CVS) can be performed during
pregnancy?
a. 4 weeks
b. 8 weeks
c. 10 weeks
d. 14 weeks
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
CVS is normally performed between 10 and 13 weeks gestation. The fetal villus tissue can be
analyzed directly for chromosomal, metabolic, or DNA abnormalities. It is too early to
perform CVS at 4 or 8 weeks of pregnancy. The test can no longer be performed a 14 weeks
gestation. Results are available within 24 to 48 hours.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. Which aspect of fetal diagnostic testing is most important to expectant parents?
a. Safety of the fetus
b. Duration of the test
c. Cost of the procedure
d. Physical discomfort caused by the procedure
ANS: A
Although all of these are considerations, parents are usually most concerned about the safety
of the fetus. Parents are concerned about the duration of the test; however, it is not the greatest
concern. The cost of the procedure is important to parents, especially those without third-party
payers; but again, this is not the greatest concern. With adequate preparation for the procedure
by the nurse physical discomfort can be allayed.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. The nurse’s role in diagnostic testing is to provide which of the following?
a. Advice to the couple
b. Information about the tests
c. Reassurance about fetal sN
afU
etR
y SINGTB.COM
d. Assistance with decision making
ANS: B
The nurse should provide the couple with all necessary information regarding a procedure so
that the couple can make an informed decision. The nurse’s role is to inform, not to advice.
Ensuring fetal safety is not possible with all the diagnostic tests. To offer this is to give false
reassurance to the parents. The nurse can inform the couple about potential problems so they
can make an informed decision. Decision making should always lie with the couple involved.
The nurse should provide information so that the couple can make an informed decision.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. Which factors should be considered a contraindication for transcervical chorionic villus
sampling?
a. Rh-negative mother
b. Gestation less than 15 weeks
c. Maternal age younger than 35 years
d. Positive for group B Streptococcus
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Maternal infection is a risk with this procedure, and it is contraindicated if the patient has an
active infection in the cervix, vagina, or pelvic area. This procedure is done between 10 and
12 weeks. This procedure is usually done for women older than 35; however, if the woman is
at high risk for fetal anomalies, her age is not a contraindication. The procedure can still be
performed; however, Rh sensitization may occur if the mother is Rh-negative. Rho(D)
immune globulin can be administered following the procedure.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with
pregnancy-induced hypertension?
a. Determine if a metabolic disorder exists.
b. Identify the sex of the fetus.
c. Identify abnormal fetal cells.
d. Determine fetal lung maturity.
ANS: D
During the third trimester, amniocentesis is most often performed to determine fetal lung
maturity. In cases of pregnancy-induced hypertension, preterm birth may be necessary
because of changes in placental perfusion. The test is done in the early portion of the
pregnancy if a metabolic disorder is genetic. Amniocentesis is done early in the pregnancy to
do genetic studies and determine the sex. Identification of abnormal cells is done during the
early portion of the pregnancy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
11. What does optimal nursing care after an amniocentesis include?
a. Pushing fluids by mouth
b. Monitoring uterine activity
c. Placing the patient in a supine position for 2 hours
d. Applying a pressure dressing to the puncture site
ANS: B
A risk with amniocentesis is the onset of spontaneous contractions. Hydration is important;
however, the woman has not been NPO, so this should not be a problem. The supine position
may decrease uterine blood flow; the side-lying position is preferred. Pressure dressings are
not necessary.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. What is the term for a nonstress test in which there are two or more fetal heart rate
accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute
period?
a. Positive
b. Negative
c. Reactive
d. Nonreactive
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The nonstress test (NST) is reactive (normal) when there are two or more fetal heart rate
accelerations of at least 15 BPM (each with a duration of at least 15 seconds) in a 20-minute
period. A positive result is not used with an NST. The contraction stress test (CST) uses
positive as a result term. A negative result is not used with an NST. The CST uses negative as
a result term. A nonreactive result means that the heart rate did not accelerate during fetal
movement.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
13. What is the purpose of initiating contractions in a contraction stress test (CST)?
a. Increase placental blood flow.
b. Identify fetal acceleration patterns.
c. Determine the degree of fetal activity.
d. Apply a stressful stimulus to the fetus.
ANS: D
The CST involves recording the response of the fetal heart rate to stress induced by uterine
contractions. The CST records the fetal response to stress. It does not increase placental blood
flow. The NST looks at fetal heart accelerations with fetal movements. The NST and
biophysical profiles look at fetal movements.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
14. A biophysical profile is performed on a pregnant patient. The following assessments are
noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs),
limited gross movements, opN
enUinRgSaI
ndNcG
loT
siB
ng.oCfO
haMng indicating the presence of fetal tone,
and adequate amniotic fluid index (AFI) meeting criteria. Which answer would be the correct
interpretation of this test result?
a. A score of 10 would indicate that the results are equivocal.
b. A score of 8 would indicate normal results.
c. A score of 6 would indicate that birth should be considered as a possible treatment
option.
d. A score of 9 would indicate reassurance.
ANS: B
The biophysical profile is used to assess fetal well-being. Five categories of assessment are
used in this combination test: fetal monitoring NST, evaluation of FBMs, gross movements,
fetal tone, and calculation of the amniotic fluid index (AFI). A maximum of 2 points is used if
criteria are met successfully in each category; thus a score in the range of 8 to 10 indicates a
normal or reassuring finding. A score of 6 provides equivocal results and further testing or
observation is necessary. A score of 4 or less requires immediate intervention, and birth may
be warranted. The provided assessments indicate a score of 8 as the only area that has not met
the stated criteria in the NST.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential/Diagnostic Tests
15. In preparing a pregnant patient for a nonstress test (NST), which of the following should be
included in the plan of care?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a. Have the patient void prior to being placed on the fetal monitor because a full
bladder will interfere with results.
b. Maintain NPO status prior to testing.
c. Position the patient for comfort, adjusting the tocotransducer belt to locate fetal
heart rate.
d. Have an infusion pump prepared with oxytocin per protocol for evaluation.
ANS: C
The nurse must adjust the tocotransducer to find the best location to pick up and record the
fetal heart rate. Positioning the patient for comfort during testing is a prime concern. Although
a full bladder may affect patient comfort, it will not interfere with testing results. NPO status
is not required for an NST. Instead, a pregnant patient should maintain her normal nutritional
intake to provide energy to herself and the fetus. An infusion pump with oxytocin is required
for a contraction stress test (CST).
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential/Diagnostic Tests
16. The results of a contraction stress test (CST) are positive. Which intervention is necessary
based on this test result?
a. Repeat the test in 1 week so that results can be trended based on this baseline
result.
b. Contact the health care provider to discuss birth options for the patient.
c. Send the patient out for a meal and repeat the test to confirm that the results are
valid.
d. Ask the patient to perform a fetal kick count assessment for the next 30 minutes
and then reassess the patiN
ent.R I G B.C M
ANS: B
U S N T
O
A positive CST test is an abnormal finding, and the provider should be notified so that birth
options can be initiated. A positive CST indicates possible fetal compromise. Intervention
should not be delayed by 1 week and results do not have to be trended. Because this is an
abnormal result, there is no need to repeat the test. Sending the patient out for a meal will
delay treatment options and may interfere with possible birth interventions if anesthesia is
needed. Fetal kick count assessment is not needed at this time and will further delay treatment
interventions for this abnormal result, which indicates fetal compromise.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation/Unexpected Response to
Therapies
17. A pregnant patient has received the results of her triple-screen testing and it is positive. She
provides you with a copy of the test results that she obtained from the lab. What would the
nurse anticipate as being implemented in the patient’s plan of care?
a. No further testing is indicated at this time because results are normal.
b. Refer to the physician for additional testing.
c. Validate the results with the lab facility.
d. Repeat the test in 2 weeks and have the patient return for her regularly scheduled
prenatal visit.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Additional genetic testing is indicated to provide the patient with treatment options. A positive
result on a triple-screen test is considered to be an abnormal finding so the patient should be
referred to the physician for additional genetic testing. Validation of the test with a lab facility
is not necessary because the patient provided you with a copy of the test results. There is no
need to repeat the clinical test because the findings have already been determined.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation/Unexpected Response to
Therapies
18. A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic
family history. Which medication does the nurse anticipate will be administered?
a. Magnesium sulfate
b. Prostaglandin suppository
c. RhoGAM if the patient is Rh-negative
d. Betamethasone
ANS: C
CVS can increase the likelihood of Rh sensitization if a woman is Rh-negative. There is no
indication for magnesium sulfate because it is used to stop preterm labor. There is no
indication for administration of a prostaglandin suppository. Betamethasone is given to
pregnant women in preterm labor to improve fetal lung maturity.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
19. For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
CeOekMs’ gestation
a. A 38-year-old gravida 2, N
paUraR1S, I
wN
hoGiT
sB
38.w
b. A 24-year-old gravida 1, para 0, who has diabetes
c. A 44-year-old gravida 6, para 5, who is at term
d. An 18-year-old gravida 1, para 0, who is in early labor at term
ANS: B
Even though an L/S ratio of 2:1 is typically considered to be a normal finding to validate fetal
lung maturity prior to 38 weeks’ gestation, the result may not be accurate in determining fetal
lung maturity if a patient is diabetic.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
20. Which complication could occur as a result of percutaneous umbilical blood sampling
(PUBS)?
a. Postdates pregnancy
b. Fetal bradycardia
c. Placenta previa
d. Uterine rupture
ANS: B
PUBS is an invasive test whereby a needle is inserted into the umbilical cord to obtain blood
as the basis for diagnostic testing with the guidance of ultrasound technology. The most
common complication is fetal bradycardia, which is temporary. PUBS has no effect on
extending the gestation of pregnancy, the development of placenta previa, or uterine rupture.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
21. A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when
she got pregnant. Scheduling an ultrasound is a standing prescription for the patient’s health
care provider. When is the best time for the nurse to schedule the patient’s ultrasound?
a. Immediately
b. In 2 weeks
c. In 4 weeks
d. In 6 weeks
ANS: A
An embryo can be seen about 5 to 6 weeks after the last menstrual period. At this time the
crown–rump length (CRL) of the embryo is the most reliable measure of gestational age. Fetal
viability is confirmed by observation of fetal heartbeat, which is visible when the CRL of the
embryo is 5 mm.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
22. The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at
16 weeks’ gestation. The nurse determines that the patient understands the teaching when she
states that will be collected for the initial screening process?
a. Urine
b. Blood
c. Saliva
NURSINGTB.COM
d. Amniotic fluid
ANS: B
Initial screening is completed with blood. AFP can be detected in amniotic fluid; however,
that procedure is more costly and invasive. Procedures progress from least invasive to most
invasive.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
23. A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the
fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the
fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse
record these findings?
a. NST positive, nonreassuring
b. NST negative, reassuring
c. NST reactive, reassuring
d. NST nonreactive, nonreassuring
ANS: C
The presence of at least three accelerations of at least 15 beats, over at least 15 seconds, over a
duration of at least 20 minutes, is considered reactive and reassuring. Nonreactive testing
reveals no or fewer accelerations over the same or longer period. The NST test is not recorded
as positive or negative.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)?
(Select all that apply.)
a. Down syndrome
b. Molar pregnancy
c. Twin gestation
d. Incorrect gestational age assessment of a normal fetus—estimation is earlier in the
pregnancy
e. Threatened abortion
ANS: C, D, E
Elevated APF levels are seen in multiple gestations, underestimation of fetal age, and
threatened abortion. Decreased levels are seen in Down syndrome and a molar pregnancy.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation/Pathophysiology
2. Transvaginal ultrasonography is often performed during the first trimester. A
6-week-gestation patient expresses concerns over the necessity for this test. The nurse should
explain that this diagnostic test may be necessary to determine which of the following? (Select
all that apply.)
a. Multifetal gestation
b. Bicornuate uterus
NURSINGTB.COM
c. Presence and location of pregnancy
d. Amniotic fluid volume
e. Presence of ovarian cysts
ANS: A, B, C, E
A bicornuate uterus, multifetal gestation, presence of ovarian cysts, and presence and location
of pregnancy can be determined by transvaginal ultrasound in the first trimester of pregnancy.
This procedure is also used for estimating gestational age, confirming fetal viability,
identifying fetal abnormalities or chromosomal defects, and identifying the maternal
abnormalities mentioned, as well as fibroids. Amniotic fluid volume is assessed during the
second and third trimesters. Conventional ultrasound would be used.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
3. A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator
(VAS) test. Which should the nurse include in the response? (Select all that apply.)
a. The test is invasive.
b. The test uses sound to elicit fetal movements.
c. The test may confirm nonreactive nonstress test results.
d. The test can only be performed if contractions are present.
e. Vibroacoustic stimulation can be repeated at 1-minute intervals up to three times.
ANS: B, C, E
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Also referred to as VAS or acoustic stimulation, the vibroacoustic stimulator (similar to an
electronic larynx) is applied to the maternal abdomen over the area of the fetal head. Vibration
and sound are emitted for up to 3 seconds and may be repeated. A fetus near term responds by
increasing the number of gross body movements, which can be easily seen and felt. The
procedure can confirm reassuring NST findings and shorten the length of time necessary to
obtain NST data. The test is noninvasive and contractions do not need to be present to perform
the test.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
4. The nurse is instructing a patient on how to perform kick counts. Which information should
the nurse include in the teaching session? (Select all that apply.)
a. Use a clock or timer when performing kick counts.
b. Your bladder should be full before performing kick counts.
c. Notify your health care provider if you have not felt movement in 24 hours.
d. Protocols can provide a structured timetable for concentrating on fetal movements.
e. You should lie on your side, place your hands on the largest part of the abdomen,
and concentrate on the number of movements felt.
ANS: A, D, E
The nurse should instruct the patient to lie on her side, place her hands on the largest part of
her abdomen, and concentrate on fetal movements. She should use a clock or timer and record
the number of movements felt during that time. Protocols are not essential; however, they may
give the patient a more structured timetable for when to concentrate on fetal movements. The
bladder does not need to be full for kick counts; it is better to have the patient empty her
bladder before beginning the assessment of fetal movements. Further evaluation is
N lsRnSo ImNove
GT
B.Cn M
recommended if the patient feeU
ments iO
12 hours; 24 hours is too long before
notifying the health care provider.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
5. The nurse is preparing a patient for a nonstress test (NST). Which interventions should the
nurse plan to implement? (Select all that apply.)
a. Ensure that the patient has a full bladder.
b. Plan approximately 15 minutes for the test.
c. Have the patient sit in a recliner with the head elevated 45 degrees.
d. Apply electronic monitoring equipment to the patient’s abdomen.
e. Instruct the patient to press an event marker every time she feels fetal movement.
ANS: C, D, E
The patient may be seated in a reclining chair or have her head elevated at least 45 degrees.
The nurse applies external electronic monitoring equipment to the patient’s abdomen to detect
the fetal heart rate and any contractions. The woman may be given an event marker to press
each time she senses movement. Before the NST, the patient should void and her baseline
vital signs should be taken. The NST takes about 40 minutes, allowing for most fetal
sleep-wake cycles, although the fetus may show a reassuring pattern more quickly or need
more time to awaken and become active. Fifteen minutes would not allow enough time to
complete the test.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 I G B.C M
NURS N T
d. Administration of aspirin (A
SA) every day ofOthe 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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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?
NURSINGTB.COM
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
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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.
NURSINGTB.COM
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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
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 theNbloRod I
lossGandBi.
tsC
effeMct on the patient and fetus. Monitoring
U
S
N
T
O
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
fetus is Rh-negative.
fetus is Rh-positive.
father is Rh-positive.
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: UndersN
tandR
ingI GOBB
J:.C
NursM
ing Process Step: Assessment
U
S
N
T
O
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
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 indicatiN
ve oR
f DI
IC iG
s onB
e.
thC
at sM
hows
a.
b.
c.
d.
U S
decreased fibrinogen.
increased platelets.
increased hematocrit.
decreased thromboplastin time.
N T
O
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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
21. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is
based on which of the followN
inU
g?RSINGTB.COM
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 diagnosis 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 nNoUdR
ocSuI
mN
enGteT
dB
p.
reC
naO
taM
l 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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Physiologic Integrity/Pathophysiology
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. ThNeUpR
atS
ieI
ntNisGpT
laB
ce.dCoO
nM
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 nurN
se w
ld dG
ifferB
en.tiC
ate M
a placenta previa from an abruptio
RouI
U S
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
N T
O
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
30. A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of
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
NURSINGTB.COM
mL.
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 theNmeR
mbI
raneG
s ruB
pt.
uC
re, tM
he presence of backache and pelvic
U
S
N
T
O
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
NURSINGTB.COM
a.
b.
c.
d.
direct Coombs test of twin A.
direct Coombs test of twin B.
indirect Coombs test of the mother.
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.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 diabeteN
s?URSINGTB.COM
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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
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
N
R
I
G
MSC: Patient Needs: Health Prom
on aN
nd M
UotiS
TaBin.teCnaOncMe
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.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 thN
e nuR
rse I
inclG
udeBw.hC
en tM
eaching a pregnant patient with Class II
U S N T
O
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
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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 N
be lR
ife-tI
hreaGtenB
in.
g.C M
U S N T
O
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.”
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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
50. Which postpartum patient reqNuirR
es furthG
er aB
ss.
esC
smeM
nt?
U SIN
a. G4 P4 who has had four saturated
padsTduringOthe 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
NURSINGTB.COM
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 survNeillR
ancI
e isG
theB
st.
anCdarM
d of care.
U S N T
O
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
•
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
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
NURSINGTB.COM
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
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 11: The Childbearing Family with Special Needs
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A pregnant patient who abuses cocaine admits to exchanging sex for her drug habit. This
behavior puts her at a greater risk for
a. postmature birth.
b. sexually transmitted diseases.
c. hypotension and vasodilation.
d. depression of the central nervous system.
ANS: B
Sex acts exchanged for drugs place the woman at increased risk for sexually transmitted
diseases because of having multiple partners and lack of protection. Premature delivery of the
infant is one of the most common problems associated with cocaine use during pregnancy.
Cocaine causes hypertension and vasoconstriction. Cocaine is a central nervous system
stimulant.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. Which factor is a major barrier to health care for adolescent mothers?
a. Health care workers have a positive attitude.
b. The hospital or clinic is within walking distance of the girl’s home.
c. Seeing a different nurse and/or health care provider at every visit.
NU, R
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d. The institution is open days
evS
eni
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turday
ANS: C
Whenever possible, the teen should be scheduled to see the same nurses and practitioners for
continuity of care. A positive attitude of the health care providers is important in teen
pregnancy care. If the hospital or clinic were within walking distance of the girl’s home, it
would prevent the teen from missing appointments due to transportation problems. If the
institution were open days, evenings, and Saturday by special arrangement, this would be
helpful for teens who work, go to school, or have other time of day restrictions. Scheduling
conflicts are a major barrier to health care.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
3. In planning sex education classes for the middle school age group, more emphasis should be
placed on
a. how to set limits for sexual behavior.
b. the inaccuracy of information from peers.
c. the use of oral contraceptives to prevent unwanted pregnancy.
d. the use of condoms to prevent sexually transmitted diseases as well as pregnancy.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Setting limits for sexual behavior is particularly important for younger teenagers who may be
pressured to become sexually active before they are physically and emotionally ready. Oral
contraceptives are not the preferred method of birth control for teenagers because they forget
to take them, and they do not protect against STIs. The use of condoms is appropriate and an
important concept to discuss but should not be the emphasis.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
4. Which action should the nurse take when counseling a teenaged patient who has decided to
relinquish her baby for adoption?
a. Question her about her feelings regarding adoption.
b. Tell her she can always change her mind about adoption.
c. Affirm her decision while acknowledging her maturity in making it.
d. Ask her if anyone is coercing her into the decision to relinquish her baby.
ANS: C
A supportive affirming approach by the nurse will strengthen the patient’s resolve and help
her appreciate the significance of the event. It is important for the nurse to support and affirm
the decision the patient has made. This will strengthen the patient’s resolve to follow through.
Later the patient should be given an opportunity to express her feelings. Telling her that she
can always change her mind about adoption should not be an option after the baby is born and
placed with the adoptive parents. It is important that the teenager be treated as an adult, with
the assumption that she is capable of making an important decision on her own.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
NURSINGTB.COM
5. A patient who is older than 35 years may have difficulty achieving pregnancy because
a. prepregnancy medical attention is lacking.
b. personal risk behaviors influence fertility.
c. contraceptives have been used for an extended period of time.
d. the ovaries may be affected by the normal aging process.
ANS: D
Once the mature woman decides to conceive, a delay in becoming pregnant may occur
because of the normal aging of the ovaries. Prepregnancy medical care is available and
encouraged. The older adult participates in fewer risk behaviors than the younger adult. The
problem is the age of the ovaries, not the past use of contraceptives. Fertility begins to decline
at age 32 and decreases more rapidly by age 37.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. Which health concern is most likely to be an issue for the older mother?
a. Nutrition and diet planning
b. Exercise and fitness
c. Having enough rest and sleep
d. Effective contraceptive methods
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The woman who delays childbearing may have unique concerns, one of which is having less
energy than younger mothers. The older mother is better off financially and can afford better
nutrition. Information about exercise and fitness is readily available. The older mother usually
has more financial means to search out effective contraceptive methods.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
7. Which is the most dangerous effect on the fetus of a patient who smokes cigarettes while
pregnant?
a. Intrauterine growth restriction
b. Genetic changes and anomalies
c. Extensive central nervous system damage
d. Fetal addiction to the substance inhaled
ANS: A
The major consequences of smoking tobacco during pregnancy are low-birth-weight infants,
prematurity, and increased perinatal loss. Cigarettes normally will not cause genetic changes
or extensive central nervous system damage. Addiction is not a normal concern with the
neonate.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
8. A patient at 24 weeks of gestation reports that she has a glass of wine with dinner every
evening. Which rationale should the nurse provide this patient regarding the necessity to
eliminate alcohol intake?
a. The fetus is placed at riskNfU
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in.gC
roOwM
th.
b. The fetus is at risk for severe nervous system injury.
c. The patient will be at risk for abusing other substances as well.
d. A daily consumption of alcohol indicates a risk for alcoholism.
ANS: A
The brain grows most rapidly in the third trimester and is most vulnerable to alcohol exposure
during this time. The major concerns are mental retardation, learning disabilities, high activity
level, and short attention span. The risk to the patient for abusing other substances is not the
major risk for the infant. It has not been proven that daily consumption of alcohol indicates a
risk for alcoholism.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
9. Which of the following is an example of healthy grieving?
a. The mother exhibits an absence of crying or expression of feelings.
b. The parents do not mention the baby in conversation with family members.
c. The mother asks that the baby be taken away from the delivery area quickly.
d. While holding the baby, the mother says to her husband, “He has your eyes and
nose.”
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Attachment behaviors are necessary for healthy grieving. Absence of crying and not
mentioning the baby may be signs of denial. By not seeing the baby, attachment and therefore
healthy grieving will not occur.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
10. A patient has delivered twins. The first twin was stillborn, and the second is in the intensive
care nursery, recovering quickly from respiratory distress. The patient is crying softly and
says, “I wish my baby could have lived.” What is the most therapeutic response?
a. “How soon do you plan to have another baby?”
b. “Don’t be sad. At least you have one healthy baby.”
c. “I have a friend who lost a twin and she’s doing just fine now.”
d. “I am so sorry about your loss. Would you like to talk about it?”
ANS: D
The nurse should recognize the woman’s grief and its significance. Asking her about plans for
another baby is denying the loss of the other infant. Pointing out the health of another baby is
belittling her feelings. Stating that the nurse has a friend who lost a twin is denying the loss of
the infant and her grief and belittling her feelings.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
11. Which action is the most appropriate nursing measure when a baby has an unexpected defect
at birth?
a. Remove the baby from the delivery area immediately.
b. Inform the parents immedNiaUteRlyStI
haNt G
soTmBe.
thC
inO
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is wrong.
c. Tell the parents that the baby has to go to the nursery immediately.
d. Explain the defect and show the baby to the parents as soon as possible.
ANS: D
Parents experience less anxiety when they are told about the defect as early as possible and are
allowed to touch and hold the baby. The parents should be able to touch and hold the baby as
soon as possible. The nurse should not take the baby away; this would raise anxiety levels of
the parents. They should be told about the defect and allowed to see the baby.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
12. Which environment can assist a pregnant teen to achieve the task of establishing a stable
identity?
a. Home schooling
b. Alternative education program
c. School-based mothers’ program
d. Continuing mainstream high school classes
ANS: C
A school-based mothers’ program that provides peer support is important. Home schooling,
alternative education, and continuing mainstream high school classes would not provide as
much peer support.
NURSINGTB.COM
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
13. Which complication of adolescent pregnancy should the nurse plan to monitor?
a. Anemia
b. Placenta previa
c. Abruptio placenta
d. Incompetent cervix
ANS: A
Adolescent pregnancies are at increased risk for anemia, nutritional deficiencies,
pregnancy-associated hypertension, HIV and other STDs, short interval until next pregnancy,
and depression. They do not have a higher incidence of placenta previa, abruptio placentae, or
incompetent cervix.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
14. The nurse is seeing a 17-year-old female in the clinic for complaints of acne. The nurse plans
on taking advantage of this teachable moment with the teen. Which topics will the nurse
include in the teen’s teaching plan?
a. Smoking habits, folic acid intake, and heart disease
b. Hyperlipidemia, distracted driving, and menstrual history
c. Sexual activity, contraception, and screening for violence
d. Optimum weight, hypothyroidism, and sexually transmitted diseases
ANS: C
All the topics mentioned are N
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screening for violence have priority
related
to theO
age and gender of the patient. Adolescents
are seen by health care providers for a variety of reasons before they become pregnant.
Counseling to improve health for a future pregnancy should be offered to them during any
health care visit. Smoking cessation, attaining optimum weight, folic acid intake, and
screening for violence are topics that should be discussed with all young women so that any
future pregnancy has the most positive outcome.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
15. A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that
she has a daily heroin habit. The nurse discusses treatment options for the patient. Which
patient statement requires follow-up?
a. “My plan is to visit the outpatient clinic daily for treatment.”
b. “I will see my health care provider at least every 2 weeks.”
c. “My baby will not have to go through withdrawal when I take methadone.”
d. “With oral methadone, my baby and I are at decreased risk of infection.”
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Pregnant women who use heroin are often prescribed an alternative drug such as methadone, a
synthetic opiate. Methadone can be taken orally once daily and is long-acting, providing
consistent blood levels to decrease the adverse fetal effects of wide swings in blood levels
found with heroin use. Methadone also reduces the risk of infections from contaminated
needles and drug-seeking behavior, such as prostitution. At therapeutic levels, it does not
produce the euphoria or sedation of heroin and allows the woman to have a relatively normal
lifestyle. The woman who receives a daily dose of methadone in a drug treatment program is
more likely to receive prenatal care. However, the newborn must withdraw from methadone
after birth.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
16. Which data in the patient’s history should the nurse recognize as being pertinent to a possible
diagnosis of postpartum depression?
a. Previous depressive episode
b. Unexpected operative birth
c. Ambivalence during the first trimester
d. Second pregnancy in a 3-year period
ANS: A
A personal or family history of depression or other mental illness is a risk factor for
postpartum depression. An operative birth, ambivalence during the first trimester, and two
pregnancies in 3 years are not risk factors for postpartum depression.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Psychosocial Integrity
NURSINGTB.COM
MULTIPLE RESPONSE
1. Which nursing diagnoses may apply to the childbearing family with special needs? (Select all
that apply.)
a. Risk for spiritual distress
b. Risk for injury
c. Readiness for enhanced nutrition
d. Ineffective breathing pattern
e. Situational low self-esteem
ANS: A, B, E
A childbearing family with special needs may be at risk to develop spiritual distress,
experience injury, and exhibit situational low self-esteem. There are no supportive data to
hypothesize an ineffective breathing pattern and/or readiness for enhanced nutrition.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Patient Needs: Health Promotion and Maintenance
2. Many teens wait until the second or even third trimester to seek prenatal care. The nurse
should understand that the reasons behind this delay include which of the following? (Select
all that apply.)
a. Continuing to deny the pregnancy
b. Uncertainty about where to go for care
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Lack of realization that they are pregnant
d. A desire to gain control over their situation
e. Wanting to hide the pregnancy as long as possible
ANS: A, B, C, E
Denying the pregnancy, uncertainty about where to go for care, lack of realization of
pregnancy, and wanting to hide the pregnancy are all valid reasons for the teen to delay
seeking prenatal care. A desire to gain control is not a reason to delay seeking health care.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Psychosocial Integrity
3. Which characteristics of fetal alcohol syndrome (FAS) should the nurse expect to assess in
affected neonates? (Select all that apply.)
a. Hydrocephaly
b. Low activity
c. Epicanthal folds
d. Short palpebral fissures
e. Flat midface, with a low nasal bridge
ANS: C, D, E
Common facial anomalies associated with FAS include microcephaly, short palpebral fissures
(the openings between the eyelids), epicanthal folds, flat midface with a low nasal bridge,
indistinct philtrum (groove between the nose and upper lip), and a thin upper lip.
Microcephaly is present, not hydrocephaly. Central nervous system impairment includes a
high activity level, not a low one.
DIF: Cognitive Level: UndersN
tandR
ingI GOBB
J:.C
NursM
ing Process Step: Assessment
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S
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T
O
MSC: Patient Needs: Physiologic Integrity
4. Which congenital defects in a newborn are associated with long-term parenting problems?
(Select all that apply.)
a. Polydactyl
b. Cleft lip and palate
c. Ventral septal defect
d. Ambiguous genitalia
ANS: B, D
Although any defect in a newborn produces extreme concern and anxiety, certain defects are
associated with long-term parenting problems. Accepting an infant with facial or genital
anomalies is particularly difficult for the family and community. Polydactyl and ventral septal
defects are reparable, with good outcomes.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Psychosocial Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 12: Processes of Birth
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. The nurse is explaining the physiology of uterine contractions to a group of nursing students.
Which statement best explains the maternal-fetal exchange of oxygen and waste products
during a contraction?
a. Little to no affect
b. Increases as blood pressure decreases
c. Diminishes as the spiral arteries are compressed
d. Continues except when placental functions are reduced
ANS: C
During labor contractions, the maternal blood supply to the placenta gradually stops as the
spiral arteries supplying the intervillous space are compressed by the contracting uterine
muscle. The exchange of oxygen and waste products is affected by contractions. The
exchange of oxygen and waste products decreases. The maternal blood supply to the placenta
gradually stops with contractions.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
2. The nurse is directing an unlicensed assistive personnel (UAP) to obtain maternal vital signs
between contractions. Which statement is the appropriate rationale for assessing maternal vital
signs between contractions rather than at another interval?
NU
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IN
M
a. Vital signs taken during co
ntra
ctio
nsGaT
reB.C
inaccOurate.
b. During a contraction, assessing fetal heart rate is the priority.
c. Maternal blood flow to the heart is reduced during contractions.
d. Maternal circulating blood volume increases temporarily during contractions.
ANS: D
During uterine contractions, blood flow to the placenta temporarily stops, causing a relative
increase in the mother’s blood volume, which in turn temporarily increases blood pressure and
slows the pulse. Vital signs are altered by contractions but are considered accurate for a period
of time. It is important to monitor the fetal response to contractions, but the question is
concerned with the maternal vital signs. Maternal blood flow is increased during a
contraction.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
3. Uncontrolled maternal hyperventilation during labor results in
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation,
resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis,
metabolic acidosis, or metabolic alkalosis.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes
the pelvic inlet?
a. Extension
b. Engagement
c. Internal rotation
d. External rotation
ANS: B
Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs
when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck
stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when
the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform
to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the
head. The head then turns to the side so the shoulders can internally rotate and are positioned
with their transverse diameter in the anteroposterior diameter of the pelvic outlet.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
5. The laboring patient asks the nurse how the labor contractions cause the cervix to dilate. The
nurse responds that labor conN
trU
acR
tiS
onIs N
faG
ciT
liB
tat.
eC
ceOrvMical dilation by
a. promoting blood flow to the cervix.
b. contracting the lower uterine segment.
c. enlarging the internal size of the uterus.
d. pulling the cervix over the fetus and amniotic sac.
ANS: D
Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic
sac are pushed downward. Blood flow decreases to the uterus during a contraction. The
contractions are stronger at the fundus. The internal size becomes smaller with the
contractions; this helps push the fetus down.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
6. Pregnant patients can usually tolerate the normal blood loss associated with childbirth because
of which physiologic adaptation to pregnancy?
a. A higher hematocrit
b. Increased leukocytes
c. Increased blood volume
d. A lower fibrinogen level
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Women have a significant increase in blood volume during pregnancy. After birth, the
additional circulating volume is no longer necessary. The hematocrit decreases with
pregnancy due to the higher fluid volume. Leukocyte levels increase during labor; however,
that is not the reason for the toleration of blood loss. Fibrinogen levels increase with
pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. The nurse is assessing the duration of a patient’s labor contractions. Which method does the
nurse implement to assess the duration of labor contractions?
a. Assess the strongest intensity of each contraction.
b. Assess uterine relaxation between two contractions.
c. Assess from the beginning to the end of each contraction.
d. Assess from the beginning of one contraction to the beginning of the next.
ANS: C
Duration of labor contractions is the average length of contractions from beginning to end.
Assessing the strongest intensity of each contraction assesses the strength or intensity of the
contractions. Assessing uterine relaxation between two contractions is the interval of the
contraction phase. Assessing from the beginning of one contraction to the beginning of the
next is the frequency of the contractions.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. Which physiologic event is the key indicator of the commencement of true labor?
NURSINGTB.COM
a. Bloody show
b. Cervical dilation and effacement
c. Fetal descent into the pelvic inlet
d. Uterine contractions every 7 minutes
ANS: B
The conclusive distinction between true and false labor is that contractions of true labor cause
progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can
occur before true labor. False labor may have contractions that occur this frequently but is
usually inconsistent.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the
pelvis?
a. Station
b. Flexion
c. Descent
d. Engagement
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The anterior-posterior diameter of the head varies with how much it is flexed. In the most
favorable situation, the head is fully flexed and the anterior-posterior diameter is the
suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting
part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal.
Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic
outlet.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an
indication of
a. lightening.
b. breech presentation.
c. urinary tract infection.
d. onset of Braxton-Hicks contractions.
ANS: A
As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic
pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech
presentation does not cause urinary frequency and leg cramps. A urinary tract infection may
cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks
contractions are irregular and mild and occur throughout the pregnancy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
11. A patient just delivered her bN
abUyRvS
iaIthNeGvT
agB
in.
alCrO
ouMte. The patient asks the nurse why the
baby’s head is not round, but oval. Which explanation should the nurse provide the patient?
a. This results from molding.
b. This results from lightening.
c. This results from the fetal lie.
d. This results from the fetal presentation.
ANS: A
The sutures and fontanels allow the bones of the fetal head to move slightly, changing the
shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the
descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis
of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the
pelvic outlet.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?
a. Latent phase
b. Active phase
c. Second stage
d. Third stage
ANS: B
NURSINGTB.COM
The active phase of labor is characterized by cervical dilation of 5 to 6 cm. Historically, the
latent phase is from the beginning of true labor until 3 cm of cervical dilation. Recent research
has suggested that the latent phase be considered to last up until 5 to 6 cm. dilated. The second
stage of labor begins when the cervix is completely dilated until the birth of the baby. The
third stage of labor is from the birth of the baby until the expulsion of the placenta.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
13. The nurse is assessing a patient in the active phase of labor. What should the nurse expect
during this phase?
a. The patient is sociable and excited.
b. The patient is requesting pain medication.
c. The patient begins to experience the urge to push.
d. The patient experiences loss of control and irritability.
ANS: B
During the active phase of labor, contraction intensity and discomfort increase to the point
where women often request pain medication. Sociability and excitability occur during the
latent phase. The urge to push occurs at the end of the transition phase or the second stage of
labor. Loss of control and irritability occur during the transition phase of labor.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
14. A laboring patient asks the nurse how she will know that the contraction is at its peak. The
nurse explains that the contraction peaks during which stage of measurement?
NURSINGTB.COM
a. The acme
b. The interval
c. The increment
d. The decrement
ANS: A
The acme is the peak or period of greatest strength during the middle of a contraction cycle.
The interval is the period between the end of the contraction and the beginning of the next.
The increment is the beginning of the contraction until it reaches the peak. The decrement
occurs after the peak until the contraction ends.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
15. A patient in labor presents with a breech presentation. The nurse understands that a breech
presentation is associated with
a. more rapid labor.
b. a high risk of infection.
c. maternal perineal trauma.
d. umbilical cord compression.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The umbilical cord can compress between the fetal body and maternal pelvis when the body
has been born but the head remains within the pelvis. Breech presentation is not associated
with a more rapid labor. There is no higher risk of infection with a breech birth. There is no
higher risk for perineal trauma with a breech birth. Most breech presentations are now
delivered by caesarean birth.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
16. The primary difference between the labor of a nullipara and that of a multipara is
a. total duration of labor.
b. level of pain experienced.
c. amount of cervical dilation.
d. sequence of labor mechanisms.
ANS: A
Multiparas usually labor more quickly than nulliparas, making the total duration of their labor
shorter. The level of pain is individual to the woman, not the number of labors she has
experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is
the same with all labors.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
17. Which maternal factor may inhibit fetal descent during labor?
a. A full bladder
b. Decreased peristalsis
c. Rupture of membranes NURSINGTB.COM
d. Reduction in internal uterine size
ANS: A
A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the
fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will
assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal
descent.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
18. Which assessment finding would cause a concern for a patient who had delivered vaginally?
a. Estimated blood loss (EBL) of 500 mL during the birth process
b. White blood cell count of 28,000 mm3 postbirth
c. Patient complains of fingers tingling
d. Patient complains of thirst
ANS: C
A patient’s complaint of fingers tingling may represent respiratory alkalosis due to
hyperventilation breathing patterns during labor. As such it requires intervention by the nurse
to have the patient slow breathing down and restore normal carbon dioxide levels.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
19. On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in
early labor is found to have a transverse lie on vaginal examination. What is the priority
intervention at this time?
a. Perform a vaginal exam to denote progress.
b. Notify the health care provider.
c. Initiate parenteral therapy.
d. Apply oxygen via nasal cannula at 8 L/minute.
ANS: B
A transverse lie is considered to be an abnormal presentation so the physician should be
notified and the process of a Caesarean section as the birth method should be initiated. The
information provided relative to transverse lie was found on vaginal exam. At this point, the
priority is to prepare for a surgical birth because assessment data also indicate that the patient
is in early labor; thus a vaginal birth is not imminent. Although initiating parenteral therapy
will be required, it is not the priority at this time. Application of oxygen is not required
because there is no evidence of fetal or maternal distress.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
20. Which assessment finding indicates that cervical dilation and/or effacement has occurred?
a. Onset of irregular contractions
b. Cephalic presentation at 0 station
c. Bloody mucus drainage from vagina
d. Fetal heart tones (FHTs) present in the lower right quadrant
ANS: C
NURSINGTB.COM
Cervical dilation and/or effacement results in loss of the mucus plug as well as rupture of
small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the
lower right quadrant do not indicate the onset of cervical ripening.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
21. If a notation on the patient’s health record states that the fetal position is LSP, this indicates
that the
a. head is in the right posterior quadrant of the pelvis.
b. head is in the left anterior quadrant of the pelvis.
c. buttocks are in the left posterior quadrant of the pelvis.
d. buttocks are in the right upper quadrant of the abdomen.
ANS: C
LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S =
sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head
is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left
anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper
quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
22. To determine if the patient is in true labor, the nurse would assess for changes in
a. cervical dilation.
b. amount of bloody show.
c. fetal position and station.
d. pattern of uterine contractions.
ANS: A
Cervical changes are the only indication of true labor and are used to determine true and false
labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine
contractions are unreliable indicators of true labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
23. The health care provider for a laboring patient makes the following entry into the patient’s
record: 3/50%/+. What instruction will the nurse implement with the patient?
a. “You will need to remain in bed attached to the electronic fetal monitor.”
b. “Breathe with me slowly, in through your nose and out through your mouth.”
c. “I will begin the administration of 1000 mL of IV fluid so you can have an
epidural.”
d. “Your partner will need to change into scrub attire to attend the imminent birth.”
ANS: B
This patient is in the latent phase of the first stage of labor. Use slow, deep chest breathing
patterns early in labor to conserve energy for the upcoming process. There is no mention in
the stem that the membranes are ruptured, which may prohibit the patient from ambulating.
Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because
GeTnB
the head is at +1 station. EpidNuU
raR
l pSlaIcN
em
t d.uC
rinOgMearly labor may slow down the labor
process and should be delayed. There is no indication that birth is imminent because the
patient is only 3 cm dilated.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
24. The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA)
position. To facilitate the labor process, how will the nurse position the laboring patient?
a. On her back
b. On her left side
c. On her right side
d. On her hands and knees
ANS: B
LOA is the desired fetal position for the birthing process. Positioning the patient on her left
side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in
the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus.
Positioning the patient on her back decreases placental perfusion. Positioning on her right may
facilitate internal rotation and move the fetus out of the LOA position. The hands and knees
position is reserved to decrease cord compression, facilitate the fetus out of a posterior
position, or increase oxygenation in the presence of hypoxia. Because none of these
conditions are present, there is no need to implement this position.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
25. The primiparous patient at 39 weeks’ gestation states to the nurse, “I can breathe easier now.”
What is the nurse’s most appropriate response?
a. “Your labor will start any day now since the baby has dropped.”
b. “That process is called lightening. Do you have to urinate more frequently?”
c. “Contact your health care provider when your contractions are every 5 minutes for
1 hour.”
d. “You will likely not feel you baby’s movements as much now, so do not be
concerned.”
ANS: B
As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes
more easily because upward pressure on her diaphragm is reduced. However, increased
pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the
pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the
pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks
before the natural onset of labor. Instructions for labor, although correct, do not address the
patient’s statement of being able to breathe easier. Fetal movement continues throughout the
final weeks of gestation. A decrease in fetal movement is a concerning sign and the health
care provider must be notified.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
26. The nurse assesses a laboring patient’s contraction pattern and notes the frequency at every 3
to 4 minutes, duration 50 to 6N0UseRcS
onIdN
s,G
anTdBth.eCinOteMnsity is moderate by palpation. What is
the most accurate documentation for this contraction pattern?
a. Stage 1, latent phase
b. Stage 2, latent phase
c. Stage 1, active phase
d. Stage 2, active phase
ANS: C
In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of
about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent
phase of stage 1, the interval between contractions shortens until contractions are about 5
minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During
stage 2, latent phase, the woman is resting and preparing to push; she likely has not
experienced the pushing reflex (sometimes referred to as the Ferguson reflex). She is actively
bearing down during the active phase of the second stage.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
27. A laboring patient states to the nurse, “I have to push!” What is the next nursing action?
a. Contact the health care provider.
b. Examine the patient’s cervix for dilation.
c. Review with her how to bear down with contractions.
d. Ask her partner to support her head with each push.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: B
When the cervix is completely dilated, the head can descend through the pelvis and stimulate
the pushing, reflex. Cervical dilation must first be confirmed because premature pushing
efforts may result in cervical edema and corresponding delay in dilation. Once complete
dilation has been confirmed, the nurse can notify the health care provider. Teaching
positioning and pushing efforts is accomplished once complete dilation has been confirmed.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
28. After birth of the placenta the patient states, “All of a sudden I feel very cold.” What is the
most appropriate nursing action at this time?
a. Place a warm blanket over the patient.
b. Place the baby on the patient’s abdomen.
c. Tell the patient that chills are expected after birth.
d. “What do you mean by your words ‘very cold’?”
ANS: A
Many women are chilled after birth. The cause of this reaction is unknown but probably
relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in
intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts
for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may
help relieve the chill and make the woman more comfortable. Placing the baby on her
abdomen may result in transfer of heat and make her feel even colder. Reassurance is
appropriate after the blanket is provided. Validation of an expected physical response to the
birthing process results in a delay of care and is unnecessary.
N R I G B.C M
U S N OBJ:
T Nursing
O Process Step: Implementation
DIF: Cognitive Level: Application
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A 28-year-old gravida 1, para 0 patient who is at term calls the labor and birth unit stating that
she thinks she is in labor. She states that she does have some vaginal discharge and feels wet;
however, it is not bloody in nature. She relates a contraction pattern that is irregular, ranging
from 5 to 7 minutes and lasting 30 seconds. Which questions should the nurse pose to the
patient during this telephone triage? (Select all that apply.)
a. Does she think that her membranes have ruptured?
b. Is there any evidence of bloody show?
c. Instruct the patient to keep monitoring her contraction pattern and call you back if
they become more regular.
d. When is her next scheduled visit with her health care provider?
e. Tell her to come into the hospital for evaluation.
ANS: A, E
NURSINGTB.COM
The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus in view of
the assessment data that the patient provided, the nurse should ascertain membrane status and
ask the patient to come in for evaluation. The patient has already indicated that the vaginal
discharge was not bloody in nature. Having the patient continue to monitor at home would not
provide assurance of maternal-fetal well-being. Asking the patient about the next scheduled
physician visit does not address current health concerns of impending labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
2. A patient asks the nurse how she can tell if labor is real. Which information should the nurse
provide to this patient? (Select all that apply.)
a. In true labor, the cervix begins to dilate.
b. In true labor, the contractions are felt in the abdomen and groin.
c. In true labor, contractions often resemble menstrual cramps during early labor.
d. In true labor, contractions are inconsistent in frequency, duration, and intensity in
the early stages.
e. In true labor your contractions tend to increase in frequency, duration, and
intensity with walking.
ANS: A, C, E
In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the
early stage, and labor contractions increase in frequency, duration, and intensity with walking.
False labor contractions are felt in the abdomen and groin and the contractions are
inconsistent in frequency, duration, and intensity.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: PhysiologNicUIR
ntS
egI
ritN
y GTB.COM
3. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the
four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
a. Powers
b. Passage
c. Position
d. Passenger
e. Psyche
ANS: A, B, D, E
•
Powers: The two powers of labor are uterine contractions and pushing efforts.
During the first stage of labor, through full cervical dilation, uterine contractions are the
primary force moving the fetus through the maternal pelvis. At some point after full dilation,
the woman adds her voluntary pushing efforts to propel the fetus through the pelvis.
•
Passage: The passage for birth of the fetus consists of the maternal pelvis and its
soft tissues. The bony pelvis is more important to the successful outcome of labor because
bones and joints do not yield as readily to the forces of labor.
•
Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude,
presentation, and position are all factors that affect the fetus as passenger.
•
Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or
fatigue decreases the woman’s ability to cope.
Position is not one of the four Ps.
NURSINGTB.COM
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. The nurse is planning care for a patient during the fourth stage of labor. Which interventions
should the nurse plan to implement? (Select all that apply.)
a. Offer the patient a warm blanket.
b. Place an ice pack on the perineum.
c. Massage the uterus if it is boggy.
d. Delay breastfeeding until the patient is rested.
e. Explain to the patient that the lochia will be light pink in color.
ANS: A, B, C
The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after
birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help
relieve the chill and make the woman more comfortable. Localized discomfort from birth
trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local
and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma
formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum
hemorrhage because large blood vessels at the placenta site are not compressed. The uterus
should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding
if maternal and infant problems are absent. The vaginal drainage after childbirth is called
lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra,
consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will
be bright red not pink.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
5. Which clinical finding should the nurse expect to assess in the third stage of labor that
indicates the placenta has separated from the uterine wall? (Select all that apply.)
a. A gush of blood appears.
b. The uterus rises upward in the abdomen.
c. The fundus descends below the umbilicus.
d. The cord descends further from the vagina.
e. The uterus becomes boggy and soft, with an elongated shape.
ANS: A, B, D
Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises
upward in the abdomen as the placenta descends into the vagina and pushes the fundus
upward. The cord descends further from the vagina. A gush of blood appears as blood trapped
behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus
with an elongated shape would not be expected.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. The clinical nurse educator is providing instruction to a group of new nurses during labor
orientation. Which information regarding the factors that have a role in the initiation of labor
should the educator include in this teaching session? (Select all that apply.)
a. Progesterone levels become higher than estrogen levels.
b. Natural oxytocin in conjunction with other substances plays a role.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Stretching, pressure, and irritation of the uterus and cervix increase.
d. The secretion of prostaglandins from the fetal membranes decreases.
ANS: B, C
Factors that appear to have a role in starting labor include the following: (1) natural oxytocin
plays a part in labor’s initiation in conjunction with other substances; and (2) stretching,
pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The
progesterone levels drop and estrogen levels increase. There is an increase in the secretion of
prostaglandins from the fetal membranes.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 13: Pain Management During Childbirth
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Childbirth preparation can be considered successful if which of the following outcomes is
achieved?
a. Labor was pain-free.
b. The birth experiences of friends and families were ignored.
c. Only nonpharmacologic methods for pain control were used.
d. The patient rehearsed labor and practiced skills to master pain.
ANS: D
Preparation allows the woman to rehearse for labor and to learn new skills to cope with the
pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a
pain-free labor. A woman should be prepared for pain and anesthesia–analgesia realistically.
Friends and families can be an important source of support if they convey realistic
information about labor pain. Women will not always achieve their desired level of pain
control by using nonpharmacologic methods alone.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Psychosocial Integrity
2. A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated
with opiate-dependent patients?
a. Nalbuphine (Nubain)
b. Hydroxyzine (Vistaril) NURSINGTB.COM
c. Promethazine (Phenergan)
d. Diphenhydramine (Benadryl)
ANS: A
Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine
is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and
vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
3. A patient is admitted to the labor and birth room in active labor; contractions are 4 to 5
minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment.
When is the best time to ask questions or perform procedures?
a. After the contraction is over
b. When it is all right with the coach
c. During the increment of the next contraction
d. After administration of analgesic-anesthetic
ANS: A
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Reduce intrusions as much as possible. Longer assessments may span several contractions.
The coach is the support person. The woman needs to feel confident in her ability to go
through labor and birth, and she should be encouraged to express her own needs and concerns.
The increment is the beginning of the next contraction. It is best to stop with questions and
procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in
the woman, preventing her from answering questions correctly.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
4. Childbirth pain is different from other types of pain in that it is
a. less intense.
b. associated with a physiologic process.
c. more responsive to pharmacologic management.
d. designed to make one withdraw from the stimulus.
ANS: B
Childbirth pain is part of a normal process, whereas other types of pain usually signify an
injury or illness. Childbirth pain is not less intense than other types of pain. Pain management
during labor may affect the course and length of labor. The pain with childbirth is a normal
process; however, it is not caused by the type of injury as when withdrawal from the stimulus
occurs.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
5. Excessive anxiety during labor heightens the patient’s sensitivity to pain by increasing
NURSINGTB.COM
a. muscle tension.
b. the pain threshold.
c. blood flow to the uterus.
d. rest time between contractions.
ANS: A
Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman’s brain
and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception,
and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can
decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets
between contractions.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
6. Which fetal position may cause the laboring patient increased back discomfort?
a. Left occiput anterior
b. Left occiput posterior
c. Right occiput anterior
d. Right occiput transverse
ANS: B
In the left occiput posterior position, each contraction pushes the fetal head against the
mother’s sacrum, which results in intense back discomfort. Back labor is seen mostly when
the fetus is in the posterior position.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. A major advantage of nonpharmacologic pain management is
a. a more rapid labor is likely.
b. more complete pain relief is possible.
c. the woman remains fully alert at all times.
d. there are no side effects or risks to the fetus.
ANS: D
Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or
anesthesia, it is harmless to the mother and the fetus. There is less pain relief with
nonpharmacologic pain management during childbirth. Pain management may or may not
alter the length of labor. At times, when pain is decreased, the mother relaxes and labor
progresses at a quicker pace. The woman’s alertness is not altered by medication, but the
increase in pain will decrease alertness.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. The best time to teach nonpharmacologic pain control methods to an unprepared laboring
patient is during which stage?
a. Latent phase
b. Active phase
c. Second stage
d. Transition phase
ANS: A
NURSINGTB.COM
The latent phase of labor is the best time for intrapartum teaching because the woman is
usually anxious enough to be attentive yet comfortable enough to understand the teaching.
During the active phase, the woman is focused internally and unable to concentrate on
teaching. During the second stage, the woman is focused on pushing. She normally handles
the pain better at this point because she is active in doing something to hasten the birth.
During transition, the woman is focused on keeping control; she is unable to focus on anyone
else or learn at this time.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
9. The primary side effect of maternal narcotic analgesia in the newborn is
a. tachypnea.
b. bradycardia.
c. acrocyanosis.
d. respiratory depression.
ANS: D
An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for
respiratory depression from the sedative effects of the narcotic. The infant who is having a
side effect to maternal analgesics normally would have a decrease in respirations, not an
increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is
an expected finding in a newborn and is not related to maternal analgesics.
NURSINGTB.COM
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. The nerve block used in labor that provides anesthesia to the lower vagina and perineum is
referred to as a(n)
a. local.
b. epidural.
c. pudendal.
d. spinal block.
ANS: C
A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an
episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at
the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs.
A spinal block provides anesthesia for the uterus, perineum, and down the legs.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
11. The nurse is teaching a childbirth education class. Which information regarding excessive
pain in labor should the nurse include in the session?
a. It usually results in a more rapid labor.
b. It has no effect on the outcome of labor.
c. It is considered to be a normal occurrence.
d. It may result in decreased placental perfusion.
ANS: D
NURSINGTB.COM
When experiencing excessive pain, the woman may react with a stress response that diverts
blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of
increased anxiety in the woman. It may affect the outcome of the labor, depending on the
cause and the effect on the woman. Pain is considered normal for labor. However, excessive
pain may be an indication of other problems and must be assessed.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. Which patient will most likely have increased anxiety and tension during labor?
a. Gravida 2 who refused any medication
b. Gravida 2 who delivered a stillborn baby last year
c. Gravida 1 who did not attend prepared childbirth classes
d. Gravida 3 who has two children younger than 3 years
ANS: B
If a previous pregnancy had a poor outcome, the patient will probably be more anxious during
labor and birth. The patient without childbirth education classes is not prepared for labor and
will have increased anxiety during labor; however, the patient with a poor previous outcome is
more likely to experience a greater degree of anxiety. A gravida 2 has previous experience and
can anticipate what to expect. By refusing any medication, she is taking control over her
situation and will have less anxiety. This gravida 3 has previous experience and is aware of
what to expect.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
13. Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm
cervical dilation?
a. Narcotics
b. Spinal block
c. Epidural anesthesia
d. Breathing and relaxation techniques
ANS: D
Nonpharmacologic methods of pain management may be the best option for a woman in
advanced labor. At 8 cm cervical dilation there is probably not enough time remaining to
administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its
peak at about the time of birth and result in respiratory depression in the newborn.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
14. A laboring patient who imagines her body opening to let the baby out is using a mental
technique called
a. imagery.
b. effleurage.
c. distraction.
d. dissociation.
ANS: A
Imagery is a technique of visN
ualiR
zing imG
ageB
s thaCt wM
ill assist the woman in coping with labor.
U SINcan
Tbe.used
O in the early latent phase by having the
Effleurage is self-massage. Distraction
woman involved in another activity. Dissociation helps the woman learn to relax all muscles
except those that are working.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
15. When administering a narcotic to a laboring patient, which statement explains why the nurse
should inject the medication at the beginning of a contraction?
a. The medication will be rapidly circulated.
b. Less medication will be transferred to the fetus.
c. The maternal vital signs will not be adversely affected.
d. Full benefit of the medication is received during that contraction.
ANS: B
Injecting the medication at the beginning of a contraction, when blood flow to the placenta is
normally reduced, limits transfer to the fetus. It will not increase the circulation of the
medication. It will not alter the vital signs any more than giving it at another time. The full
benefit of the medication will be received by the patient.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
16. The method of anesthesia in labor that is considered the safest for the fetus is
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
epidural block.
pudendal block.
local infiltration.
spinal (subarachnoid) block.
ANS: C
Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus.
With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects
and maternal hypotension.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
17. To improve placental blood flow immediately after the injection of an epidural anesthetic, the
nurse should
a. give the woman oxygen.
b. turn the woman to the right side.
c. decrease the intravenous infusion rate.
d. place a wedge under the woman’s right hip.
ANS: D
Tilting the woman’s pelvis to the left side relieves compression of the vena cava and
compensates for a lower blood pressure without interfering with dispersal of the epidural
medication. Oxygen administration will not improve placental blood flow. The woman needs
to maintain the supine position for proper dispersal of the medication. Placing a wedge under
the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be
increased to prevent hypotension.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
18. Which physiologic effect may occur in the presence of increased maternal pain perception
during labor?
a. Increase in uterine contractions in response to catecholamine secretion
b. Decrease in blood pressure in response to alpha receptors
c. Decreased perfusion to the placenta in response to catecholamine secretion
d. Increased uterine blood flow, causing increase in maternal blood pressure
ANS: C
Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A
decrease in uterine contractions is seen in response to catecholamine secretion. Maternal
blood pressure is increased in response to alpha receptors. Decreased uterine blood flow
causes an increase in maternal blood pressure.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
19. Which of the following factors would affect pain perception or tolerance for the laboring
patient?
a. Right occiput posterior fetal position during labor
b. Bishop score of 10 prior to the induction of labor
c. Gynecoid pelvis
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Absence of Ferguson’s reflex
ANS: A
A fetus in the posterior position during labor can cause increased back pain to the mother
because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable
for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is
engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal
birth. Ferguson’s reflex occurs when a contraction is stimulated as a result of vaginal
stimulation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
20. A patient in labor is approaching the transition stage and already has an epidural in place. An
additional dose of medication has been prescribed and administered to the patient. Which
priority intervention should be performed in order to evaluate the clinical response to
treatment?
a. Obtain a pain scale response from the patient based on a 0 to 10 scale.
b. Document maternal blood pressure and fetal heart rates following medication
administration and observe for any variations.
c. Document intake and output on the electronic health record (EHR).
d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.
ANS: B
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based
practice guidelines note that maternal blood pressure and fetal heart tones should be assessed
following any bolus of additional medication via the epidural route. Obtaining a pain scale
response is not typically usedNfU
orRthe
atien
SIlaNbGorTinBg.pC
OMt but used for postoperative and/or
chronic pain patients. Intake and output should be documented as part of the clinical record
but is not the priority intervention based on this patient’s situation. Increasing the flow rate of
parenteral fluids requires a physician’s order, and there is no clinical evidence that this is
needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
21. The process of labor places significant metabolic demands on the obstetric patient. Which
physiologic findings would be expected?
a. Decreased maternal blood pressure as a result of stimulation of alpha receptors
b. Uterine vasoconstriction as a result of stimulation of beta receptors
c. Increased maternal demand for oxygen
d. Increased blood flow to placenta because of catecholamine release
ANS: C
With regard to labor, one would expect to see an increase in maternal blood pressure because
of stimulation of alpha receptors. Uterine vasoconstriction would occur in response to
stimulation of alpha receptors. One would expect to see a decrease in blood flow to the
placenta. The maternal metabolic rate is increased during labor, along with an increase in
maternal demand for oxygen.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
22. A labor patient, gravida 2, para 1, at term has received meperidine (Demerol) for pain control
during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal
vital signs have been stable and the EFM tracing has not shown any baseline changes. Which
medication does the nurse anticipate would be required in the birth room for administration?
a. Oxytocin (Pitocin)
b. Naloxone (Narcan)
c. Bromocriptine (Parlodel)
d. Oxygen
ANS: B
Because birth is imminent, and considering that the patient has had a recent dose of narcotics,
the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat
the effects of the opioid. Although Pitocin will be given following birth of the placenta, the
newborn will be delivered prior to that and will receive priority intervention. Parlodel is not
typically given in the labor and birth area any more. It was previously used to suppress
lactation. At present, there is no need for the administration of oxygen because there is no
evidence that the mother is showing any signs of respiratory depression.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
23. Which statement is true with regard to the type of pain associated with childbirth experience?
a. Pain is constant throughout the labor experience.
b. Labor pain during childbirth is considered to be an abnormal response.
c. Pain associated with childbirth is self-limiting.
NbUirR
d. Pain associated with child
thSdI
oeN
sG
noTt B
al.
loC
wOfM
or adequate preparation.
ANS: C
The pain associated with childbirth is self-limiting in that it typically stops once the child is
delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a
normal response during childbirth. Pregnant woman can prepare for the expected pain of
childbirth by taking prepared childbirth classes and using relaxation techniques during the
course of labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
24. A patient in labor reports a feeling of burning pain during the second stage of labor. This type
of pain is associated with
a. visceral pain.
b. tissue ischemia.
c. somatic pain.
d. cervical dilation.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
This is an example of somatic pain experienced as a result of distention of the vagina and
perineum during the second stage of labor. Visceral pain occurs in response to pressure on
pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the
uterus. The pain of cervical dilation is a major pain source during labor but, during the second
stage of labor, the patient is already fully dilated so this would not be a factor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
25. A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the
patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely
apprehensive because this is her first childbirth experience and asks for an epidural to be
administered now. What is the priority nursing response based on this patient assessment?
a. Use contact anesthesia for an epidural and prepare the patient per protocol.
b. Tell the patient that she will not need any pain medication because the birth will be
over in a matter of minutes and the pain will stop.
c. Assist the patient with nonpharmacologic methods of pain distraction during this
time as you prepare for vaginal birth.
d. Call the physician for admitting orders.
ANS: C
By assisting the patient with nonpharmacologic methods of pain distraction, the nurse is
focusing on the patient’s needs while still preparing for vaginal birth. The patient presents in
an emergent situation with birth being imminent. Thus there is not enough time to administer
an epidural. Telling the patient that she will not need any pain medication because the birth
will be over soon does not address the patient’s concerns of apprehension and therefore is not
therapeutic. Because this is an emergency birth situation, the nurse should be attending to the
N e RanSd/o
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B.Cr can
M contact the physician.
patient. If needed, another nursU
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pervisoO
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
26. A labor patient has brought in a photograph of her two children and asks the nurse to place it
on the wall so that she can look at it during labor contractions. This is an example of
a. focal point.
b. distraction.
c. effleurage.
d. relaxation.
ANS: A
The use of a focal point (image and/or point reference in the labor room) is an example of
nonpharmacologic pain control during labor. The image of the patient’s children is not serving
as a method of distraction. Effleurage is the use of massage techniques to minimize pain
perception. The image of the patient’s children is not serving as a method of relaxation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
27. A pregnant woman in labor is quite anxious and has been breathing rapidly during
contractions. She now complains of a tingling sensation in her fingers. What is the priority
nursing intervention at this time?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
Perform a vaginal exam to denote progress.
Reposition the patient to a side lying position.
Instruct the patient to breathe into her cupped hands.
Notify the physician about current findings.
ANS: C
This patient is exhibiting signs of hyperventilation associated with a rapid breathing pattern,
which can occur during the labor process. The nurse should instruct the patient to breathe into
her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process.
A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in
labor progress. Repositioning the patient may be an option but is not the priority intervention
at this time. Notifying the physician is not appropriate at this time because the RN should
attend to actions that are readily available to her based on her scope of practice and standard
of care. The physician may have to be notified once the intervention has been performed.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
28. A laboring patient has asked the nurse to assist her in utilizing a cutaneous stimulation
strategy for pain management. The nurse would
a. assist her into the shower.
b. apply a heat pack to lower back.
c. help her to create a relaxing mental scene.
d. encourage cleansing breaths and slow-paced breathing.
ANS: B
Cutaneous stimulation includes self-massage, massage by others, counterpressure, touch,
thermal stimulation, and acupNrU
esR
suS
reI
.A
w.
erC
, tO
ubM, and whirlpool are forms of
NGshToB
hydrotherapy; creating a relaxed mental scene is mental stimulation. The use of cleansing
breaths and patterned breathing is part of breathing techniques for labor.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
29. To relieve a mild postdural puncture headache, the nurse should encourage the intake of
a. milk.
b. orange juice.
c. tea or coffee.
d. beef or chicken bouillon.
ANS: C
Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk,
juices, and bouillon will add oral hydration but lack the added benefit of the caffeine. Some
patients prefer a cold caffeinated soft drink over coffee or tea.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
30. Which patient will be most receptive to teaching about nonpharmacologic pain control
methods?
a. Gravida 1, para 0, in transition
b. Gravida 2, para 1, admitted at 8 cm
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Gravida 1, para 0, dilated 2 cm, 80% effaced
d. Gravida 3, para 2, complaining of intense perineal pressure
ANS: C
The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is
the first centimeter of cervical dilation. Patients in the transition phase (8 to 10 cm) are
experiencing intense pain and are not receptive to teaching. A multigravida complaining of
intense perineal pressure indicates a patient whose birth is imminent.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
31. The nurse is providing care to a patient in the active phase of the first stage of labor. The
patient is crying out loudly with each contraction. What is the nurse’s most respectful
approach for this patient?
a. Ask the patient’s labor coach if this is a usual expression of pain for her.
b. Refer to the patient’s chart to determine any orders for pain medication.
c. Tell the patient that she is disturbing the other laboring patients on the unit.
d. Encourage the patient to try to suppress her noisiness during contractions.
ANS: A
Women should be encouraged to express themselves in any way they find comforting, and the
diversity of their expressions must be respected. Loud and vigorous expression may be a
woman’s personal pain coping mechanism, whereas a quiet woman may need medication
relief but feels the need to remain stoic. Accepting a woman’s individual response to labor
and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are
challenging to work with and may disturb others.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
32. A multipara’s labor plan includes the use of jet hydrotherapy during the active phase of labor.
What is the priority patient assessment prior to assisting the patient with this request?
a. Maternal pulse
b. Maternal temperature
c. Maternal blood pressure
d. Maternal blood glucose level
ANS: B
A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several
studies have shown benefits of water therapy during labor, including immersion in a tub or
whirlpool (jet hydrotherapy, or Jacuzzi). The major concern regarding immersion therapy has
been newborn and postpartum maternal infections caused by microorganisms in the water.
Infections can be caused by the woman’s own ascending vaginal bacteria or by preexisting
organisms in an improperly cleaned tub. Several studies have not found a significant
association between newborn or postpartum maternal infections and the use of immersion
hydrotherapy with proper cleaning.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
33. A patient in active labor requests an epidural for pain management. What is the nurse’s most
appropriate intervention at this juncture?
a. Assess the fetal heart rate pattern over the next 30 minutes.
b. Take the patient’s blood pressure every 5 minutes for 15 minutes.
c. Determine the patient’s contraction pattern for the next 30 minutes.
d. Initiate an IV infusion of lactated Ringer’s solution at 2000 mL/hour over 30
minutes.
ANS: D
Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringer’s or
normal saline, before initiation of the block fills the vascular system to offset vasodilation.
Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with
corresponding hypotension can reduce placental perfusion and is most likely to occur within
the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every
30 minutes is the standard of care. The patient is in active labor, which indicates a contraction
pattern resulting in cervical dilation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. You are preparing a patient for epidural placement by a nurse anesthetist in the LDR. Which
interventions should be included in the plan of care? (Select all that apply.)
a. Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter
placement.
b. Have ephedrine availableNat bRedsI
in.
gC
caO
thM
eter placement.
U S idNeGduTrB
c. Monitor blood pressure of patient frequently during catheter insertion and for the
first 15 minutes of epidural administration.
d. Insert a Foley catheter prior to epidural catheter placement.
e. Monitor the patient for hypertension in response to epidural insertion.
ANS: B, C
A bolus of nondextrose fluid is recommended prior to epidural administration to prevent
maternal hypotension. Ephedrine should be available at the bedside in case maternal
hypotension is exhibited. Blood pressure should be monitored frequently during insertion and
for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to
epidural catheter placement. Hypertension is not a common clinical response to this treatment
but hypotension is.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
2. While developing an intrapartum care plan for the patient in early labor, it is important that
the nurse recognize that psychosocial factors may influence a woman’s experience of pain.
These include which of the following? (Select all that apply.)
a. Culture
b. Anxiety and fear
c. Support systems
d. Preparation for childbirth
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
e. Previous experiences with pain
ANS: A, B, C, D, E
•
Culture: A woman’s sociocultural roots influence how she perceives, interprets, and
responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of
pain, whereas others value self-control. The nurse should avoid praising some behaviors
(stoicism) while belittling others (noisy expression).
•
Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a
woman’s ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area,
which counters the expulsive forces of uterine contractions and pushing efforts.
•
Support systems: An anxious partner is less able to provide help and support to a
woman during labor. A woman’s family and friends can be an important source of support if
they convey realistic and positive information about labor and birth.
•
Preparation for childbirth: This does not ensure a pain-free labor. Preparation does
reduce anxiety and fear. It also allows a woman to rehearse for labor.
•
Previous experiences with pain: Fear and withdrawal are natural responses to pain
during labor.
Learning about these normal sensations ahead of time helps a woman suppress her natural
reactions of fear regarding the impending birth. If a woman previously had a long and difficult
labor, she is likely to be anxious. She may also have learned ways to cope and may use these
skills to adapt to the present labor experience.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
3. The nurse detects hypotension in a laboring patient after an epidural. Which actions should the
nurse plan to implement? (SeN
lectRall I
thatGapB
y.)C M
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a. Encourage the patient to drink
b. Place the patient in a Trendelenburg position.
c. Administer a normal saline bolus as prescribed.
d. Administer oxygen at 8 to 10 L/minute per face mask.
e. Administer IV ephedrine in 5- to 10-mg increments as prescribed.
ANS: C, D, E
If hypotension occurs after an epidural has been placed, techniques such as a rapid
nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are
implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments
can be prescribed to promote vasoconstriction to raise the blood pressure. The patient in active
labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat,
with the feet elevated. This would not be a position to use for a pregnant patient.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
4. The nurse is preparing a patient for a cesarean birth scheduled to be performed under general
anesthesia. Which should the nurse plan to administer, if ordered by the health care provider,
to prevent aspiration of gastric contents? (Select all that apply.)
a. Citric acid (Bicitra)
b. Ranitidine (Zantac)
c. Hydroxyzine (Vistaril)
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Glycopyrrolate (Robinul)
e. Promethazine (Phenergan)
ANS: A, B, D
To prevent aspiration of gastric contents during general anesthesia administration of
medications to raise the gastric pH and make secretions less acidic, such as citric acid (Bicitra)
and ranitidine (Zantac) may be prescribed. In addition, medications to reduce secretions, such
as glycopyrrolate (Robinul) may be prescribed. Hydroxyzine (Vistaril) and promethazine
(Phenergan) are used to prevent and relieve nausea often associated with opioids.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
COMPLETION
1. The health care provider’s prescription reads diphenhydramine (Benadryl), 25 mg IV stat. The
medication vial reads diphenhydramine (Benadryl), 50 mg/mL. The nurse should prepare how
many milliliters to administer the correct dose? Record your answer to one decimal point.
mL
ANS:
0.5
Desired/available  volume = milliliters per dose
25 mg/50 mg  1 mL = 0.5 mL/dose
DIF: Cognitive Level: ApplicN
ationR I GOBB
J:.C
NursM
ing Process Step: Implementation
U S Care
N TEnvironment
O
MSC: Patient Needs: Safe and Effective
2. The nurse is administering fentanyl (Sublimaze) to a patient in labor. The health care
provider’s prescription reads fentanyl (Sublimaze), 100 mcg IV stat. The medication vial
reads fentanyl (Sublimaze), 50 mcg/mL. The nurse should prepare how many milliliters to
administer the correct dose? Record your answer as a whole number.
_ mL
ANS:
2
Desired/available  volume = milliliters per dose
100 mcg/50 mcg  1 mL = 2 mL/dose
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 14: Intrapartum Fetal Surveillance
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations.
The deceleration begins near the acme of the contraction and continues well beyond the end of
the contraction. Which nursing action indicates the proper evaluation of this situation?
a. This pattern reflects variable decelerations. No interventions are necessary at this
time.
b. Document this Category I fetal heart rate pattern and decrease the rate of the
intravenous (IV) fluid.
c. Continue to monitor these early decelerations, which occur as the fetal head is
compressed during a contraction.
d. This deceleration pattern is associated with uteroplacental insufficiency. The nurse
must act quickly to improve placental blood flow and fetal oxygen supply.
ANS: D
A pattern similar to early decelerations, but the deceleration begins near the acme of the
contraction and continues well beyond the end of the contraction, describes a late
deceleration. Oxygen should be given via a snug face mask. Position the patient on her left
side to increase placental blood flow. Variable decelerations are caused by cord compression.
A vaginal examination should be performed to identify this potential emergency. This is not a
normal pattern, rather it is a Category III tracing, predictive of abnormal fetal acid status at the
time of observation. The IV rate should be increased in order to add to the mother’s blood
volume. These are late deceleNratiR
onsI
, noG
t eaB
rly.; C
therM
efore interventions are necessary.
U S N T
O
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
2. Which maternal condition should be considered a contraindication for the application of
internal monitoring devices?
a. Unruptured membranes
b. Cervix dilated to 4 cm
c. Fetus has known heart defect
d. Maternal HIV
ANS: A
To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4
cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A
compromised fetus should be monitored with the most accurate monitoring devices. An
internal electrode should not be placed if the patient has hemophilia, maternal HIV, or genital
herpes.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
3. The nurse is instructing a nursing student on the application of fetal monitoring devices.
Which method of assessing the fetal heart rate requires the use of a gel?
a. Doppler
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b. Fetoscope
c. Scalp electrode
d. Tocodynamometer
ANS: A
Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it
requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is
not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The
tocodynamometer does not require gel. This device monitors uterine contractions.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
4. Proper placement of the tocotransducer for electronic fetal monitoring is
a. Inside the uterus.
b. On the fetal scalp.
c. Over the uterine fundus.
d. Over the mother’s lower abdomen.
ANS: C
The tocotransducer monitors uterine activity and should be placed over the fundus, where the
most intensive uterine contractions occur. The tocotransducer is for external use. The
tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at
the fundus; this is the best placement area.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
N R I G B.C M
U S N T
5. Which clinical finding can be determined
only byOelectronic fetal monitoring?
a. Variability
b. Tachycardia
c. Bradycardia
d. Fetal response to contractions
ANS: A
Beat-to-beat variability cannot be determined by auscultation because auscultation provides
only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any
of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR
monitoring techniques. The fetal response to the contractions is usually noted by an increase
or decrease in fetal heart rate. These can be determined by any of the FHR monitoring
techniques.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. Which method of intrapartum fetal monitoring is the most appropriate when a woman has a
history of hypertension during pregnancy?
a. Continuous auscultation with a fetoscope
b. Continuous electronic fetal monitoring
c. Intermittent assessment with a Doppler transducer
d. Intermittent electronic fetal monitoring for 15 minutes each hour
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: B
Maternal hypertension may reduce placental blood flow through vasospasm of the spiral
arteries. Reduced placental perfusion is best assessed with continuous electronic fetal
monitoring to identify patterns associated with this condition. It is not practical to provide
continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is
at high risk for complications.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
7. Why is continuous electronic fetal monitoring generally used when oxytocin is administered?
a. Fetal chemoreceptors are stimulated.
b. The mother may become hypotensive.
c. Maternal fluid volume deficit may occur.
d. Uteroplacental exchange may be compromised.
ANS: D
The uterus may contract more firmly and the resting tone may be increased with oxytocin use.
This response reduces the entrance of freshly oxygenated maternal blood into the intervillous
spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is
not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit;
oxytocin administration does not increase the risk.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
8. The nurse is concerned that a patient’s uterine activity is too intense and that her obesity is
preventing accurate assessmeNnU
t oRf S
thI
eN
acG
tuTalBi.
ntC
raO
utM
erine pressure. Based on this information,
which action should the nurse take?
a. Reposition the tocotransducer.
b. Reposition the Doppler transducer.
c. Obtain an order from the health care provider for a spiral electrode.
d. Obtain an order from the health care provider for an intrauterine pressure catheter.
ANS: D
An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer
measures the uterine pressure externally; this would not be accurate with an obese patient,
even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral
electrode) measures the fetal heart rate (FHR).
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
9. If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should
assess the fetal heart rate in which quadrant of the maternal abdomen?
a. Right upper
b. Left upper
c. Right lower
d. Left lower
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
If the fetus is in a right occiput anterior position, the fetal spine will be on the mother’s right
side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be
in the right lower quadrant. The right upper, left upper, and left lower areas are not the best
locations for assessing the fetal heart rate in this case.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal
finding?
a. The fetus is at 30 weeks of gestation.
b. The mother has a history of fast labors.
c. The mother has been given an epidural block.
d. The mother has mild preeclampsia but is not in labor.
ANS: A
The normal preterm fetus may have a baseline rate slightly higher than the term fetus because
of an immature parasympathetic nervous system that does not yet exert a slowing effect on the
fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR
with an epidural is not considered an expected outcome. Preeclampsia should not cause a
normal elevation of the FHR.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
11. When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which
nursing action is indicated?
a. Reposition the patient. NURSINGTB.COM
b. Apply a fetal scalp electrode.
c. Record this normal pattern.
d. Administer oxygen by nasal cannula.
ANS: C
The periodic pattern described is early deceleration that is not associated with fetal
compromise and requires no intervention. This is a Category I tracing which is a normal
pattern. Repositioning the patient, applying a fetal scalp electrode, or administering oxygen
would be interventions performed for Category II or III patterns.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. When the mother’s membranes rupture during active labor, the fetal heart rate should be
observed for the occurrence of which periodic pattern?
a. Early decelerations
b. Variable decelerations
c. Nonperiodic accelerations
d. Increase in baseline variability
ANS: B
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where
it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a
variable deceleration pattern. Early declarations are considered reassuring; they are not a
concern after rupture of membranes. Accelerations are considered reassuring; they are not a
concern after rupture of membranes. Increase in baseline variability is not an expected
occurrence after the rupture of membranes.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
13. The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best
interpretation of this is that the fetus is showing
a. a worsening hypoxia.
b. progressive acidosis.
c. an expected response.
d. parasympathetic stimulation.
ANS: C
The fetus with adequate reserve for the stress of labor will usually respond to vibroacoustic
stimulation with a temporary increase in the fetal heart rate (FHR) baseline. An increase in the
FHR with stimulation does not indicate hypoxia. An increase in the FHR after stimulation is
an anticipated response and does not indicate acidosis. An increase in the FHR after
stimulation is a normal pattern, and does not indicate problems with the parasympathetic
nervous system. A Category I pattern is normal and strongly predictive of adequate fetal
acid-base status.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health PrN
om
onIaN
ndGM
UoRtiS
TaBin.teCnaOncMe
14. When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left
side, which nursing action is indicated?
a. Lower the head of the bed.
b. Place a wedge under the left hip.
c. Change her position to the right side.
d. Place the mother in Trendelenburg position.
ANS: C
A Category II pattern indicates an indeterminate fetal heart rate. Repositioning on the opposite
side may relieve compression on the umbilical cord and improve blood flow to the placenta.
Lowering the head of the bed would not be the first position change choice. The woman is
already on her left side, so a wedge on that side would not be an appropriate choice.
Repositioning to the opposite side is the first intervention. If unsuccessful with improving the
FHR pattern, further changes in position can be attempted; the Trendelenburg position might
be the choice.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
15. Which nursing action is correct when initiating electronic fetal monitoring?
a. Lubricate the tocotransducer with an ultrasound gel.
b. Securely apply the tocotransducer with a strap or belt.
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Inform the patient that she should remain in the semi-Fowler position.
d. Determine the position of the fetus before attaching the electrode to the maternal
abdomen.
ANS: B
The tocotransducer should fit snugly on the abdomen to monitor uterine activity accurately.
The tocotransducer does not need gel to operate appropriately. The patient should be
encouraged to move around during labor. The tocotransducer should be placed at the fundal
area of the uterus.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
16. Which statement correctly describes the nurse’s responsibility related to electronic
monitoring?
a. Report abnormal findings to the physician before initiating corrective actions.
b. Teach the woman and her support person about the monitoring equipment and
discuss any of their questions.
c. Document the frequency, duration, and intensity of contractions measured by the
external device.
d. Inform the support person that the nurse will be responsible for all comfort
measures when the electronic equipment is in place.
ANS: B
Teaching is an essential part of the nurse’s role. Corrective actions should be initiated first to
correct abnormal findings as quickly as possible. Electronic monitoring will record the
contractions and FHR response. The support person should still be encouraged to assist with
NURSINGTB.COM
the comfort measures.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
17. Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior
baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation?
a. Inhibition of epinephrine
b. Inhibition of norepinephrine
c. Stimulation of the vagus nerve
d. Sympathetic stimulation
ANS: D
Sympathetic nerve innervation would result in an increase in fetal heart rate. The release of
epinephrine as a result of sympathetic innervation would lead to an increase in fetal heart rate.
The release of norepinephrine as a result of sympathetic innervation would lead to an increase
in fetal heart rate. Stimulation of the vagus nerve would indicate parasympathetic innervation
and result in a decreased heart rate.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
18. Which of the following therapeutic applications provides the most accurate information
related to uterine contraction strength?
a. External fetal monitoring (EFM)
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b. Internal fetal monitoring
c. Intrauterine pressure catheter (IUPC)
d. Maternal comments based on perception
ANS: C
IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength.
EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine
contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and
contraction pattern. It only estimates uterine contraction strength. Maternal comments related
to pain may not be related to uterine contraction strength and thus are influenced by the
patient’s own pain perception.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
19.
What is the most likely cause for this fetal heart rate pattern?
a. Administration of an epidural for pain relief during labor
b. Cord compression
c. Breech position of fetus
d. Administration of meperidine (Demerol) for pain relief during labor
ANS: B
Variable deceleration patterns are seen in response to head compression or cord compression.
A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly,
administration of medication and/or an epidural would not cause this fetal heart rate pattern.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: PhysiologNic IR
ntegI
rity/G
PhyB
sio.loCgicM
Adaptation
U S N T
O
20. The patient presenting at 38 weeks’ gestation, gravida 1, para 0, vaginal exam 4 cm, 100%
effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern?
a. Continue oxytocin (Pitocin) infusion.
b. Contact the anesthesia department for epidural administration.
c. Change maternal position.
d. Administer Narcan to patient and prepare for immediate vaginal delivery.
ANS: C
Late decelerations indicate fetal compromise (uteroplacental insufficiency) and are considered
to be a significant event requiring immediate assessment and intervention. Of all the options
listed, changing maternal position may increase placental perfusion. In the presence of late
decelerations, Pitocin infusion should be stopped. Contacting anesthesia for epidural
administration will not solve the existing problem of late decelerations. There are no data to
support the administration of Narcan and because patient is still in early labor, birth is not
imminent.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
21. The physician has ordered an amnioinfusion for the laboring patient. Which data supports the
use of this therapeutic procedure?
a. Presenting part not engaged
b. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM)
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Breech position of fetus
d. Twin gestation
ANS: B
Amnioinfusion is a procedure utilized during labor when cord compression or the detection of
gross meconium staining is found in the amniotic fluid. An isotonic (Lactated Ringers or
normal saline) solution is used as an irrigation method through the IUPC (intrauterine pressure
catheter).
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
22. Which of the following is the priority intervention for a supine patient whose monitor strip
shows decelerations that begin after the peak of the contraction and return to the baseline after
the contraction ends?
a. Increase IV infusion.
b. Elevate lower extremities.
c. Reposition to left side-lying position.
d. Administer oxygen per face mask at 4 to 6 L/minute.
ANS: C
Decelerations that begin at the peak of the contractions and recover after the contractions end
are caused by uteroplacental insufficiency. When the patient is in the supine position, the
weight of the uterus partially occludes the vena cava and descending aorta, resulting in
hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower
extremities, and administering O2 will not be effective as long as the patient is in a supine
position.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity
23. Decelerations that mirror the contractions are present with each contraction on the monitor
strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should
a. maintain the normal assessment routine.
b. administer O2 at 8 to 10 L/minute by face mask.
c. increase the IV flow rate from 125 to 150 mL/hour.
d. assess the maternal blood pressure for a systolic pressure below 100 mm Hg.
ANS: A
Decelerations that mirror the contraction are early decelerations caused by fetal head
compression. Early decelerations are not associated with fetal compromise and require no
intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are
not necessary within early decelerations.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
24. To clarify the fetal condition when baseline variability is absent, the nurse should first
a. monitor fetal oxygen saturation using fetal pulse oximetry.
b. notify the physician so that a fetal scalp blood sample can be obtained.
c. apply pressure to the fetal scalp with a glove finger using a circular motion.
d. increase the rate of nonadditive IV fluid to expand the mother’s blood volume.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An
acceleration in response to the massage suggests that the fetus is in normal oxygen and
acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer
available in the United States. Obtaining a fetal scalp blood sample is invasive and the results
are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the
fetal condition.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
25. Which patient is a candidate for internal monitoring with an intrauterine pressure catheter?
a. Obese patient whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds
b. Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds
c. Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds
d. Gravida 2, para 1, in latent phase whose contractions are irregular and mild
ANS: A
A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their
apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60
seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of
uterine activity. Irregular and mild contractions are common in the latent phase.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
26. Which of the following is theNpriR
oritI
y inG
tervB
en.tiC
on fM
or the patient in a left side-lying position
U S N T
O beyond the end of the contraction?
whose monitor strip shows a deceleration
that extends
a. Administer O2 at 8 to 10 L/minute.
b. Decrease the IV rate to 100 mL/hour.
c. Reposition the ultrasound transducer.
d. Perform a vaginal exam to assess for cord prolapse.
ANS: A
A deceleration that returns to baseline after the end of the contraction is a late deceleration
caused by placental perfusion problems. Administering oxygen will increase the patient’s
blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate,
repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord
prolapse are not effective interventions to improve fetal oxygenation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
27. When a pattern of variable decelerations occur, the nurse should immediately
a. administer O2 at 8 to 10 L/minute.
b. place a wedge under the right hip.
c. increase the IV fluids to 150 mL/hour.
d. position patient in a knee-chest position.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Variable decelerations are caused by conditions that reduce flow through the umbilical cord.
The patient should be repositioned when the FHR pattern is associated with cord compression.
The knee–chest position uses gravity to shift the fetus out of the pelvis to relieve cord
compression. Administering oxygen will not be effective until cord compression is relieved.
Increasing the IV fluids and placing a wedge under the right hip are not effective interventions
for cord compression.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
28. The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and
notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and
returns to the baseline well after the completion of the patient’s contractions. How will the
nurse document these findings?
a. Late decelerations
b. Early decelerations
c. Variable decelerations
d. Proximal decelerations
ANS: A
Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest
rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin
after the peak of the contraction. The FHR returns to baseline after the contraction ends. The
early decelerations mirror the contraction, beginning near its onset and returning to the
baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring
near the contraction’s peak. The rate at the lowest point of the deceleration is usually no lower
than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord
Ntion
RS
I hese
GTdecele
B.COrations
M do not have the uniform appearance
may result in variable deceleraU
s. TN
of early and late decelerations. Their shape, duration, and degree of fall below baseline rate
vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord
compression, unlike the gradual fall and rise of early and late decelerations. Proximal
deceleration is not a recognized term.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
29. A patient at 41 weeks’ gestation is undergoing an induction of labor with an IV administration
of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late
decelerations with moderate variability. What is the nurse’s priority action?
a. Stop the infusion of Pitocin.
b. Reposition the patient from her right to her left side.
c. Perform a vaginal exam to assess for a prolapsed cord.
d. Prepare the patient for an emergency cesarean birth.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
There are multiple reasons for late decelerations. Address the probable cause first, such as
uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations.
Repositioning can increase oxygenation to the fetus but does not address the cause of the
problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of
moderate variability, the fetus continues to have adequate oxygen reserves. If a Category II
(indeterminate) or III (abnormal) tracing is interpreted, a prompt approach to assessing
oxygenation should be completed.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
30. The nurse admits a laboring patient at term. On review of the prenatal record, the patient’s
pregnancy has been unremarkable and she is considered low risk. In planning the patient’s
care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the
first stage of labor?
a. Every 10 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every 60 minutes
ANS: C
Evaluate the fetal monitoring strip systematically for the elements noted. The following are
recommended assessment and documentation intervals for IA and EFM (although facility
policies may be different): low-risk women, every 30 minutes during the active phase and
every 15 minutes during the second stage.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health PrN
om
onIaN
ndGM
UoRtiS
TaBin.teCnaOncMe
31. The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the
electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action?
a.
b.
c.
d.
Administer oxygen with a face mask at 8 to 10 L/minute.
Reposition the fetal monitor ultrasound transducer.
Assist the patient to the bathroom to empty her bladder.
Continue to monitor the patient and fetal heart rate patterns.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Late decelerations are similar to early decelerations in that the FHR slows (30 to 40 bpm);
however, the decelerations are shifted to the right in relation to the contraction. They often
begin after the peak of the contraction. They reflect possible impaired placental exchange
(uteroplacental insufficiency). Administration of 100% oxygen through a snug face mask
makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10
L/minute. The pattern is abnormal, so repositioning the fetal ultrasound transducer, assisting
the patient to the bathroom, or continuing to monitor the pattern will not correct the problem.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
32. The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the
electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action at
this time?
a. Decrease the rate of the IN
V flR
uidsI. G B.C M
U
O
b. Document the fetal heart rate pS
atteN
rn. T
c. Explain to the patient that the pattern is normal.
d. Perform a vaginal exam to detect a prolapsed cord.
ANS: D
Variable decelerations do not have the uniform appearance of early and late decelerations.
Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly
(within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and
rise of early and late decelerations. A vaginal examination may identify a prolapsed cord,
which may cause variable decelerations, bradycardia, or both as it is compressed. A vaginal
examination also evaluates the woman’s labor status, which helps the birth attendant decide if
labor should continue. This is a Category III tracing (abnormal); therefore the IV rate should
be increased and an intervention needs to occur.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
33. Which clinical finding would be considered normal for a preterm fetus during the labor
period?
a. Baseline tachycardia
b. Baseline bradycardia
c. Fetal anemia
d. Acidosis
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: A
Because the nervous system is immature, it is expected that the preterm fetus will have a
baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline
bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal
compromise.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
MULTIPLE RESPONSE
1. Which medications could potentially cause hyperstimulation of the uterus during labor?
(Select all that apply.)
a. Oxytocin (Pitocin)
b. Misoprostol (Cytotec)
c. Dinoprostone (Cervidil)
d. Methylergonovine maleate (Methergine)
ANS: A, B, C, D
Oxytocin, misoprostol, and dinoprostone fall under the general category of uterine stimulants.
Cytotec and Cervidil are prostaglandins. Methergine is an ergot alkaloid.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
2. When evaluating the patient’s progress, the nurse knows that four of the five fetal factors that
interact to regulate the heart rate
N RareI(Select
G Bal.l that
C Mapply.)
a. baroreceptors.
U S N T
O
b. adrenal glands.
c. chemoreceptors.
d. uterine activity.
e. autonomic nervous system.
ANS: A, B, C, E
The sympathetic and parasympathetic branches of the autonomic nervous system are balanced
forces that regulate FHR. Sympathetic stimulation increases the heart rate, whereas
parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR, and
maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and
decrease the blood pressure. These are located in the carotid arch and major arteries. The
chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are
found in the medulla oblongata and aortic and carotid bodies. The adrenal medulla secretes
epinephrine and norepinephrine in response to stress, causing accelerations in FHR.
Hypertonic uterine activity can reduce the time available for the exchange of oxygen and
waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous
system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and
decrease when the fetus sleeps.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
3. The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of
the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp
stimulation? (Select all that apply.)
a. Post-term fetus
b. Maternal fever
c. Placenta previa
d. Induction of labor
e. Prolonged rupture of membranes
ANS: B, C, E
Fetal scalp stimulation is not done when there is maternal fever (possibility of introducing
microorganisms into the uterus), placenta previa (placenta overlies the cervix, and hemorrhage
is likely), or prolonged rupture of membranes (risk of infection). Fetal scalp stimulation may
be used to evaluate a post-term fetus’ response to stimulation. It is also used to evaluate a
fetus when labor is being induced.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
4. The nurse is preparing supplies for an amnioinfusion on a patient with intact membranes.
Which supplies should the nurse gather? (Select all that apply.)
a. Extra underpads
b. Solution of 3% normal saline
c. Amniotic hook to perform an amniotomy
d. Solid intrauterine pressure catheter with a pressure transducer on its tip
ANS: A, C
Amnioinfusion is performed N
wU
ithRlS
acItaNteGdTRB
in.
gC
erO
’sM
solution or normal saline, not 3%. Normal
saline is infused into the uterus through an intrauterine pressure catheter (IUPC). The
underpads must be changed regularly because fluid leaks out constantly. The membranes need
to be ruptured before an amnioinfusion can be initiated so an amniotic hook will be needed.
The IUPC must have a double lumen to run the infusion through.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
COMPLETION
1. A nurse documents that the fetal heart rate variability is marked. This indicates that the range
is greater than how many beats per minute? Record your answer as a whole number.
bpm
ANS:
25
There are four categories of fetal heart rate variability:
Absent: Amplitude range is visually undetectable
Minimal: Detectable to less than or equal to 5 beats/minute
Moderate (normal): 6 to 25 beats/minute
Marked: Range >25 beats/minute
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 15: Nursing Care During Labor and Birth
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. The nurse is preparing to perform Leopold’s maneuvers. Please select the rationale for the
consistent use of these maneuvers by obstetric providers?
a. To determine the status of the membranes
b. To determine cervical dilation and effacement
c. To determine the best location to assess the fetal heart rate
d. To determine whether the fetus is in the posterior position
ANS: C
Leopold’s maneuvers are often performed before assessing the fetal heart rate (FHR). These
maneuvers help identify the best location to obtain the FHR. A pH test or fern test can be
performed to determine the status of the fetal membranes. Dilation and effacement are best
determined by vaginal examination. Assessment of fetal position is more accurate with
vaginal examination.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
a. Recommend frequent position changes.
b. Palpate her filling bladder every 15 minutes.
c. Offer warm wet cloths to use on the patient’s face and neck.
NUtheRSpati
INent
GT
B.C
M can see everything.
d. Keep the room lights lit so
and
herOcoach
ANS: A
Frequent maternal position changes reduce the discomfort from constant pressure and promote
fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2
hours. Women in labor become very hot and perspire. Cool cloths will provide greater relief.
Soft indirect lighting is more soothing than irritating bright lights.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. Which assessment finding is an indication of hemorrhage in the recently delivered postpartum
patient?
a. Elevated pulse rate
b. Elevated blood pressure
c. Firm fundus at the midline
d. Saturation of two perineal pads in 4 hours
ANS: A
An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were
diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is
contracting and compressing the open blood vessels at the placental site. Saturation of one pad
within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours
is within normal limits.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which intervention is an essential part of nursing care for a laboring patient?
a. Helping the woman manage the pain
b. Eliminating the pain associated with labor
c. Feeling comfortable with the predictable nature of intrapartal care
d. Sharing personal experiences regarding labor and birth to decrease her anxiety
ANS: A
Helping a patient manage the pain is an essential part of nursing care because pain is an
expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully
relieved. The labor nurse should always be assessing for unpredictable occurrences.
Decreasing anxiety is important; however, managing pain is a top priority.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
5. A patient at 40 weeks’ gestation should be instructed to go to a hospital or birth center for
evaluation when she experiences
a. increased fetal movement.
b. irregular contractions for 1 hour.
c. a trickle of fluid from the vagina.
d. thick pink or dark red vaginal mucus.
ANS: C
A trickle of fluid from the vaN
ginaRmaIy inGdicB
ate rupt
ure of the membranes, requiring evaluation
COM
U SDecreased
N T .
for infection or cord compression.
or the
lack of fetal movement requires further
assessment. Irregular contractions are a sign of false labor and do not require further
assessment. Bloody show may occur before the onset of true labor. It does not require
professional assessment unless the bleeding is pronounced.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
6. Which patient at term should proceed to the hospital or birth center the immediately after
labor begins?
a. Gravida 2, para 1, who lives 10 minutes away
b. Gravida 1, para 0, who lives 40 minutes away
c. Gravida 2, para 1, whose first labor lasted 16 hours
d. Gravida 3, para 2, whose longest previous labor was 4 hours
ANS: D
Multiparous women usually have shorter labors than do nulliparous women. The woman
described in option D is multiparous with a history of rapid labors, increasing the likelihood
that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to
have a longer labor than the gravida in option C. The fact that she lives close to the hospital
allows her to stay home for a longer period of time. A gravida 1 will be expected to have the
longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3,
especially because her first labor was 16 hours.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
7. A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing
assessments include
a. contraction pattern, amount of discomfort, and pregnancy history.
b. fetal heart rate, maternal vital signs, and the woman’s nearness to birth.
c. last food intake, when labor began, and cultural practices the couple desires.
d. identification of ruptured membranes, the woman’s gravida and para, and access to
a support person.
ANS: B
All options describe relevant intrapartum nursing assessments, but the focus assessment has
priority. If the maternal and fetal conditions are normal and birth is not imminent, other
assessments can be performed in an unhurried manner. Contraction pattern, amount of
discomfort, and pregnancy history are important nursing assessments but do not take priority
if the birth is imminent. Last food intake, when labor began, and cultural practices the couple
desires is an assessment that can occur later in the admission process, if time permits.
Identification of ruptured membranes, the woman’s gravida and para, and her support person
are assessments that can occur later in the admission process if time permits.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The
fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in
duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from
admission). Membranes are iN
ntU
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heNnGuT
rsB
e.
shC
ouOldMexpect the patient to be
a. discharged home with a sedative.
b. admitted for extended observation.
c. admitted and prepared for a cesarean birth.
d. discharged home to await the onset of true labor.
ANS: D
The situation describes a patient with normal assessments who is probably in false labor and
will probably not deliver rapidly once true labor begins. The patient will probably be
discharged, and there is no indication that a sedative is needed. These are all indications of
false labor; there is no indication that further assessment or observations are indicated. These
are all indications of false labor without fetal distress. There is no indication that a cesarean
birth is indicated.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing
intervention is most appropriate at this time?
a. Inform the mother that the fetal heart rate is normal.
b. Reassess the fetal heart rate in 5 minutes because the rate is too high.
c. Report the fetal heart rate to the physician or nurse-midwife immediately.
d. Suggest to the mother that she is going to have a boy because the heart rate is fast.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: A
The FHR is within the normal range, so no other action is indicated at this time. The FHR is
within the expected range; reassessment should occur, but not in 5 minutes. The FHR is
within the expected range; no further action is necessary at this point. The gender of the baby
cannot be determined by the FHR.
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
10. Which clinical finding would be an indication to the nurse that the fetus may be
compromised?
a. Active fetal movements
b. Fetal heart rate in the 140s
c. Contractions lasting 90 seconds
d. Meconium-stained amniotic fluid
ANS: D
When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of
meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The
expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions
lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood
flow.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
11. The nurse is caring for a low-risk patient in the active phase of labor. At which interval should
the nurse assess the fetal heaN
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a. Every 15 minutes
b. Every 30 minutes
c. Every 45 minutes
d. Every 1 hour
ANS: B
For the fetus at low risk for complications, guidelines for frequency of assessments are at least
every 30 minutes during the active phase of labor. 15-minute assessments would be
appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are
not frequent enough to monitor for complications. 1-hour assessments during the active phase
of labor are not frequent enough to monitor for complications.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. Which nursing assessment indicates that a patient who is in the second stage of labor is almost
ready to give birth?
a. Bloody mucous discharge increases.
b. The vulva bulges and encircles the fetal head.
c. The membranes rupture during a contraction.
d. The fetal head is felt at 0 station during the vaginal examination.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before
birth. Bloody show occurs throughout the labor process and is not an indication of an
imminent birth. Rupture of membranes can occur at any time during the labor process and
does not indicate an imminent birth. Birth of the head occurs when the station is +4. A zero
station indicates engagement.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
13. During labor a vaginal examination should be performed only when necessary because of the
risk of
a. infection.
b. fetal injury.
c. discomfort.
d. perineal trauma.
ANS: A
Vaginal examinations increase the risk of infection by carrying vaginal microorganisms
upward toward the uterus. Properly performed vaginal examinations should not cause fetal
injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not
the main reason for limiting them. A properly performed vaginal examination should not
cause perineal trauma.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
14. A 25-year-old primigravida patient is in the first stage of labor. She and her husband have
been holding hands and breatN
hU
inR
gS
toI
geN
thG
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hr.
ouCgO
hM
each contraction. Suddenly, the patient
pushes her husband’s hand away and shouts, “Don’t touch me!” This behavior is most likely
a. a sign of abnormal labor progress.
b. an indication that she needs analgesia.
c. normal and related to hyperventilation.
d. common during the transition phase of labor.
ANS: D
The transition phase of labor is often associated with an abrupt change in behavior, including
increased anxiety and irritability. This change of behavior is an expected occurrence during
the transition phase. If she is in the transitional phase of labor, analgesia may not be
appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
15. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical
heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant’s
trunk is pink and the hands and feet are blue. The Apgar score for this infant is
a. 7.
b. 8.
c. 9.
d. 10.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant’s
blue hands and feet. The baby received 2 points for each of the categories except color.
Because the infant’s hands and feet were blue, this category is given a grade of 1. The baby
received 2 points for each of the categories except color. Because the infant’s hands and feet
were blue, this category is given a grade of 1. The infant had 1 point deducted because of the
blue color of the hands and feet.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
16. If a woman’s fundus is soft 30 minutes after birth, the nurse’s first action should be to
a. massage the fundus.
b. take the blood pressure.
c. notify the physician or nurse-midwife.
d. place the woman in Trendelenburg position.
ANS: A
The nurse’s first response should be to massage the fundus to stimulate contraction of the
uterus to compress open blood vessels at the placental site, limiting blood loss. The blood
pressure is an important assessment to determine the extent of blood loss but is not the top
priority. Notification should occur after all nursing measures have been attempted with no
favorable results. The Trendelenburg position is contraindicated for this woman at this point.
This position would not allow for appropriate vaginal drainage of lochia. The lochia
remaining in the uterus would clot and produce further bleeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
17. The nurse thoroughly dries the infant immediately after birth primarily to
a. reduce heat loss from evaporation.
b. stimulate crying and lung expansion.
c. increase blood supply to the hands and feet.
d. remove maternal blood from the skin surface.
ANS: A
Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss.
Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The
main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not
remove all of the maternal blood.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
18. The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her
fingertips and talking to him softly in high-pitched tones. Based on this observation, which
action should the nurse take?
a. Request a social service consult for psychosocial support.
b. Observe for other signs that the mother may not be accepting of the infant.
c. Document this evidence of normal early maternal-infant attachment behavior.
d. Determine whether the mother is too fatigued to interact normally with her infant.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact,
and using a high-pitched voice when talking to the infant. There is no indication at this point
that a social service consult is necessary. The signs are of normal attachment behavior. These
are signs of normal attachment behavior; no other assessment is necessary at this point. The
mother may be fatigued but is interacting with the infant in an expected manner.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Psychosocial Integrity
19. Which nursing diagnosis would take priority in the care of a primipara patient with no visible
support person in attendance? The patient has entered the second stage of labor after a first
stage of labor lasting 4 hours.
a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process
b. Fatigue related to length of labor requiring increased energy expenditure
c. Acute pain related to increased intensity of contractions
d. Anxiety related to imminent birth process
ANS: D
A primipara is experiencing the birthing event for the first time and may experience anxiety
due to fear of the unknown. It would be important to recognize this because the patient is
alone in the labor-birth room and will need additional support and reassurance. Although FVD
may occur as a result of fluid loss, prospective management of labor patients includes the use
of parenteral fluid therapy; the patient should be monitored for FVD and, if symptoms
warrant, receive intervention. Because the patient has been in labor for 4 hours, this is not
considered to be a prolonged labor pattern for a primipara patient. Although the patient may
be tired, this nursing diagnosis would not be a priority unless there were other symptoms
manifested. The patient is entering the second stage of labor; therefore she will be allowed to
N s RofSpai
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push with contractions. In termU
this time because of imminent birth.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Patient Needs: Psychosocial Integrity
20. Which of the following behaviors would be applicable to a nursing diagnosis of “risk for
injury” in a patient who is in labor?
a. Length of second-stage labor is 2 hours.
b. Patient has received an epidural for pain control during the labor process.
c. Patient is using breathing techniques during contractions to maximize pain relief.
d. Patient is receiving parenteral fluids during the course of labor to maintain
hydration.
ANS: B
A patient who has received medication during labor is at risk for injury as a result of altered
sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the
second stage of labor is within the range of normal. Breathing techniques help maintain
control over the labor process. Fluids administered during the labor process are used to
prevent potential fluid volume deficit.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Safe and Effective Care Environment/Management of Care
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
21. A nursing priority during admission of a laboring patient who has not had prenatal care is
a. obtaining admission labs.
b. identifying labor risk factors.
c. discussing her birth plan choices.
d. explaining importance of prenatal care.
ANS: B
When a patient has not had prenatal care, the nurse must determine through interviewing and
examination the presence of any pregnancy or labor risk factors, obtain admission labs, and
discuss birth plan choices. Explaining the importance of prenatal care can be accomplished
after the patient’s history has been completed.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity
22. The patient in labor experiences a spontaneous rupture of membranes. Which information
related to this event must the nurse include in the patient’s record?
a. Fetal heart rate
b. Pain level
c. Test results ensuring that the fluid is not urine
d. The patient’s understanding of the event
ANS: A
Charting related to membrane rupture includes the time, FHR, and character and amount of
the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic
fluid, which is anticipated during labor, it is not necessary to verify this by testing. The
patient’s understanding of the event would only need to be documented if it presents a
problem.
NURSINGTB.COM
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
23. The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal
complications?
a. Bloody
b. Clear with bits of vernix caseosa
c. Green and thick
d. Yellow and cloudy with foul odor
ANS: B
Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal
skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The
newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with
meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection.
Bloody fluid may indicate partial placental separation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential
24. The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of
labor. Which size IV cannula is best for this patient?
a. 18-gauge
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b. 20-gauge
c. 22-gauge
d. 24-gauge
ANS: A
The nurse should select the largest bore cannula possible. An 18-gauge cannula is the largest
size available. A 24-gauge cannula would be the smallest. IV access is initiated for hydration
prior to epidural placement and for use in an emergency. Both require the rapid administration
of fluid, which is most easily accomplished with a large bore cannula.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
25. The nurse is reviewing the cardinal maneuvers of labor and birth with a group of nursing
students. Which maneuver will immediately follow the birth of the baby’s head?
a. Expulsion
b. Restitution
c. Internal rotation
d. External rotation
ANS: B
After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as
the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior
diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered.
Internal rotation occurs prior to birth of the head.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health PrN
omoRtionIandGMaB
in.
teC
nancMe
U S N T
O
26. The nurse is performing Leopold’s maneuvers on her patient. Which figure depicts the
Leopold’s maneuver that determines whether the fetal presenting part is engaged in the
maternal pelvis? Refer to Figures A to D.
a.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b.
c.
NURSINGTB.COM
d.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The maneuver that determines whether the presenting part is engaged (widest diameter at or
below a zero station) in the maternal pelvis is performed by palpating the suprapubic area.
Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If
the presenting part is not engaged, the grasping movement of the fingers moves it upward in
the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus.
Palpating the uterine fundus distinguishes between a cephalic and breech presentation.
Holding the left hand steady on one side of the uterus while palpating the opposite side of the
uterus determines on which side of the uterus is the fetal back and on which side are the fetal
arms and legs. Placing your hands on each side of the uterus with fingers pointed toward the
inlet determines whether the head is flexed (vertex) or extended (face).
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
27. After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and
a firm fundus. Which other data would indicate the presence of a potential vaginal wall
hematoma?
a. Lack of an episiotomy
b. Mild, intermittent perineal pain
c. Lack of pain in the perineal area
d. Edema and discoloration of the labia and perineum
ANS: D
The nurse should monitor for edema and discoloration. Using a cold application to the labia
and perineum reduces pain by numbing the area and limiting bruising and edema for the first
12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with
vaginal hematoma is severe aNnd R
constan
t. The
I G
B.pCain Massociated with vaginal hematoma is
U S N T
O
severe.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
28. Which patient presentation is an acceptable indication for serial oxytocin induction of labor?
a. Multiple fetuses
b. Polyhydramnios
c. History of long labors
d. Past 42 weeks of gestation
ANS: D
Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal
health. Multiple fetuses overdistend the uterus, making induction of labor high risk.
Polyhydramnios also overdistends the uterus, creating a high risk for induction. A history of
rapid labors is a reason for induction of labor because of the possibility that the baby would
otherwise be born in uncontrolled circumstances.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
29. The nurse is explaining the technique of internal version to a nursing orientee. Which
statement best describes the technique of internal version?
a. Manipulation of the fetus from a breech to a cephalic presentation before labor
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
begins
b. Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean
birth
c. Manipulation of the second twin from an oblique lie to a transverse lie before labor
begins
d. Manipulation of the second twin from a transverse lie to a breech presentation
during vaginal birth
ANS: D
Internal version is used only during vaginal birth to manipulate the second twin into a
presentation that allows it to be born vaginally. For internal version to occur, the cervix needs
to be completely dilated. For internal version to occur, the cervix needs to be dilated. Internal
version is done to turn the second twin after the first twin is born.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
30. A maternal indication for the use of vacuum extraction is
a. a wide pelvic outlet.
b. maternal exhaustion.
c. a history of rapid deliveries.
d. failure to progress past 0 station.
ANS: B
The patient who is exhausted will be unable to assist with the expulsion of the fetus. With a
wide pelvic outlet, vacuum extraction would not be necessary. With a rapid birth, vacuum
extraction would not be necessary. A station of 0 is too high for a vacuum extraction.
NURSINGTB.COM
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
31. For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
a. A patient in transition with contractions every 2 minutes lasting 90 seconds each
b. A patient in early labor with contractions every 5 minutes lasting 40 seconds each
c. A patient in active labor with contractions every 3 minutes lasting 60 seconds each
d. A patient in active labor with contractions every 2 to 3 minutes lasting 70 to 80
seconds each
ANS: A
This patient’s contraction pattern represents hyperstimulation, and inadequate resting time
occurs between contractions to allow placental perfusion. Oxytocin may assist this patient’s
contractions to become closer and more efficient when the contractions are 5 minutes apart.
There is an appropriate resting period between this patient’s contractions. There is an
appropriate resting period between this patient’s contractions for her stage of labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
32. Immediately following the forceps-assisted birth of an infant, which action should the nurse
implement?
a. Assess the infant for signs of trauma.
b. Apply a cold pack to the infant’s scalp.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Give the infant prophylactic antibiotics.
d. Measure the circumference of the infant’s head.
ANS: A
Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This
would put the infant at risk for cold stress and would be contraindicated. Prophylactic
antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is
part of the initial nursing assessment.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
33. While assisting with a vacuum extraction birth, which alteration should the nurse immediately
report to the obstetric provider?
a. Maternal pulse rate of 100 bpm
b. Maternal blood pressure of 120/70 mm Hg
c. Persistent fetal bradycardia below 100 bpm
d. Decreased intensity of uterine contractions
ANS: C
Fetal bradycardia may indicate fetal distress and may require immediate intervention.
Maternal pulse rate may increase due to the pushing process. Blood pressure of 120/70 mm
Hg is within expected norms for this stage of labor. Decreased intensity of uterine
contractions indicates the birth is imminent at this point.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
N R I G B.C M
U S inNtheTpatientOwho has just had a cesarean birth, which
34.3 To monitor for potential hemorrhage
4 action should the recovery room nurse implement?
. a. Monitor her urinary output.
b. Maintain an intravenous infusion at 1 mL/hour.
c. Assess the abdominal dressings for drainage.
d. Assess the uterus for firmness every 15 minutes.
ANS: D
Maintaining contraction of the uterus is important for controlling bleeding from the placental
site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is
an important assessment, but hemorrhage will first be noted vaginally. Assessing the
abdominal dressing is an important assessment to prevent future hemorrhaging from occurring
but is not the first priority assessment in the recovery room.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
35. The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of
her patient. With which patient should the nurse question the use of vaginal prostaglandin as a
cervical ripening agent?
a. The patient who has a Bishop’s score of 5
b. The patient who is at 42 weeks of gestation
c. The patient who had a previous low transverse cesarean birth
d. The patient who had previous surgery in the upper uterus
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: D
Prostaglandins are contraindicated in patients who have had a previous surgery in the upper
uterus, such as a previous classic cesarean incision or extensive surgery for uterine fibroids. A
side effect of prostaglandin administration is hyperstimulation of the uterus. A Bishop’s score
of 5, 42 weeks of gestation, or a previous low transverse cesarean birth are not
contraindications for cervical ripening.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
36. A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is
experiencing a contraction pattern of more than eight contractions in a 10-minute period.
Which intervention would be a priority?
a. Increase rate of Pitocin infusion to help spread out contraction pattern.
b. Place oxygen on patient at 8 to 10 L/minute via face mask and turn patient to left
side.
c. Stop Pitocin infusion.
d. Call physician to obtain an order for initiation of magnesium sulfate.
ANS: C
The patient is exhibiting uterine tachysystole (uterine tetany). Priority intervention is to stop
the infusion. The next course of action is to place oxygen on the patient and reposition and
increase the flow rate of the primary infusion. If the condition does not improve, the physician
may be called for additional orders.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and N
EffeR
ctivI
e CaG
re EB
nv.irC
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37. On vaginal exam, the patient’s cervix is anterior, soft, 70% effaced, dilated 2 cm, and the
presenting part is at 0 station. The Bishop’s score for this patient is
a. 6.
b. 9.
c. 10.
d. 12.
ANS: B
On the Bishop’s scoring system, an anterior cervix = 2 points, soft cervix = 2 points, 70%
effaced = 2 points, 2 cm dilated = 1 point, and 0 station = 2 points, for a total score of 9.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
38. Which assessment would be important for a 6-hour-old infant who has bruising over the
cheeks from a forceps birth?
a. Presence of newborn reflexes
b. Symmetry of facial movements
c. Caput and molding of the head
d. Anterior and posterior fontanels
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial
asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and
molding, and changes in the anterior and posterior fontanels are not risks associated with
trauma to the infant’s face.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
39. Which aspect of newborn assessment may be limited by the application of a vacuum extractor
at birth?
a. Anterior fontanel
b. Coronal suture lines
c. Posterior fontanel
d. Biparietal diameter
ANS: C
The vacuum extractor is applied on the occipital bone and may create scalp edema at the
application site. The posterior fontanel connects the occipital bone to the parietal bones. The
anterior fontanel, coronal suture lines, and parietal bones are not part of the application area
for a vacuum extractor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
40. Which breech presentation should the nurse recognize as being favorable for an external
cephalic version?
a. 36-week gestation with low-lying placenta
b. 38-week gestation with oN
neUpRreSvI
ioN
usGcT
esB
ar.eaCnOM
c. 37-week gestation with fetal weight of 7 lb
d. 40-week gestation with several uterine fibroids
ANS: C
An external cephalic version (changing the fetal presentation from breech to cephalic) is more
successful when the pregnancy is at least 37 weeks and there is still adequate room and fluid
to manipulate the fetus but prior to term or onset of labor. A low-lying placenta, previous
cesarean birth, and uterine fibroids are contraindications for version.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
41. Following an external cephalic version, which assessment finding indicates a complication?
a. Onset of irregular contractions
b. Maternal blood pressure of 110/70 mm Hg
c. Deceleration of FHR to 88 bpm
d. Maternal pulse rate of 100 bpm
ANS: C
A serious risk of external cephalic version is that the fetus may become entangled in the
umbilical cord, compressing its vessels and resulting in hypoxia. The onset of irregular
contractions, maternal blood pressure of 110/70 mm Hg, and maternal pulse rate of 100 bpm
are normal findings.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
42. The pregnant patient expresses a desire to schedule birth during the baby’s father’s furlough
from military service. The nurse explains that prior to induction of labor, it is essential to
determine which clinical finding?
a. Dilated cervix
b. Fetal lung maturity
c. Rupture of membranes
d. Uterine hypertonia
ANS: B
Reassurance of fetal lung maturity is essential before elective procedures such as induction or
cesarean. The cervix must be favorable for dilation but need not be dilated prior to induction.
Prior rupture of membranes is not necessary for induction. Uterine hypertonia is a risk factor
associated with induction of labor.
DIF: Cognitive Level: Knowledge
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
43. The labor nurse is developing a plan of care for a patient admitted in active labor with
spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On
admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR)
baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2 C (99 F). What
is the priority nursing action for this patient?
a. Fetal acoustic stimulation
b. Assess temperature every 2 hours
c. Change absorption pads uNnU
deRr S
heIr N
hiG
psTeBv.
erC
yO
2M
hours
d. Review white blood cell count (WBC) drawn at admission
ANS: B
The woman’s temperature should be assessed at least every 2 to 4 hours after the membranes
rupture. Elevations above 38C (100.4F) should be reported. A rising FHR and fetal
tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high
end of the acceptable range and the maternal temperature is slightly above normal. These
parameters warrant watching closely with more frequent vital signs. The WBC is often falsely
elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160
bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted.
Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be
changed as needed.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse
understands that according to laboring down, the advantages of waiting until an urge to push
are which of the following? (Select all that apply.)
a. Less maternal fatigue
NURSINGTB.COM
b.
c.
d.
e.
Less birth canal injuries
Decreased pushing time
Faster descent of the fetus
An increase in frequency of contractions
ANS: A, B, C
Delayed pushing has been shown to result in less maternal fatigue and decreased pushing
time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth
canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she
pushed spontaneously and in response to her body’s signals. A brief slowing of contractions
often occurs at the beginning of the second stage.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
2. Which interventions should be performed in the birth room to facilitate thermoregulation of
the newborn? (Select all that apply.)
a. Place the infant covered with blankets in the radiant warmer.
b. Dry the infant off with sterile towels.
c. Place stockinette cap on infant’s head.
d. Bathe the newborn within 30 minutes of birth.
e. Remove wet linen as needed.
ANS: B, C, E
Following birth, the newborn is at risk for hypothermia. Therefore nursing interventions are
aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps
stimulate crying and lung expansion, which helps in the transition period following birth.
Placing a cap on the infant’s N
heUaR
dS
heI
lpN
sG
prT
evBe.
ntChO
eaM
t loss. Removal of wet linens helps
minimize further heat loss caused by exposure. Newborns should not be covered while in a
radiant warmer with blankets because this will impede birth of heat transfer. Bathing a
newborn should be delayed for at least a few hours so that the newborn temperature can
stabilize during the transition period.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care
3. When caring for a patient in labor who is considered to be at low risk, which assessments
should be included in the plan of care? (Select all that apply.)
a. Check the DTR each shift.
b. Monitor and record vital signs frequently during the course of labor.
c. Document the FHR pattern, noting baseline and response to contraction patterns.
d. Indicate on the EFM tracing when maternal position changes are done.
e. Provide food, as tolerated, during the course of labor.
ANS: B, C, D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Nursing care of the normal laboring patient would include monitoring and documentation of
vital signs as part of the labor assessment, documentation the FHR, checking patterns to look
for assurance of fetal well-being by evaluating baseline and the fetal response to contraction
patterns, and noting any position changes on the monitor tracing to evaluate the fetal response.
Providing dietary offerings during the course of labor is not part of the nursing care plan
because the introduction of food may lead to nausea and vomiting in response to the labor
process and might affect the mode of birth.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care
4. The nurse is monitoring a patient in the active stage of labor. Which conditions associated
with fetal compromise should the nurse monitor? (Select all that apply.)
a. Maternal hypotension
b. Fetal heart rate of 140 to 150 bpm
c. Meconium-stained amniotic fluid
d. Maternal fever—38C (100.4F) or higher
e. Complete uterine relaxation of more than 30 seconds between contractions
ANS: A, C, D
Conditions associated with fetal compromise include maternal hypotension (may divert blood
flow away from the placenta to ensure adequate perfusion of the maternal brain and heart),
meconium-stained (greenish) amniotic fluid, and maternal fever (38C [100.4F] or higher).
Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a
normal finding.
DIF: Cognitive Level: Analysis
N R I GOBBJ:.NurC sMing Process Step: Evaluation
O
MSC: Patient Needs: PhysiologicUIntS
egritN
y T
5. The nurse is caring for a patient in the fourth stage of labor. Which assessment findings
should the nurse identify as a potential complication? (Select all that apply.)
a. Soft boggy uterus
b. Maternal temperature of 37.2C (99F)
c. High uterine fundus displaced to the right
d. Intense vaginal pain unrelieved by analgesics
e. Half of a lochia pad saturated in the first hour after birth
ANS: A, C, D
Assessment findings that may indicate a potential complication in the fourth stage include a
soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain
unrelieved by analgesics. The maternal temperature may be slightly elevated after birth
because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after
birth is within expected amounts.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver
the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for
this procedure and therefore must be cognizant of the specific conditions appropriate for labor
induction, including which of the following? (Select all that apply.)
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
e.
Fetal death
Postterm pregnancy
Rupture of membranes at or near term
Convenience of the patient or her health care provider
Chorioamnionitis (inflammation of the amniotic sac)
ANS: A, B, C, E
Fetal death, postterm pregnancy, rupture of members, and chorioamnionitis are all acceptable
indications for induction. Other conditions include intrauterine growth retardation (IUGR),
maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective
inductions for convenience of the patient or her provider are not recommended; however, they
have become common. Factors such as rapid labors and living a long distance from a health
care facility may be a valid reason in such a circumstance.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
COMPLETION
1. The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan)
intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should
prepare how many milliliters to administer the correct dose? Fill in the blank and record your
answer using two decimal places. mL
ANS:
0.75
NURSINGTB.COM
Use the medication calculation formula to calculate the correct dose:
Desired/available  volume = milliliters per dose
(0.3 mg/0.4 mg)  1 mL = 0.75 mL/dose
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 16: Intrapartum Complications
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which pelvic shape is most conducive to vaginal labor and birth?
a. Android
b. Gynecoid
c. Platypelloid
d. Anthropoid
ANS: B
The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered
the most suitable for a vaginal birth. An android pelvis has been described as heart shaped,
with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more
difficult, with the need for harder pushing and often some form of instrumentation. The
anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than
the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval
and has a very poor prognosis for vaginal birth. Most women have characteristics from two or
more types of pelvic shapes.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. Which action by the nurse prevents infection in the labor and birth area?
a. Using clean techniques for all procedures
N RSINGTB.COM
b. Keeping underpads and linU
ens as dry as possible
c. Cleaning secretions from the vaginal area by using a back to front motion
d. Performing vaginal examinations every hour while the patient is in active labor
ANS: B
Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes
are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should
be removed with a front to back motion to decrease fecal contamination. Vaginal
examinations should be limited to decrease transmission of vaginal organisms into the uterine
cavity.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
3. A pregnant patient with premature rupture of membranes is at higher risk for postpartum
infection. Which assessment data indicates a potential infection?
a. Fetal heart rate, 150 beats/minute
b. Maternal temperature, 37.2C (99F)
c. Cloudy amniotic fluid, with strong odor
d. Lowered maternal pulse and decreased respiratory rates
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than
160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C
(100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to
identify tachycardia or tachypnea, which often accompany temperature elevation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
4. A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP)
suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart
monitor indicates bradycardia and variable decelerations. Which action should be taken next?
a. Perform Leopold maneuvers.
b. Perform a vaginal examination.
c. Apply warm saline soaks to the vagina.
d. Place the patient in a high Fowler position.
ANS: B
A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority
is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action
at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the
fetus will be delivered before this occurs. The high Fowler position will increase cord
compression and decrease fetal oxygenation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
5. Which technique is least effective for the patient with persistent occiput posterior position?
a.
b.
c.
d.
NURSINGTB.COM
Squatting
Lying supine and relaxing
Sitting or kneeling, leaning forward with support
Rocking the pelvis back and forth while on hands and knees
ANS: B
Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent.
A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the
pelvis encourages rotation from occiput posterior to occiput anterior.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
6. Birth for the nulliparous patient with a fetus in a breech presentation is usually
a. cesarean birth.
b. vaginal birth.
c. vacuumed extraction.
d. forceps-assisted birth.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean
birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest
part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so
the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum
extractor birth is difficult. Most breech births are difficult. The health care provider may assist
rotation of the head with forceps. A cesarean birth may be required.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction
during labor?
a. A primigravida who is 17 years old
b. A 22-year-old multiparous patient with ruptured membranes
c. A primigravida who has requested no analgesia during her labor
d. A multiparous patient at 39 weeks of gestation who is expecting twins
ANS: D
Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction
because the stretched uterine muscle contracts poorly. A young primigravida usually will have
good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication
that this patient’s uterus is overdistended, which is the main cause of hypotonic dysfunction.
A primigravida usually will have good uterine muscle tone, and there is no indication of an
overdistended uterus.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?
a. Incomplete uterine relaxation
b. Maternal fatigue and exhaustion
c. Maternal sedation with narcotics
d. Administration of tocolytic drugs
ANS: A
A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal
blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually
does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not
decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood
flow.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9.
After a birth complicated by a shoulder dystocia, the infant’s Apgar scores were 7 at 1 minute
and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should
a. palpate the infant’s clavicles.
b. encourage the parents to hold the infant.
c. perform a complete newborn assessment.
d. give supplemental oxygen with a small face mask.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Because of the shoulder dystocia, the infant’s clavicles may have been fractured. Palpation is
a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs
to be assessed for clavicle fractures before excessive movement. A complete newborn
assessment is necessary for all newborns, but assessment of the clavicle is top priority for this
infant. The Apgar indicates that no respiratory interventions are needed.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of
low intensity. How should the nurse respond to complaints of constant cramping pain?
a. “You are only 2 cm dilated, so you should rest and save your energy for when the
contractions get stronger.”
b. “Let me take off the monitor belts and help you get into a more comfortable
position.”
c. “You must breathe more slowly and deeply so there is greater oxygen supply for
your uterus. That will decrease the pain.”
d. “I have notified the doctor that you are having a lot of discomfort. Let me rub your
back and see if that helps.”
ANS: D
Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is
important to help the patient cope with the situation, no matter at what stage. It is important to
get her into a more comfortable position and fetal monitoring should continue. An alteration
in breathing pattern will not decrease the pain in this situation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health PrN
om
onIaN
ndGM
UoRtiS
TaBin.teCnaOncMe
11. Which nursing action should be initiated first when there is evidence of prolapsed cord?
a. Notify the health care provider.
b. Apply a scalp electrode.
c. Prepare the mother for an emergency cesarean birth.
d. Reposition the mother with her hips higher than her head.
ANS: D
The priority is to relieve pressure on the cord. Changing the maternal position will shift the
position of the fetus so that the cord is not compressed. Notifying the health care provider is a
priority but not the first action. It would not be appropriate to apply a scalp electrode at this
time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may
need to hold the presenting part away from the cord until delivery is complete.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. A patient who has had two previous cesarean births is in active labor when she suddenly
complains of pain between her scapulae. Which should be the nurse’s priority action?
a. Notify the health care provider promptly.
b. Observe for abnormally high uterine resting tone.
c. Decrease the rate of nonadditive intravenous fluid.
d. Reposition the patient with her hips slightly elevated.
NURSINGTB.COM
ANS: A
Pain between the scapulae may occur when the uterus ruptures because blood accumulates
under the diaphragm. This is an emergency that requires medical intervention. Observing for
high uterine resting tones should have been done before the sudden pain. High uterine resting
tones put the patient at high risk for uterine rupture. The patient is now at high risk for shock.
Nonadditive intravenous fluids should be increased. Repositioning the patient with her hips
slightly elevated is the treatment for a prolapsed cord. That position in this scenario would
cause respiratory difficulties.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
13. Which factor should alert the nurse to the potential for a prolapsed umbilical cord?
a. Oligohydramnios
b. Pregnancy at 38 weeks of gestation
c. Presenting part at a station of –3
d. Meconium-stained amniotic fluid
ANS: C
Because the fetal presenting part is positioned high in the pelvis and is not well applied to the
cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the patient at
high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the patient
at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus
already has been compromised but does not increase the chance of a prolapsed cord.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: PhysiologNic IR
ntegI
rity G B.C M
U S N T
O
14. The fetus in a breech presentation is often born by cesarean birth because
a. the buttocks are much larger than the head.
b. compression of the umbilical cord is more likely.
c. internal rotation cannot occur if the fetus is breech.
d. postpartum hemorrhage is more likely if the patient delivers vaginally.
ANS: B
After the fetal legs and trunk emerge from the patient’s vagina, the umbilical cord can be
compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the
head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is
no relationship between breech presentation and postpartum hemorrhage.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
15. A patient who is 32 weeks pregnant telephones the nurse at her obstetrician’s office and
complains of constant backache. She asks what pain reliever is safe for her to take. The best
nursing response is
a. “You should come into the office and let the doctor check you.”
b. “Acetaminophen is acceptable during pregnancy. You should not take aspirin,
however.”
c. “Back pain is common at this time during pregnancy because you tend to stand
with a sway back.”
NURSINGTB.COM
d. “Avoid medication because you are pregnant. Try soaking in a warm bath or using
a heating pad on low before taking any medication.”
ANS: A
A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may
prevent preterm birth. The patient needs to be assessed for preterm labor before providing
pain relief.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
16. Which is the priority nursing assessment for the patient undergoing tocolytic therapy with
terbutaline (Brethine)?
a. Intake and output
b. Maternal blood glucose level
c. Internal temperature and odor of amniotic fluid
d. Fetal heart rate, maternal pulse, and blood pressure
ANS: D
All assessments are important; however, those most relevant to tocolytic therapy include the
fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure,
which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important
assessments to monitor for side effects of terbutaline. Internal temperature and odor of
amniotic fluid are important if the membranes have ruptured; however, these are not relevant
to the medication.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health PrN
omoRtionIandGMaB
in.
teC
nancMe
U S N T
O
17. Which clinical finding during assessment indicates uterine rupture?
a. Fetal tachycardia occurs.
b. The patient becomes dyspneic.
c. Labor progresses unusually quickly.
d. Contractions abruptly stop during labor.
ANS: D
A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of
hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an
early sign of a rupture. Contractions will stop with a rupture.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
18. Which intervention should be incorporated in the plan of care for a labor patient who is
experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80%
effaced, and 0 station presenting part vertex.
a. Augmentation of labor with oxytocin (Pitocin)
b. AROM
c. Performing a vaginal exam to denote progress
d. Preparing the patient for epidural administration as ordered by the physician
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The administration of an epidural may help relieve increased uterine resting tone by
decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine
resting tone; therefore augmentation would not be advised at this time because it would cause
further uterine irritation in the form of contractions. Rupture of membranes would not be
warranted at this time because the critical issue is to resolve the increased uterine resting tone.
There is no indication that a vaginal exam is required at this time based on the information
provided.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
19. During the course of the birth process, the physician suspects that a shoulder dystocia is
occurring and asks the nurse for assistance. Which priority action should be taken in response
to this request?
a. Put pressure on the fundus.
b. Ask the physician if he or she would like you to prepare for a surgical method of
birth.
c. Tell the patient not to push until you prepare the vacuum extraction device for
physician.
d. Reposition the patient to facilitate birth.
ANS: B
In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated
to avoid complications from this type of abnormal presentation. Fundal pressure is no longer
recommended as a treatment strategy because it may cause additional problems. Vacuum
extraction will not help to resolve the birth issue and may lead to further complications.
Repositioning of the patient m
effeB
ct.
ivC
e toMrelieve this condition and facilitate birth.
NayRnotIbe G
U S N T
O
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
20. A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her
third child. The physician has ordered a fetal fibronectin test. Which instructions should be
given to the patient regarding this clinical test?
a. Patient must be NPO prior to testing.
b. Blood work will be drawn every week to help confirm the start of preterm labor.
c. Patient should refrain from sexual activity prior to testing.
d. A urine specimen will be collected for testing.
ANS: C
Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A
specimen is collected from the vaginal area. False-positive results can occur in response to
excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
21. An obstetric patient has been identified as being high risk. The patient has had activities
restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks’
gestation and has two other children at home, ages 3 and 6. The patient’s husband works at
home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement
potentially identifies a long-term goal?
a. The patient and husband will be able to adapt their schedules accordingly to meet
activities of daily living until the patient’s next scheduled antepartum visit the
following week.
b. The patient and husband will hire a nanny to act as an additional caregiver for the
next month.
c. The patient will continue to take care of her children at home, taking frequent rest
periods.
d. The patient and husband will make arrangements for child care routine activity
assistance for the rest of the pregnancy.
ANS: D
A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for
the specified timeframe. Planning for caregiving for the next week or month provide evidence
of short-term goals. It is not realistic for the patient to take care of her children at home with
rest period because the patient will not be maintaining the prescribed therapy regimen and
thus may be at risk to further develop complications.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
22. A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following
attempts at pushing for 2 houN
rs wRithI
no pGrogBre.ssC. BM
ased on this information, which birth
O
method is most appropriate? U S N T
a. Vaginal birth with vacuum extraction
b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and
strengthen contractions
c. Cesarean section
d. Insertion of Foley catheter into empty bladder to provide more room for fetal
descent
ANS: C
The presence of CPD is a contraindication for vaginal birth. To prevent further complications,
the patient should be prepped for a cesarean section.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency
23. A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic
intervention does the nurse expect will be included in the plan of care?
a. Administration of antihypertensive medication
b. Initiation of CPR and other life support measures
c. Respiratory treatments with nebulizers
d. Internal fetal monitoring
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare
complication that results in a medical emergency in which CPR measures are initiated and
mechanical ventilation, correction of shock and hypotension, and blood component therapy
are also begun. Meconium-stained fluid is associated with particulate matter that may be
found in the maternal circulation. Internal fetal monitoring may provide a potential source of
entry because it is an invasive procedure. The use of nebulizers is not indicated. The patient
with this condition will be hypotensive, not hypertensive.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency
24. A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks’ gestation on
admission to the labor and birth unit. The patient is not in labor at the current time; however,
she has been sent over by the physician to be admitted for the induction of labor. The patient
indicates to you that she would rather go home and wait for natural labor to start. How should
the nurse respond to the patient’s request?
a. There is no way to tell if any complications would arise. Because the patient is not
presenting with any problems, the nurse should call the health care provider and
inform her or him of the patient’s decision to go home and wait.
b. Inform the patient that there are a number of serious concerns related to a postdate
pregnancy and that she would be better off to be monitored in a clinical setting.
c. Tell the patient that an assessment will be done and if there are no findings
indicating that an induction of labor would be favorable, the patient will be sent
home.
d. Tell the patient that confirmation of a due date can be off by 2 weeks and possibly
be even later than 42 weeks, so it is better to follow the physician’s directions.
ANS: B
NURSINGTB.COM
The most serious concern related to a postdate pregnancy is that of fetal compromise based on
the fact that the placenta function deteriorates. Although one can appreciate that the patient
wants to have a natural labor experience, some women do not go into labor for various
physiologic reasons. Therefore it is best for the patient to remain in a supervised clinical
setting. Indicating that the patient could possibly go home would place the patient at risk and
the nurse at risk for practicing outside of his or her scope of practice. Even though there can
be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone
longer than 42 weeks.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency
25. Which presentation is least likely to occur with a hypotonic labor pattern?
a. Prolonged labor duration
b. Fetal distress
c. Maternal comfort during labor
d. Irregular labor contraction pattern
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak
and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in
duration and patients are typically comfortable but can become easily tired and frustrated
because of the inability of their labor to progress to conclusion. The least likely occurrence is
that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong
enough to exert pressure.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Pathophysiologic Integrity
26. Which finding on vaginal examination would be a concern if a spontaneous rupture of the
membranes has occurred?
a. Cephalic presentation
b. Left occiput position
c. Dilation 2 cm
d. Presenting part at + station
ANS: D
If membranes rupture while the presenting part is at a high station, prolapse of the umbilical
cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are
normal findings.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Safe and Effective Care Environment/Management of Care
27. Which intervention would be most effective if the fetal heart rate drops following a
spontaneous rupture of the membranes?
N/U
a. Apply oxygen at 8 to 10 L
mR
inS
utI
e.NGTB.COM
b. Stop the Pitocin infusion.
c. Position the patient in the knee-chest position.
d. Increase the main line infusion to 150 mL/hour.
ANS: C
A drop in the fetal heart rate following rupture of the membranes indicates a compressed or
prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The
knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the
umbilical cord, applying oxygen will not be effective until compression is relieved, and
stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord
compression.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Safe and Effective Care Environment/Management of Care
28. Which finding would be indicative of an adverse response to terbutaline (Brethine)?
a. Fetal heart rate (FHR) of 134 bpm
b. Heart rate of 122 bpm
c. Two episodes of diarrhea
d. Fasting blood glucose level of 100 mg/dL
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This
action results primarily in bronchodilation, inhibition of uterine muscle activity, increased
pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose
level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this
medication.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
29. A dose of dexamethasone 12 mg was administered to a patient in preterm labor at 0830 hours
on March 12. The nurse knows that the next dose must be scheduled for
a. 1430 hours on March 12th.
b. 2030 hours on March 12th.
c. 0830 hours on March 13th.
d. 1430 hours on March 13th.
ANS: C
The current recommendation for betamethasone for threatened preterm birth is two doses of
12 mg 24 hours apart; 1430 hours on March 12th, 2030 hours on March 12th, and 1430 hours
on March 13th do not fall within this recommendation. The next dose should be scheduled for
0830 hours on March 13th.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
30. When reviewing the prenatal record of a patient at 42 weeks’ gestation, the nurse recognizes
that induction of labor is based upon which indication
a. reduced amniotic fluid voNluUmReS
. INGTB.COM
b. cervix 2 cm at last prenatal visit.
c. fundal height measured at the xyphoid process.
d. 1-lb weight gain at each of the last two weekly visits.
ANS: A
Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency
and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord
compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process,
and 1-lb weight gain at each of the last two weekly visits are normal prenatal findings for a
42-week gestation.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
31. Which assessment finding in the postpartum patient following a uterine inversion indicates
normovolemia?
a. Blood pressure of 100/60 mm Hg
b. Urine output >30 mL/hour
c. Rebound skin turgor <5 seconds
d. Pulse rate <120 beats/minute
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hour;
blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120
beats/minute may be indications of hypovolemia.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
32. Which assessment finding indicates a complication in the patient attempting a vaginal birth
after cesarean (VBAC)?
a. Complaint of pain between the scapulae
b. Change in fetal baseline from 128 to 132 bpm
c. Contractions every 3 minutes lasting 70 seconds
d. Pain level of 6 on scale of 0 to 10 during acme of contraction
ANS: A
A patient attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the
abdomen, pain occurs between the scapulae or in the chest because of irritation from blood
below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every
3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of
contraction would be normal findings during labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment/Management of Care
33. The labor nurse is providing care to a multigravida with moderate to strong contractions every
2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm,
80%, and +2. An epidural was administered shortly thereafter. Two hours after admission, her
contraction pattern remains tN
heUsR
am
rvO
icM
al assessment is 5 cm, 90%, and +2. What
SeIaNndGhTeBr c.eC
is the nurse’s next action?
a. Palpate the patient’s bladder for fullness.
b. Contact the health care provider for a prescription to augment the labor.
c. Obtain an order for an internal pressure catheter.
d. Reassure the patient that she is making adequate progress.
ANS: A
The fetal presenting part is expected to descend at a minimal rate of 1 cm/hour in the nullipara
and 2 cm/hour in the parous woman. Despite an active labor pattern, cervical dilation and
descent have not occurred for 2 hours. The nurse must consider the possibility of an
obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder
distention reduces available space in the pelvis and intensifies maternal discomfort. The
woman should be assessed for bladder distention regularly and encouraged to void every 1 to
2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses
her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended
bladder.
DIF: Cognitive Level: Synthesis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
34.
Which patient is most at risk for a uterine rupture?
a. A gravida 4 who had a classic cesarean incision
b. A gravida 5 who had two vaginal births and one cesarean birth
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. A gravida 3 who has had two low-segment transverse cesarean births
d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant
ANS: A
The classic cesarean incision is made into the upper uterine segment. This part of the uterus
contracts forcefully during labor, and an incision in this area may rupture in subsequent
pregnancies. The patient who had two vaginal deliveries and one cesarean is not a high-risk
candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture.
Low-segment incisions do not raise the risk of uterine ruptures.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
35. A pregnant woman develops hypertension. The nurse monitors the patient’s blood pressure
closely at subsequent visits because the nurse is aware that hypertension is associated with
which complication?
a. Abruptio placentae
b. Cardiac abnormalities in the neonate
c. Neonatal jaundice
d. Reduced placental blood flow
ANS: D
Hypertension associated with pregnancy is associated with reduced placental blood flow.
Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not
directly related to maternal hypertension.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: PhysiologNic IR
ntegI
rity/G
RedB
uc.
tiC
on oM
f Risk Potential
U S N T
36.
O
After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine
atony. Which clinical finding would increase the nurse’s concern regarding this risk?
a. Hypovolemia
b. Iron-deficiency anemia
c. Prolonged use of oxytocin
d. Uteroplacental insufficiency
ANS: C
Postpartum uterine atony is more likely if she has received oxytocin for a long time because
the uterine muscle becomes fatigued and does not contract effectively to compress vessels at
the placental site.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
MULTIPLE RESPONSE
1. Emergency measures used in the treatment of a prolapsed cord include which of the
following? (Select all that apply.)
a. Administration of oxygen via face mask at 8 to 10 L/minute
b. Maternal change of position to knee-chest
c. Administration of tocolytic agent
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Administration of oxytocin (Pitocin)
e. Vaginal elevation
f. Insertion of cord back into vaginal area
ANS: A, B, C, E
Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to
increase perfusion from mother to fetus. The maternal position change to knee-chest or
Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such
as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent
pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset
pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are
contraindicated.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency
2. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that
apply.)
a. Increased risk for placenta previa
b. Painful uterine contractions
c. Increased resting tone
d. Uterine vasodilation
e. Increased uterine pressure
f. Effective uterine contraction
ANS: B, C, E
Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine
ischemia occurs, leading to vN
asU
oR
coS
nsItrN
icG
tioTnBa.
ndCcOoM
nstant cramplike abdominal pain. Thus
there is an increased risk for placental abruption as compared with placenta previa, which is
based upon malpresentation of the placental attachment. The contractions are painful but not
effective for progression of labor.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Pathophysiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 17: Postpartum Adaptations and Nursing Care
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which patient would be most likely to have severe afterbirth pains and request a narcotic
analgesic?
a. Gravida 5, para 5
b. Primipara who delivered a 7-lb boy
c. Patient who is bottle feeding her first child
d. Patient who is breastfeeding her second child
ANS: A
The discomfort of afterpains is more acute for multiparas because repeated stretching of
muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain
contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The
non-nursing mother may have engorgement problems that will cause her discomfort. The
patient who is nursing her second child will have more afterpains than her first pregnancy;
however, they will not be as severe as the grand multiparous patient.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
2. Which maternal event is abnormal in the early postpartal period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
N R I G B.C M
c. Extreme hunger and thirst U S N T
O
d. Lochial color changes from rubra to alba
ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at
about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of
increased plasma volume. Urine output of 3000 mL/day is common for the first few days after
birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for
days. Many women anticipate pain during defecation and are unwilling to exert pressure on
the perineum. The new mother is hungry because of energy used in labor and thirsty because
of fluid restrictions during labor.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. Which fundal assessment finding at 12 hours after birth requires further assessment?
a. The fundus is palpable at the level of the umbilicus.
b. The fundus is palpable two fingerbreadths above the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
d. The fundus is palpable two fingerbreadths below the umbilicus.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus
that is above the umbilicus may indicate uterine atony or urinary retention. The fundus
palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The
fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding
for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an
unusual finding for 12 hours postpartum; however, it is still appropriate.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. If the patient’s white blood cell (WBC) count is 25,000/mm3 on her second postpartum day,
which action should the nurse take?
a. Document the finding.
b. Inform the health care provider.
c. Begin antibiotic therapy immediately.
d. Have the laboratory draw blood for reanalysis.
ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal
and not a sign of infection. The nurse should document the finding. There is no reason to alert
the health care provider. Antibiotics are not needed because the elevated WBCs are caused by
the stress of labor and not an infectious process. There is no need for reassessment as it is
expected for the WBCs to be elevated.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
5. Postpartal overdistention of tN
heUbRlaS
dI
deN
rG
anT
dB
u.
rinCaO
ryMretention can lead to which complication?
a. Fever and increased blood pressure
b. Postpartum hemorrhage and eclampsia
c. Urinary tract infection and uterine rupture
d. Postpartum hemorrhage and urinary tract infection
ANS: D
Incomplete emptying and overdistention of the bladder can lead to urinary tract infection.
Overdistention of the bladder displaces the uterus and prevents contraction of the uterine
muscle. There is no correlation between bladder distention and blood pressure or fever. There
is no correlation between bladder distention and eclampsia. The risk of uterine rupture
decreases after the birth.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best
response?
a. “No, never.”
b. “Yes, eventually.”
c. “They will fade to silvery lines but won’t disappear completely.”
d. “They will continue to fade and should be gone by your 6-week checkup.”
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating
never is true, but more information can be added, such as the changes that will occur with the
stretch marks. Stretch marks do not disappear.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
7. A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The
nurse knows the pigmentation will fade after birth due to
a. increased estrogen.
b. increased progesterone.
c. decreased human placental lactogen.
d. decreased melanocyte-stimulating hormone.
ANS: D
Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes
in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth.
Progesterone levels decrease after birth. Human placental lactogen production continues to aid
in lactation. However, it does not affect pigmentation.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
8. Which clinical finding should the nurse suspect if the fundus is palpated on the right side of
the abdomen above the expected level?
a. Distended bladder
b. Normal involution
c. Been lying on her right siN
deUtR
ooSlI
onNgGTB.COM
d. Stretched ligaments that are unable to support the uterus
ANS: A
The presence of a full bladder will displace the uterus. A palpated fundus on the right side of
the abdomen above the expected level is not an expected finding. Position of the patient
should not alter uterine position. The problem is a full bladder displacing the uterus.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
9. Which situation would require the administration of Rho(D) immune globulin?
a. Mother Rh-negative, baby Rh-positive
b. Mother Rh-negative, baby Rh-negative
c. Mother Rh-positive, baby Rh-positive
d. Mother Rh-positive, baby Rh-negative
ANS: A
An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells
that entered her bloodstream when the placenta separated. The Rho(D) immune globulin
works to destroy the fetal cells in the maternal circulation before sensitization occurs. When
the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody
formation would be anticipated. If the Rh-positive blood of the mother comes in contact with
the Rh-negative blood of the infant, no antibodies would develop because the antigens are in
the mother’s blood, not the infant’s.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
10. If the rubella vaccine is indicated for a postpartum patient, which instructions should be
provided?
a. No specific instructions
b. Drinking plenty of fluids to prevent fever
c. Recommendation to stop breastfeeding for 24 hours after the injection
d. Explanation of the risks of becoming pregnant within 28 days following injection
ANS: D
Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine
administration. The mother does need to understand potential side effects and that pregnancy
is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts
of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue
breastfeeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
11. Which measure is optimal in order to prevent abdominal distention following a cesarean
birth?
a. Rectal suppositories
b. Carbonated beverages
c. Early and frequent ambulation
d. Tightening and relaxing abdominal muscles
ANS: C
NURSINGTB.COM
Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal
suppositories can be helpful after distention occurs; however, do not prevent it. Carbonated
beverages may increase distention. Ambulation is the best prevention. Abdominal
strengthening will not prevent distention.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
12. To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse
utilize?
a. Assess lochial flow rather than palpating the fundus.
b. Palpate forcefully through the abdominal dressing.
c. Place hands on both sides of the abdomen and press downward.
d. Gently palpate, applying the same technique used for vaginal deliveries.
ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation
should never be used. The top of the fundus, not the sides, should be palpated and massaged.
Assessing lochial flow is not adequate; the fundus also needs to be checked.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
13. The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago.
Which amount of lochia consists of a moderate amount?
a. Saturated peripad
b. 10 to 15 cm (4- to 6-inch) stain on the peripad
c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
d. Less than a 1-inch stain on the peripad
ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record flow by
estimating the amount of lochia in 1 hour using the following labels:
•
Scant—less than 2.5 cm (1-inch) stain on the peripad
•
Light—less than a 10 cm (4 inch) stain
•
Moderate—less than a 15 cm (6 inch) stain
•
Heavy—saturated peripad
•
Excessive—saturated peripad in 15 minutes
Determining the time interval that the peripad is in place is also important. Lochia is less for
women who have had a cesarean birth because some of the endometrial lining is removed
during surgery.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
14. The postpartum nurse has completed discharge teaching for a patient being discharged after an
uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is
necessary?
a. “I may not have a bowel movement until the 2nd postpartum day.”
b. “If I breastfeed and supplN
emeRnt w
m.
ulC
a, I M
SIith
NGfor
TB
Owon’t need any birth control.”
c. “I know my normal patternUof bowel
elimination won’t return until about 8 to 10
days.”
d. “If I am not breastfeeding, I should use birth control when I resume sexual
relations with my husband.”
ANS: B
For some women, ovulation resumes as early as 3 weeks postpartum. Therefore contraceptive
measures are important considerations when sexual relations are resumed for lactating and
nonlactating women. Further teaching would be needed if the patient does not feel any need
for birth control with breastfeeding and supplementing with formula. The first stool usually
occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume
by 8 to 14 days after birth.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
15. The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago.
Which assessment finding should the nurse report to the health care provider?
a. Pulse rate of 50
b. Temperature of 38C (100.4F)
c. Firm fundus, but excessive lochia
d. Lightheaded when moving from a lying to standing position
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal.
The health care provider must be notified so that lacerations can be located and repaired.
Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the
large amount of blood that returns to the central circulation after birth of the placenta. A
temperature of up to 38C (100.4F) is common during the first 24 hours after childbirth and
may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement
of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when
the woman moves from a recumbent to a sitting position. This change causes mothers to feel
dizzy or lightheaded or to faint when they stand.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
16. To facilitate adequate urinary elimination during the postpartum period, the nurse should
incorporate which intervention into the plan of care?
a. Have the patient drink carbonated beverages to promote urinary excretion.
b. Tell the patient that because of postpartum diuresis there is less risk to develop
dehydration.
c. Limit fluid intake to prevent polyuria.
d. Teach the patient to perform pelvic floor exercises to combat potential stress
incontinence.
ANS: D
Educating the patient to use pelvic floor exercises (Kegel exercises) will help strengthen
pelvic floor muscles. Carbonated beverages will lead to increased gas and potential
gastrointestinal discomfort. During the postpartum period, the patient is at greater risk for
dehydration and thus should N
incrR
easeIfluG
ids.BL.
im
tion of fluids is not warranted during the
CitaM
U
S
N
T
O
postpartum period.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
17. When assessing the A of the acronym REEDA, the nurse should evaluate the
a. skin color.
b. degree of edema.
c. edges of the episiotomy.
d. episiotomy for discharge.
ANS: C
In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the
other letters of the acronym refer to other components of wound assessment: R = redness, E =
edema, E = ecchymosis, and D = drainage.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
18. Which assessment finding 24 hours after vaginal birth would indicate a need for further
intervention?
a. Pain level 5 on scale of 0 to 10
b. Saturated pad over a 2-hour period
c. Urinary output of 500 mL in one voiding
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Uterine fundus 2 cm above the umbilicus
ANS: D
By the second postpartum day, the fundus descends by approximately 1 cm/day and should be
1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and
urinary output of 500 mL in one voiding are normal findings in the postpartum patient.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity
19. The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse
palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority
action related to this finding?
a. Inform the health care provider.
b. Encourage the patient to urinate.
c. Massage the uterus to expel clots.
d. Document the finding in the patient’s chart.
ANS: D
The location of the uterine fundus helps determine whether involution is progressing
normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball
and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the
symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus
rises to approximately the level of the umbilicus. This finding is expected and can be followed
with documentation. No further action is needed.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health PrN
omoRtionIandGMaB
in.
teC
nancMe
U S N T
O
20. The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report,
the preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment,
the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after
breastfeeding her infant. What is the nurse’s priority action with this finding?
a. Weigh the peripad.
b. Replace the peripad.
c. Contact the health care provider.
d. Document the finding in the patient’s chart.
ANS: C
The lochia of the cesarean birth mother will go through the same phases as that of the woman
who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad
is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care
provider needs to be notified immediately. Weighing the peripad will give an estimation of the
blood loss; but, this assessment can result in a delay of care. Replacing the peripad and
documentation of the findings are appropriate when the data are within normal limits.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
21. The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment
finding indicates the treatment has been effective?
a. No swelling or edema to the perineal area
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b. Patient complains that the sitz bath is too cold.
c. Patient reports she took two sitz baths in 12 hours.
d. Edges of the perineal laceration are well approximated.
ANS: A
Sitz baths may be offered two to four times a day to women with episiotomies, painful
hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and
cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and
may be most effective within the first 24 hours. Ice can be added to cool the water to a
comfortable level as the woman sits in it. Approximation of the edges of a wound facilitates
wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue
trauma.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
22. Which description best explains the term reciprocal attachment behavior?
a. Behavior during the sensitive period when the infant is in the quiet alert stage
b. Positive feedback that the infant exhibits toward parents during the attachment
process
c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye
contact
d. Behavior by the infant during the sensitive period to elicit feelings of “falling in
love” from the parents
ANS: B
In this definition, reciprocal refers to the feedback from the infant during the attachment
process. The quiet alert state N
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ooIdNtiG
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boO
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ding; however, does not define reciprocal
attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
23. The postpartum patient who continually repeats the story of her labor, birth, and recovery
experiences is performing which of the following tasks?
a. Making the birth experience “real”
b. Accepting her response to labor and birth
c. Providing others with her knowledge of events
d. Taking hold of the events leading to her labor and birth
ANS: A
Reliving the birth experience makes the event real and helps the mother realize that the
pregnancy is over and that the infant is born and is now a separate individual. She is in the
taking-in phase, trying to make the birth experience seem real. This is to satisfy her needs, not
the needs of others.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
24. During which stage of role attainment do the parents become acquainted with their baby and
combine parenting activities with cues from the infant?
a. Formal
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b. Informal
c. Personal
d. Anticipatory
ANS: A
A major task of the formal stage of role attainment is getting acquainted with the infant. The
informal stage begins once the parents have learned appropriate responses to their infant’s
cues. The personal stage is attained when parents feel a sense of harmony in their role. The
anticipatory stage begins during the pregnancy when the parents choose a physician and
attend childbirth classes.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
25. The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies
awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
a. Hand the baby to the woman.
b. Explain “taking-in” to the woman.
c. Offer to hand the baby to the woman.
d. No action, because this situation is perfectly acceptable.
ANS: A
During the taking-in phase of maternal adaptation, in which the mother may be passive and
dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This
is done best by simply giving the baby to the mother. She learns best during the taking-hold
phase. The woman is dependent and passive at this stage and may have difficulty making a
decision. This is expected behavior during the taking-in phase; however, interventions that
facilitate infant bonding can N
beUtR
akS
enI. NGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
26. The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours
ago. The partner is watching his wife and asking questions about newborn care. The
4-year-old big brother is punching his mother on the back. What should the nurse do next?
a. Report the incident to the social services department.
b. Advise the parents that the older son needs to be reprimanded.
c. No action; this is a normal family adjusting to family change.
d. Report to oncoming staff that the mother is probably not a good disciplinarian.
ANS: C
The observed behaviors are normal variations of families adjusting to change. There is no
need to report this one incident. Giving advice at this point would make the parents feel
inadequate. This is normal for an adjusting family.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
27. During which phase of maternal adjustment will the mother relinquish the baby of her
fantasies and accept the real baby?
a. Letting-go
b. Taking-in
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Taking-on
d. Taking-hold
ANS: A
Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go
phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her
own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase,
the mother assumes responsibility for her own care and shifts her attention to the infant.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
28. A new father calls the nurse’s station stating that his wife, who delivered last week, is happy
one minute and crying the next. He states, “She was never like this before the baby was born.”
How should the nurse best respond?
a. Reassure him that this behavior is normal.
b. Advise him to get immediate psychological help for her.
c. Tell him to ignore the mood swings because they will go away.
d. Instruct him in the signs, symptoms, and duration of postpartum blues.
ANS: A
Before providing further instructions, inform family members of the fact that postpartum
blues are a normal process to allay anxieties and increase receptiveness to learning.
Postpartum blues are a normal process that is short-lived; no medical intervention is needed.
Telling him to ignore the moods blocks communication and may belittle the husband’s
concerns. Patient teaching is important; however, his anxieties need to be allayed before he
will be receptive to teaching.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
29. To promote bonding and attachment immediately after birth, which action should the nurse
take?
a. Assist the mother in feeding her baby.
b. Allow the mother quiet time with her infant.
c. Teach the mother about the concepts of bonding and attachment.
d. Assist the mother in assuming an en face position with her newborn.
ANS: D
Assisting the mother in assuming an en face position with her newborn will support the
bonding process. After birth is a good time to initiate breastfeeding, but first the mother needs
time to explore the new infant and begin the bonding process. The mother should be given as
much privacy as possible; however, nursing assessments must still be continued during this
critical time. The mother has just delivered and is more focused on the infant; she will not be
receptive to teaching at this time.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
30. Which patient is more likely to have less stress adjusting to her role as a mother?
a. A 26-year-old woman who is returning to work in 10 weeks
b. A 35-year-old anxious mother who has had no contact with babies or children
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. A 16-year-old teenager who lives with her parents and has a strained relationship
with her mother
d. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant
with twins, who were delivered by cesarean birth
ANS: A
The woman who has the least amount of stress in her life will adjust more quickly to her role
as a mother. The anxious mother with no real experience with babies may have a difficult time
adjusting to motherhood. The teenager has a significant amount of stress in her life, which
could make adjusting to her role as a mother more difficult. The 25-year-old mother has the
added stress of twins, which may make motherhood adjustment more difficult.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Psychosocial Integrity
31. Which anticipatory guidance action by the nurse makes role transition to parenthood easier?
a. Helps the new parents identify resources.
b. Recommends employing babysitters frequently.
c. Tells the parents about the realities of parenthood.
d. Offers a home phone number and tells parents to call if they have a question.
ANS: A
Available resources within the community can assist the parents in role transition. Some
parents may not be able to afford babysitters. Also, this removes them from the parenthood
role. Each adult sees parenthood in a different light. They cannot be compared. Searching out
resources for the parents is an important task; however, the nurse should not give her personal
number to patients.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
32. Which action should the nurse take in order to provide support and encouragement to the new
postpartum patient?
a. Recount how she solved her own problems.
b. Correct the new mother at every opportunity.
c. Praise the mother’s early attempts at infant care.
d. Explain to the new mother that everything will be fine.
ANS: C
Positive reinforcement of the mother’s attempt to provide care to the newborn will promote a
healthy self-concept. The mother needs to learn how to solve problems on her own. Each
person may use different techniques that work for that person. Correcting her actions would
be discouraging to a new mother. She needs encouragement. Saying everything will be fine is
blocking communication and further teaching.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
33. Which should the nurse do to provide support to a patient who must return to full-time
employment 6 weeks after a vaginal birth?
a. Discuss child care arrangements with her.
b. Allow her to solve the problem on her own.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Reassure her that she’ll get used to leaving her baby.
d. Allow her to express her positive and negative feelings freely.
ANS: D
Allowing the patient to express feelings will provide positive support in her process of
maternal adjustment. Discussing child care arrangements is an important step in anticipatory
guidance, although this is not the best way to offer support. The new mother should be
instrumental in solving the problem; however, allowing her time to express her feelings and
talk the problem over will assist her in making this decision. Reassuring her that she will get
used to leaving the baby blocks communication and belittles the patient’s feelings.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
34. The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the
following should the nurse expect to observe as a dietary practice for this culture?
a. Special foods brought from home.
b. Preference for fresh fruits.
c. Preference for “cold” foods.
d. Request for ice water instead of hot water.
ANS: A
Specific foods brought from home are a welcome sign of caring in many cultures. Some
Asians believe that after childbirth the woman should eat only “hot” foods such as chicken,
meat, and fish. Fresh fruit would be considered a “cold” food. Although ice water is
commonly given to hospital patients, it is not acceptable to many Asians. For example,
Southeast Asian women may refuse cold or ice water and prefer hot water or other warm
NURSINGTB.COM
beverages to keep warm.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
35. An example of binding in during the postpartum period is a
a. new mother telling her friends all about her labor and birth experience.
b. father looking at his newborn and stating that he “looks like I did when I was a
baby.”
c. mother reporting increasing anxiety during the postpartum period because she feels
like she is without support.
d. mother wanting some time alone so that she can catch up on needed sleep.
ANS: B
A new mother telling her friends all about her labor and birth experience is an example of
binding in or claiming. A new mother telling her friends all about her labor and birth
experience is an example of the taking-in phase of maternal adaptation. A mother who reports
increasing anxiety during the postpartum period because she feels like she is all alone may be
problematic and indicates that the patient is experiencing significant stressors during the
postpartum period. A mother wanting some time alone so that she can catch up on needed
sleep is a normal reaction to the demands of the newborn and reflects that the patient may
need additional support during this time.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Psychosocial Integrity
36. Which of the following behaviors would be applicable to a nursing diagnosis of Risk for
Impaired Parenting?
a. En face behavior is observed between father and infant.
b. Mother relates that she feels exhilarated postbirth.
c. Mother states that she feels excessive fatigue as a result of the childbirth
experience.
d. Father displays finger tipping behavior toward infant.
ANS: C
Fatigue can contribute to altered parenting, because it may affect the level of interaction
between parent and child. En face behavior acknowledges maternal-paternal attachment. A
feeling of exhilaration is normal following a changing life cycle event such as childbirth.
Finger tipping behavior conveys a sense of identification or claiming behavior.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Diagnosis
MSC: Patient Needs: Health Promotion and Maintenance
37. A family is concerned about how their 2-year-old son is going to react to the new baby.
Which intervention would help facilitate sibling attachment?
a. Have the mother and father spend individual time with their son to allay potential
anxiety over the new baby coming in and displacing his position in the family as
the only child.
b. Make sure that their son is supervised at all times when the baby is brought home
from the hospital and is in his presence.
c. Include the son in helping to take care of the baby and reinforce the label of “big
brother” as a special role.NURSINGTB.COM
d. Observe the son’s reaction to the baby and let him decide when he wants to be
introduced to his new sibling.
ANS: C
Providing the older son with a special role designation and involving him in the care of the
baby will facilitate sibling attachment. Spending individual time with the older child is
recommended but will not facilitate sibling attachment. Although the older child should be
supervised because of his age in terms of infant safety, this level of overprotection may inhibit
sibling attachment. Observation of his behavior may be warranted; however, the age of the
child (2 years) does not warrant this type of control.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
38. The nurse is developing a plan of care for the patient’s fourth stage of labor. One nursing
intervention is to promote bonding. Specifically, which nursing action will facilitate the
bonding process?
a. Encourage the patient to call the baby by his or her first name.
b. Stimulate the grasp reflex by placing the patient’s finger in the infant’s palm.
c. Ask the patient if she wants her baby placed on her chest immediately after birth.
d. Assess for familial characteristics and remark on the resemblance to the patient or
the father.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
Bonding refers to the rapid initial attraction felt by parents for their infant. It is unidirectional,
from parent to child, and is enhanced when parents and infants are permitted to touch and
interact during the first 30 to 60 minutes after birth. During this time, the infant is in a quiet,
alert state and seems to gaze directly at the parents. Infants are often placed skin to skin on the
mother’s chest or abdomen for bonding time immediately after birth. Nurses frequently delay
procedures such as measurements and medication administration that would interfere with this
time, so that parents can focus on their newborn baby. Attachment follows a progressive or
developmental course that changes over time. It is rarely instantaneous. Unlike bonding,
attachment is reciprocal—it occurs in both directions between parent and infant.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
39. A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness,
and anxiety. What is the nurse’s most appropriate response at this time?
a. “When did these symptoms begin?”
b. “Sounds like normal postpartum depression.”
c. “Are you having trouble getting enough sleep?”
d. “Are you able to get out of bed and provide care for your baby?”
ANS: D
Postpartum blues must be distinguished from postpartum depression and postpartum
psychosis, which are disabling conditions and require therapeutic management for full
recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily
life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and
resolve in 2 weeks. The response “Sounds like postpartum depression” does not offer the
NUent
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patient any help or encouragem
this chOallenging
time. Asking if she is getting
enough sleep does not add to the assessments already identified in the stem. Enough
information exists to determine that she has the signs and symptoms of postpartum blues. The
nurse must differentiate between postpartum blues and depression.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which vaccinations are indicated for the postpartum patient if she does not have immunity?
(Select all that apply.)
a. Pertussis
b. Rubella
c. Diphtheria, tetanus (Tdap)
d. RhoGAM
e. Varicella
ANS: A, B, C, E
If a patient who has delivered does not have evidence of immunity, CDC recommendations
advise that pertussis, rubella, Tdap, and varicella should be administered. RhoGAM is
required if there is evidence of sensitization in response to Rh factor identification based on
maternal and fetal blood results.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. The nurse is planning comfort measures to implement for a patient after a vaginal birth.
Which measures should the nurse plan to include in the patient’s care plan? (Select all that
apply.)
a. Sitz baths four times a day
b. Use of only warm water with the sitz baths
c. Topical anesthetic spray after perineal care
d. Ice pack to the perineum for the first 24 hours
e. Relax the perineal and buttock areas when sitting
ANS: A, C, D
Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized
perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to
prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow
more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and
may be most effective within the first 24 hours. The mother should be advised to squeeze her
buttocks together, not relax them, before sitting, and to lower her weight slowly onto her
buttocks.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. The nurse is teaching a non–breastfeeding patient measure to suppress lactation. Which
information should the nurse include in the teaching session? (Select all that apply.)
a. Avoid massaging the breN
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. SINGTB.COM
b. Allow warm shower water to run over the breasts.
c. If the breasts become engorged, pumping is recommended.
d. Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort.
e. Wear a sports bra 24 hours a day until the breasts become soft.
ANS: A, D, E
The patient should be advised to avoid massaging the breasts because this will stimulate milk
production. Instruct the patient to wear a sports bra or other well-fitting bra 24 hours a day
until the breasts become soft. Manage breast discomfort by application of ice, or cold cabbage
leaves, which reduce vasocongestion. Advise the patient to refrain from allowing warm water
to fall directly on the breasts during showers and pumping because these actions will stimulate
milk production.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
4. The nurse is conducting discharge teaching for a patient going home after a cesarean birth.
Which signs and symptoms should the patient be taught to report? (Select all that apply.)
a. Mild incisional pain
b. Feeling of pelvic fullness
c. Lochia changing from red to pink in color
d. Frequency, urgency, or burning on urination
e. Redness or edema of the abdominal incision
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: B, D, E
The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness,
frequency, urgency or burning on urination, and redness or edema of the abdominal incision.
Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a
pinkish color (serosa).
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
5. Which of the following are nursing measures that can promote parent-infant bonding and
attachment? (Select all that apply.)
a. Provide comfort and ample time for rest.
b. Keep the baby wrapped to avoid cold stress.
c. Position the infant face to face with the mother.
d. Point out the characteristics of the infant in a positive way.
e. Limit the amount of modeling so the mother doesn’t feel insecure.
ANS: A, C, D
Provide comfort and ample time for rest, because the mother must replenish her energy and be
relatively free of discomfort before she can progress to initiating care of the infant. Position
the infant in an en face position and discuss the infant’s ability to see the parent’s face. Face to
face and eye to eye contact is a first step in establishing mutual interaction between the infant
and parent. Point out the characteristics of the infant in a positive way: “She has such pretty
little hands and beautiful eyes.” The baby should be kept warm, but parents should be assisted
to unwrap the baby (keeping or rewrapping the body part not being inspected) to inspect the
toes, fingers, and body. The nurse should model behaviors by holding the infant close, making
eye contact with the infant, aN
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tched, soothing tones.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
COMPLETION
1. The postpartum nurse is administering ibuprofen (Advil) to a patient with episiotomy
discomfort. The prescribed order is 400 mg of Advil by mouth every 6 to 8 hours PRN for
discomfort. The Advil sent by the pharmacy is 200 mg/tablet. How many tablet(s) should the
nurse administer to the patient? Record your answer as a whole number.
tab(s)
ANS:
2
Use the medication calculation formula to calculate the correct dose.
Formula:
Desired/available  volume = mg/dose
400 mg/200 mg  1 tab = 2 tabs
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 18: Postpartum Maternal Complications
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which statement by a postpartum patient indicates that further teaching regarding thrombus
formation is unnecessary?
a. “I’ll keep my legs elevated with pillows.”
b. “I’ll sit in my rocking chair most of the time.”
c. “I’ll stay in bed for the first 3 days after my baby is born.”
d. “I’ll put my support stockings on every morning before rising.”
ANS: D
Venous congestion begins as soon as the patient stands up. The stockings should be applied
before she rises from the bed in the morning. The patient should avoid knee pillows because
they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent
position causes pooling of blood in the lower extremities. As soon as possible, the patient
should ambulate frequently.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
2. The nurse understands that late postpartum hemorrhage may be prevented by
a. manually removing the placenta.
b. inspecting the placenta after birth.
c. administering broad-spN
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s.C M
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Nbiot
TB
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d. pulling on the umbilical cord to hasten the birth of the placenta.
ANS: B
If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing
fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal
of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will
be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30
minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a
4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The
nurse has the patient void and massages her fundus; however, the fundus remains difficult to
find and the rubra lochia remains heavy. Which action should the nurse take next?
a. Recheck vital signs.
b. Insert a Foley catheter.
c. Notify the health care provider.
d. Continue to massage the fundus.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Treatment of excessive bleeding requires the collaboration of the health care provider and
the nurses. Do not leave the patient alone. The nurse should call the clinician while a second
nurse rechecks the vital signs. The patient has voided successfully, therefore a Foley
catheter is not needed at this time. The uterine muscle can be overstimulated by massage,
leading to uterine atony and rebound hemorrhage.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
4. Early postpartum hemorrhage is defined as a blood loss greater than
a. 500 mL within 24 hours after a vaginal birth.
b. 750 mL within 24 hours after a vaginal birth.
c. 1000 mL within 48 hours after a cesarean birth.
d. 1500 mL within 48 hours after a cesarean birth.
ANS: B
The average amount of bleeding after a vaginal birth is 500 mL. Early postpartum
hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean birth
averages 1000 mL. Late postpartum hemorrhage is 48 hours and later.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
5. A steady trickle of bright red blood from the vagina in the presence of a firm fundus
suggests
a. uterine atony.
b. perineal hematoma. NURSINGTB.COM
c. infection of the uterus.
d. lacerations of the genital tract.
ANS: D
Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations will
not be affected by uterine contraction. The fundus would be boggy with a clinical finding of
uterine atony. A hematoma would occur internally with swelling and discoloration. With an
infection of the uterus, there would be an odor to the lochia and systemic symptoms such as
fever and malaise.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. A postpartum patient would be at increased risk for postpartum hemorrhage if she delivered
a(n)
a. 5-lb, 2-oz infant with outlet forceps.
b. 6.5-lb infant after a 2-hour labor.
c. 7-lb infant after an 8-hour labor.
d. 8-lb infant after a 12-hour labor.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction.
Delivering a 5-lb, 2-oz infant with outlet forceps would put this patient at risk for lacerations
due to the use of forceps. A 7-lb infant after an 8-hour labor is a normal labor progression.
Less than 3 hours is considered a rapid labor and can produce uterine muscle exhaustion. An
8-lb infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid
birth and may cause the uterine muscles failure to contract.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. The nurse should expect medical intervention for subinvolution to include
a. oral fluids to 3000 mL/day.
b. intravenous fluid and blood replacement.
c. oxytocin intravenous infusion for 8 hours.
d. oral methylergonovine maleate (Methergine) for 48 hours.
ANS: D
Methergine provides sustained contraction of the uterus. There is no correlation between
dehydration and subinvolution. There is no indication that excessive blood loss has
occurred. Oxytocin provides intermittent contractions.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
8. If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is
appropriate to correct the cause of this condition?
a. Hysterectomy
NURSINGTB.COM
b. Laparoscopy
c. Laparotomy
d. Dilation and curettage (D&C)
ANS: D
D&C allows examination of the uterine contents and removal of any retained placenta or
membranes. A hysterectomy is the removal of the uterus and is not indicated in this
situation. A laparoscopy is the insertion of an endoscope through the abdominal wall to
examine the peritoneal cavity and would also not be necessary at this juncture. A
laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.
This patient requires a D&C rather than a laparotomy.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. A positive sign of thrombophlebitis includes
a. visible varicose veins.
b. positive Homans sign.
c. pedal edema in the affected leg.
d. local tenderness, heat, and swelling.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of
the inflammation. Varicose veins may predispose the patient to thrombophlebitis; however,
are not an indication of thrombophlebitis. A positive Homans sign is indicative of deep vein
thrombosis (DVT).
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. Which nursing measure would be most appropriate to prevent thrombophlebitis in the
recovery period following a cesarean birth?
a. Limit the patient’s oral intake of fluids for the first 24 hours.
b. Assist the patient in performing leg exercises every 2 hours.
c. Ambulate the patient as soon as her vital signs are stable.
d. Roll a bath blanket and place it firmly behind the patient’s knees.
ANS: B
Leg exercises promote venous blood flow and prevent venous stasis while the patient is still
on bed rest. Limiting oral intake will produce hemoconcentration, which may lead to
thrombophlebitis. The patient may not have full return of leg movements, and ambulating at
this time is contraindicated. The blanket behind the knees will cause pressure and decrease
venous blood flow.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
11. Which temperature indicates the presence of postpartum infection?
stR4S
8I
hoNuG
rsTB.COM
a. 37.5°C (99.6°F) in the fNirU
b. 37.7°C (100°F) for 2 days postpartum
c. 38°C (100.4°F) in the first 24 hours
d. 38.2°C (100.8°F) on the second and third postpartum days
ANS: D
A temperature elevation of greater than 38°C (100.4°F) on two postpartum days, not
including the first 24 hours, signifies infection. 37.5°C (99.6°F) in the first 48 hours is an
expected finding due to dehydration. To be classified as an infection, the temperature needs
to be greater than 38°C (100.4°F). It is anticipated that women have an elevated temperature
the first 24 hours after delivery.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
12. A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum
day indicates
a. possible infection.
b. normal WBC limit.
c. serious infection.
d. suspicion of a sexually transmitted disease.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A WBC count in the upper ranges of normal (20,000 to 30,000 cells/mm3) may indicate an
infection. An elevated WBC count is anticipated but becomes a concern as it hits the upper
range. An elevated WBC count may be an indication of different types of infection.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
13. The patient who is being treated for endometritis is placed in the Fowler position because
this position
a. promotes comfort and rest.
b. facilitates drainage of lochia.
c. prevents spread of infection to the urinary tract.
d. decreases tension on the reproductive organs.
ANS: B
Lochia and infectious material are eliminated by gravity drainage. The Fowler position may
not be the position of comfort, but it does allow for drainage. Good hygiene practice aids in
preventing the spread of infection to the urinary tract. This position aids in the drainage of
lochia and infectious material.
DIF: Cognitive Level: Comprehension OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
14. Nursing measures that help prevent postpartum urinary tract infection include
a. forcing fluids to at least 3000 mL/day.
b. promoting bed rest for 12 hours after birth.
ofUgR
raS
pI
efN
ruG
it T
juB
ic.
eC
anOdMcarbonated beverages.
c. encouraging the intake N
d. discouraging voiding until the sensation of a full bladder is present.
ANS: A
Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products.
The patient should be encouraged to ambulate early. Drinks that acidify urine also inhibit
bacterial growth. These include apricot, plum, prune, and cranberry juice. Grapefruit juice
and soda should be avoided as they increase urine alkalinity. With pain medications, trauma
to the area, and anesthesia, the sensation of a full bladder may be decreased. The patient
needs to be encouraged to void frequently.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
15. Which measure may prevent mastitis in a breastfeeding patient?
a. Wearing a tight-fitting bra.
b. Applying ice packs prior to feeding.
c. Initiating early and frequent feedings.
d. Nursing the infant for 5 minutes on each breast.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Early and frequent feedings prevent stasis of milk, which contributes to engorgement and
mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the
milk. A firm-fitting bra will support the breast, but not prevent mastitis. The breast should
not be bound. Warm packs before feeding will increase the flow of milk.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
16. A patient with mastitis is concerned about breastfeeding while she has an active infection.
Which is an appropriate response by the nurse?
a. Organisms will be inactivated by gastric acid.
b. Organisms that cause mastitis are not passed through the milk.
c. The infant is not susceptible to the organisms that cause mastitis.
d. The infant is protected from infection by immunoglobulins in the breast milk.
ANS: B
The organisms are localized in the breast tissue and are not excreted in the breast milk. The
organism will not get into the infant’s gastrointestinal system. Because of an immature
immune system, infants are susceptible to many infections; however, this infection is in the
breast tissue and is not excreted in the breast milk. The patient is just producing the
immunoglobulin from this infection, so it is not available for the infant.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
17. The nurse suspecting a uterine infection in a postpartum patient should assess the
a. episiotomy site.
NURSINGTB.COM
b. odor of the lochia.
c. abdomen for distention.
d. pulse and blood pressure.
ANS: B
An abnormal odor of the lochia indicates infection in the uterus. The infection may move to
the episiotomy site if proper hygiene is not followed. The abdomen becomes distended
usually because of a decrease of peristalsis, such as after cesarean section. The pulse may be
altered with an infection, but the odor of the lochia will be an earlier sign and will be more
specific.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
18. Following a difficult vaginal birth of a singleton pregnancy, the patient starts bleeding
heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because
the uterine fundus is soft and displaced laterally from midline. Vital signs are 37.6°C
(99.8°F), pulse 90 beats/minute, respirations 20 breaths per minute, and BP 130/90 mm Hg.
Which pharmacologic intervention is indicated?
a. Oxytocin (Pitocin) to be administered in a piggyback solution
b. Administration of methylergonovine (Methergine)
c. Administration of prostaglandin analog
d. Increase in parenteral fluids
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
Prostaglandin analogs can be administered intramuscularly to stop uterine bleeding.
Although Pitocin may be indicated in an attempt to stop uterine bleeding, it is not
administered in a piggyback solution. Methergine is contraindicated in the presence of
hypertension. Increasing fluids will not stop uterine bleeding.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic Parental Therapies
19. Following a vaginal birth, a patient has lost a significant amount of blood and is starting to
experience signs of hypovolemic shock. Which clinical signs would be consistent with this
diagnosis?
a. Decrease in blood pressure, with an increase in pulse pressure
b. Compensatory response of tachycardia and decreased pulse pressure
c. Decrease in heart rate and an increase in respiratory effort
d. Flushed skin
ANS: B
Clinical signs consistent with the early stages of hypovolemic shock include normal blood
pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
20. A patient has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has
stabilized and slowed down considerably. The peripad in place reveals a moderate amount
RSexp
INelle
GTdB.C
M
of bright red blood, with noNcU
lots
whenOmassaging
the fundus. The patient now
complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious
sounds. Based on this clinical presentation, the priority nursing action is to
a. evaluate intake and output of the past 12 hours following birth.
b. initiate a rapid response intervention.
c. obtain an order from the physician for type and crossmatch of 2 units packed red
blood cells (PRBCs).
d. reposition the patient and reassess in 15 minutes. Initiate frequent vital sign
assessments.
ANS: B
Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the
recent patient history, she has received an additional Pitocin infusion relative to the direct
observation of postpartum hemorrhage. Adventitious breath sounds and the patient’s
complaints of difficulty breathing suggest that the patient is progressing to pulmonary
edema. An appropriate intervention is to initiate a rapid response intervention so that the
patient can be stabilized. Calling the physician for a type and crossmatch order is not
indicated. Repositioning the patient, even with the initiation of frequent vital signs, will not
treat the emerging clinical condition. Evaluation of intake and output, although necessary, is
not the priority nursing action at this time.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
21. A postpartum patient has developed deep vein thrombosis (DVT) and treatment with
warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view
of this treatment regimen?
a. Fresh fruits
b. Milk
c. Lentils
d. Soda
ANS: C
Foods that are high in vitamin K should be restricted and/or limited in consumption while
on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
22. To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should
frequently assess
a. temperature.
b. lochial flow.
c. fundal height.
d. breath sounds.
ANS: D
Pulmonary edema is a potential adverse effect of carboprost tromethamine (Hemabate).
Auscultation of breath sounds will identify pulmonary edema; temperature, lochial flow,
and fundal height are not afNfecR
ted by
his m
ion.
I tG
Be.dCicatM
U S N T
O
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
23. If the nurse suspects a complication of a low forceps birth labor, she should immediately
a. administer a strong oral analgesic.
b. assess the perineal and vaginal areas.
c. assess the position of the uterine fundus.
d. review the labor record for duration of second stage.
ANS: B
A low forceps birth may result in significant vaginal trauma. Assessment will provide
information on the extent of trauma of the perineum and vagina. Administering an analgesic
may interfere with obtaining an accurate assessment of the problem, assessing the position
of the uterine fundus will not provide any information on vaginal or perineal trauma, and
reviewing the labor record may support the suspicion that trauma has occurred but will not
identify extent of trauma.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
24. Prior to ambulating the patient whose admission hemoglobin level was 10.2 g/dL to the
bathroom, the nurse should
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
request repeat hemoglobin and hematocrit.
assess the resting pulse rate.
dangle her on the side of the bed.
administer the ordered oral analgesic.
ANS: C
Patients with a low hemoglobin level prior to birth will most likely have a drop in the
hemoglobin level following birth. A low hemoglobin level will result in dizziness and place
the patient at risk for fainting when first ambulating. Having the patient sit on the side of the
bed and dangle her legs prior to standing will allow for the blood pressure to stabilize and
prevent fainting. Requesting additional labs will delay ambulation at a time when the patient
needs to empty her bladder, assessing the resting pulse rate will not provide any information
about the effect of ambulation on her cardiovascular system, and administering an ordered
oral analgesic may contribute to feelings of faintness.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
25. If a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the
nurse recognizes that this hemorrhage occurred
a. on the first postpartum day.
b. during recovery phase of labor.
c. during the third stage of labor.
d. on the second postpartum day.
ANS: D
A late postpartum hemorrhage occurs after the first 24 hours and up to 12 weeks after birth.
N ing
RSthe
INreco
GTvery
B.CphOase,
M and during the third stage are all within
The first postpartum day, durU
the first 24 hours after birth and would be classified as early postpartum hemorrhage.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
26. Which patient data received during report should the nurse recognize as being at risk for
postpartum complications?
a. Gravida 5, para 5
b. Labor duration of 4 hours
c. Infant weight greater than 3800 g
d. Epidural anesthesia for labor and birth
ANS: A
Multiparity (five or more deliveries) is a risk factor for postpartum uterine atony and
hemorrhage. A labor duration of 4 hours is not a risk factor because it is not a precipitate
labor and birth (less than 3 hours), infant weight of 3800 g is not a risk factor because the
infant is not macrosomic, and epidural anesthesia is not a risk factor because epidural
anesthesia does not affect uterine contractions.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
27. Before administering methylergonovine (Methergine), the nurse checks the
a. color of the lochia.
b. blood pressure.
c. location of the fundus.
d. last administration of analgesics.
ANS: B
Methylergonovine (Methergine) elevates the blood pressure and should not be given to a
woman who is hypertensive. The color of the lochia, location of the fundus, and analgesics
are not related to the administration of or contraindicated to this medication.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
28. To evaluate the desired response of methylergonovine (Methergine), the nurse would assess
the patient’s
a. uterine tone.
b. pain level.
c. blood pressure.
d. last voiding.
ANS: A
Methylergonovine (Methergine) simulates sustained contraction of the uterus as evidenced
by the tone of the uterus. The pain level, blood pressure, and voiding patterns are not related
to the effectiveness of the medication.
DIF: Cognitive Level: AN
ppliR
catiI
on G B.OCBJ:M Nursing Process Step: Evaluation
MSC: Patient Needs: PhysioUlogS
ic InNtegT
rity/PhaOrmacologic and Parenteral Therapies
29. As you receive a report, which assessment finding should you recognize as an indication of
a vaginal laceration?
a. Fundus firm at the umbilicus
b. Pulse of 90 bpm, blood pressure of 110/78 mm Hg
c. Bright red continuous trickle of blood from vagina
d. Patient requested pain medication twice during last shift
ANS: C
Lacerations of the birth canal should always be suspected if excessive bleeding continues
when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the
darker red color of lochia; a firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg,
and being medicated twice in one shift are common findings in the postpartum patient.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
30. The nurse observes the patient as she ambulates to the bathroom. Which clinical finding
might indicate development of a DVT (deep vein thrombosis)?
a. Slow gait
b. Shuffling gait
c. Stiffness of right leg
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Leans on husband for support
ANS: C
Deep vein thrombosis may cause pain on ambulation and stiffness of the affected leg. A
slow gait, shuffling gait, and needing ambulatory support are common observations of the
postpartum patient because of weakness and discomfort of the perineum.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
31. If a DVT (deep vein thrombosis) is suspected, the nurse should
a. perform a Homans sign on the affected leg.
b. dorsiflex the foot of the affected leg.
c. palpate the affected leg for edema and pain.
d. place the patient on bed rest, with the affected leg elevated.
ANS: D
Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote
venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are
contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment/Management of Care
32. If the nurse suspects a pulmonary embolism in the patient who suddenly complains of chest
pain, she or he should immediately
a. assess for abnormal breN
ath R
souI
nds.G B.C M
ask S
at 8Nto 1T0 L/miO
nute.
b. apply O2 via tight face mU
c. position the patient in a supine position with the head of the bed flat.
d. monitor pulse oximetry for decreased oxygen saturation.
ANS: B
Administration of oxygen will increase oxygen saturation and decrease hypoxia; assessing
breath sounds and monitoring pulse oximetry provide assessment data but do not correct the
problem. A supine position with the head of the bed flat is incorrect because the head of the
bed should be elevated to facilitate respiratory function.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment/Management of Care
33. To prevent infection of the reproductive tract, the nurse should instruct the patient to
a. change the peripad once per shift.
b. cleanse the perineum from front to back.
c. perform pericare at least twice during the shift.
d. increase fluid intake to 2500 to 3000 mL/day.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Lack of knowledge of hygiene measures increases the risk of postpartum infection. Wiping
the perineum from front to back prevents introduction of infection into the reproductive tract
from the anal area. Changing the peripad once per shift and performing pericare twice in a
shift are incorrect because these interventions should be done at every voiding or bowel
elimination, and increasing fluid intake does not prevent infection of the reproductive tract.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
34. The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the
midline, and 2 cm above the umbilicus. What is the nurse’s priority action?
a. Massage the fundus of the uterus.
b. Assist the patient out of bed to void.
c. Increase the infusion of oxytocin (Pitocin).
d. Ask another nurse to bring in a straight catheter tray.
ANS: A
If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is
firm and to express clots that may have accumulated in the uterus. One hand is placed just
above the symphysis pubis to support the lower uterine segment, while the other hand gently
but firmly massages the fundus in a circular motion. Clots that may have accumulated in the
uterine cavity interfere with the ability of the uterus to contract effectively. They are
expressed by applying firm but gentle pressure on the fundus in the direction of the vagina.
If the uterus does not remain contracted as a result of uterine massage or if the fundus is
displaced, the bladder may be distended. A full bladder lifts the uterus, moving it up and to
the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate
or catheterize her to correcN
t uU
teR
riS
neIaN
toG
nT
yB
ca.
usCedOM
by bladder distention. Note the urine
output. When the fundus is boggy, begin uterine massage. Check the woman’s bladder for
distention and have her empty it if necessary. If she is not able to void and the bladder is
distended, catheterize the patient. Weigh blood-soaked pads.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which information should the nurse recognize as contributing to mastitis in the
breastfeeding mother? (Select all that apply.)
a. Insufficient emptying
b. Feeding every 2 hours
c. Supplementing feedings
d. Blisters on both nipples
e. Alternating breastfeeding positions
ANS: A, C, D
Mastitis may develop because of stasis of milk, inadequate emptying of the breast, skipped
feedings, and introduction of bacteria through injured areas of the nipple. Feeding every 2
hours and alternating breastfeeding positions are both interventions that promote emptying
of the breasts and support successful breastfeeding.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Safe Effective Care Environment/Management of Care
2. The visiting nurse must be aware that women who have had a postpartum hemorrhage are
subject to a variety of complications after discharge from the hospital. These include which
of the following? (Select all that apply.)
a. Anemia
b. Dehydration
c. Exhaustion
d. Postpartum infection
e. Failure to attach to her infant
ANS: A, C, D, E
Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated.
Exhaustion is common after hemorrhage. It may take the new patient weeks to feel like
herself again. Fatigue may interfere with normal parent-infant bonding and the attachment
processes. The patient is likely to require assistance with housework and infant care.
Excessive blood loss increases the risk for infection. The excessive blood loss that this
patient has experienced is likely to lead to risk for infection rather than dehydration. It is
important that all mothers be educated about adequate fluid intake after birth.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 19: Normal Newborn: Processes of Adaptation
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A nursing student is helping the mother-baby nurse with morning vital signs. A baby born
10 hours ago via cesarean birth is found to have moist lung sounds. Which is the best
interpretation of this information?
a. This is an emergency situation.
b. The neonate must have aspirated surfactant.
c. If this baby was born vaginally, it could indicate a pneumothorax.
d. The lungs of a baby delivered by cesarean birth may sound moist for 24 hours after
birth.
ANS: D
The condition will resolve itself within a few hours. For this common condition of
newborns, surfactant acts to keep the expanded alveoli partially open between respirations.
During vaginal birth, the absorption of remaining fluid in the lungs is accelerated by the
process of labor and birth. Remaining lung fluid will move into interstitial spaces and be
absorbed by the circulatory and lymphatic systems. This is a common condition for infants
delivered by cesarean birth. Surfactant is produced by the lungs; therefore aspiration is not a
concern. It is common to have some fluid left in the lungs; this will be absorbed within a
few hours.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: HealN
thUPRroSmIoN
tiG
onTaB
nd.M
aiM
ntenance
CO
2. Which of the following organs are nonfunctional during fetal life?
a. Eyes and ears
b. Lungs and liver
c. Kidneys and adrenals
d. Gastrointestinal system
ANS: B
Most of the fetal blood flow bypasses the nonfunctional lungs and liver. Near term, the eyes
are open and the fetus can hear. Kidneys and adrenals function during fetal life. The fetus
continuously swallows amniotic fluid, which is filtered through the kidneys. The
gastrointestinal system functions during fetal life.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. Which method of heat loss may occur if a newborn is placed on a cold scale or touched with
cold hands?
a. Radiation
b. Conduction
c. Convection
d. Evaporation
NURSINGTB.COM
ANS: B
Conduction occurs when the infant comes in contact with cold objects. Radiation is the
transfer of heat to a cooler object that is not in direct contact with the infant. Convection
occurs when heat is transferred to the air surrounding the infant. Evaporation can occur
during birth or bathing as a result of wet linens or clothes, or insensible heat loss.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
4. How can nurses prevent evaporative heat loss in the newborn?
a. Placing the baby away from the outside wall and the windows
b. Keeping the baby out of drafts and away from air conditioners
c. Drying the baby after birth and wrapping the baby in a dry blanket
d. Warming the stethoscope and nurse’s hands before touching the baby
ANS: C
Wet linens or wet clothes can cause heat loss by evaporation. Radiation heat loss is caused
by placing the baby near cold surfaces or equipment. Heat loss by convection occurs when
drafts come from open doors and air currents created by people moving around. Conduction
heat loss occurs when the baby comes into contact with cold objects or surfaces.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
5. The nurse is explaining how a newly delivered baby initiates respirations. Which statement
explains this process most accurately?
a. Drying off the infant NURSINGTB.COM
b. Chemical, thermal, and mechanical factors
c. An increase in the PO2 and a decrease in the PCO2
d. The continued functioning of the foramen ovale
ANS: B
A variety of these factors are responsible for initiation of respirations. Tactile stimuli aid in
initiating respirations but are not the main cause. The PO2 decreases at birth and the PCO2
increases. The foramen ovale closes at birth.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
6. During fetal circulation the pressure is greatest in the
a. left atrium.
b. right atrium.
c. hepatic system.
d. pulmonary veins.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Pressure in the fetal circulation is greatest in the right atrium, which allows right-to-left
shunting that aids in bypassing the lungs during intrauterine life. The pressure increases in
the left atrium after birth and will close the foramen ovale. The liver does not filter the blood
during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein
during fetal life.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. The infant’s heat loss immediately at birth is predominantly from
a. radiation.
b. conduction.
c. convection.
d. evaporation.
ANS: D
Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs
quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct
contact with the infant. Conduction occurs when the infant comes into contact with a cold
surface. The crib should be preheated to prevent this from occurring. Convection occurs
when heat is transferred to the air surrounding the infant.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. The nurse is explaining the risk of hypothermia in the newborn to a group of nursing
students. Which statement N
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ibGesTtB
he.m
ifestations of hypothermia in the newborn?
CaOnM
a. Newborns shiver to generate heat.
b. Newborns have decreased oxygen demands.
c. Newborns have increased glucose demands.
d. Newborns have a decreased metabolic rate.
ANS: C
In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate,
thus requiring more glucose. Shivering is not an effective method of heat production for
newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with
hypothermia.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
9. Which infant has the lowest risk of developing high levels of bilirubin?
a. The infant who developed a cephalohematoma
b. The infant who was bruised during a difficult birth
c. The infant who uses brown fat to maintain temperature
d. The infant who is breastfed during the first hour of life
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The infant who is fed early will be less likely to retain meconium and resorb bilirubin from
the intestines back into the circulation. Cephalohematomas will release bilirubin into the
system as the red blood cells die off. Bruising will release more bilirubin into the system.
Brown fat is normally used to produce heat in the newborn.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
10. The nurse is preparing to administer a vitamin K injection to the infant shortly after birth.
Which statement is important to understand regarding the properties of vitamin K?
a. It is necessary for the production of platelets.
b. It is important for the production of red blood cells.
c. It is not initially synthesized because of a sterile bowel at birth.
d. It is responsible for the breakdown of bilirubin and the prevention of jaundice.
ANS: C
The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food
is introduced into the bowel. The platelet count in term of newborns is near adult levels.
Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is
important for blood clotting. Vitamin K is necessary to activate the clotting factors.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
11. A meconium stool can be differentiated from a transitional stool in the newborn because the
meconium stool is
a. seen at 3 days of age. NURSINGTB.COM
b. the residue of a milk curd.
c. passed in the first 24 hours of life.
d. lighter in color and looser in consistency.
ANS: C
Meconium should be passed in the first 24 hours of life. Meconium stool is the first stool of
the newborn. Meconium stool is made up of matter in the intestines during intrauterine life.
Meconium is dark in color and sticky.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
12. Which of the following is the most likely cause of regurgitation when a newborn is fed?
a. The gastrocolic reflex
b. A relaxed cardiac sphincter
c. An underdeveloped pyloric sphincter
d. Placing the infant in a prone position following a feeding
ANS: B
The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. The
gastrocolic reflex increases intestinal peristalsis after the stomach fills. The pyloric sphincter
goes from the stomach to the intestines. The infant should be placed in a supine position.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
13. The process in which bilirubin is changed from a fat-soluble product to a water-soluble
product is known as
a. albumin binding.
b. enterohepatic circuit.
c. conjugation of bilirubin.
d. deconjugation of bilirubin.
ANS: C
Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a
water-soluble product. Albumin binding attaches something to a protein molecule.
Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the
intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated
bilirubin is fat-soluble.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
14. A newborn is admitted to the special care nursery with hypothermia. Which complication
should the nurse monitor for closely?
a. Hyperglycemia
b. Metabolic acidosis
c. Respiratory acidosis
d. Vasodilation of peripheral blood vessels
N R I G B.C M
U S N T
O
ANS: B
Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the
presence of insufficient oxygen causes increased production of acids. Metabolism of brown
fat also releases fatty acids. The result can be metabolic acidosis, which can be a
life-threatening condition. Cold stress causes hypoglycemia because glucose is being
metabolized. Cold stress does not cause respiratory acidosis. As the infant’s body attempts
to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to
reduce heat loss from the skin surface.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
15. Which action by the nurse can result in hyperthermia in the newborn?
a. Placing a cap on the newborn
b. Wrapping the newborn in a warm blanket
c. Placing the newborn in a skin to skin position with the mother
d. Placing the newborn in the radiant warmer without attaching the skin probe
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Newborns may be overheated by poorly regulated equipment designed to keep them warm.
When radiant warmers, warming lights, or warmed incubators are used, the temperature
mechanism must be set to vary the heat according to the infant’s skin temperature; this
prevents too much or too little heat. Alarms to signal that the infant’s temperature is too
high or too low should be functioning properly. If the skin probe is not used, the alarms will
not function properly. Putting a hat on the newborn, wrapping the newborn in a warm
blanket, or placing the newborn skin to skin with the mother will not cause hyperthermia.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
16. A multiparous patient arrives to the labor unit and urgently states, “The baby is coming
RIGHT NOW!” The nurse assists the patient into a comfortable position and delivers the
infant. To prevent infant heat loss from conduction, what is the priority nursing action?
a. Dry the baby off.
b. Turn up the temperature in the patient’s room.
c. Pour warmed water over the baby immediately after birth.
d. Place the baby on the patient’s abdomen after the cord is cut.
ANS: D
Movement of heat away from the body occurs when newborns have direct contact with
objects that are cooler than their skin. Placing infants on cold surfaces or touching them with
cool objects causes this type of heat loss. The reverse is also true; contact with warm objects
increases body heat by conduction. Warming objects that will touch the infant or placing the
unclothed infant against the mother’s skin (skin to skin) helps prevent conductive heat loss.
Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature
in the patient’s room helps N
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ithRhSeI
atNloGsT
s tB
hr.oC
ugOhMconvection. Pouring warm water over a
baby occurs with the first bath, which is conducted after the baby’s temperature has
stabilized. Pouring warm water over the baby prior to that time will increase heat loss
through evaporation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
17. The nurse is planning to conduct the initial assessment of a full-term newborn. Included in
the plan is providing a neutral thermal environment. To accomplish this plan, what is the
desired environmental temperature to conduct the assessment?
a. 24 to 27°C (75.2 to 80.6°F)
b. 28 to 31.5°C (82.4 to 88.7°F)
c. 32 to 33.5°C (89.6 to 92.3°F)
d. 34 to 37.5°C (93.2 to 99.5°F)
ANS: C
A neutral thermal environment is one in which the infant can maintain a stable body
temperature with minimal oxygen need and without an increase in metabolic rate. The range
of environmental temperature that allows this stability is called the thermoneutral zone. In
healthy, unclothed, full-term newborns, an environmental temperature of 32 to 33.5°C (89.6
to 92.3°F) provides a thermoneutral zone. When the infant is dressed, the thermoneutral
range is 24 to 27°C (75.2 to 80.6°F).
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
18. An infant at 39 weeks’ gestation was just delivered; included in the protocol for a term
infant is an initial blood glucose assessment. The nurse obtains the blood sample and the
reading is 58 mg/dL. What is the priority nursing action based upon this reading?
a. Document the finding in the newborn’s chart.
b. Double-wrap the newborn under a warming unit.
c. Feed the newborn a 10% dextrose solution.
d. Notify the neonatal intensive care unit (NICU) of the pending admission.
ANS: A
In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90
mg/dL thereafter. There is no general consensus regarding the level of blood glucose that
defines hypoglycemia; however, a level below 40 to 45 mg/dL in the term infant is often
used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the
glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only
administered when the glucose levels are very low. There is no information in the stem
indicating the need for admission to the NICU.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
19. During the first few minutes after birth, which physiologic change occurs in the newborn as
a response to vascular pressure changes in increased oxygen levels?
a. Increased pulmonary vascular resistance
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b. Decreased systemic resN
c. Decreased pressure in the left heart
d. Dilation of pulmonary vessels
ANS: D
Dilation of pulmonary vessels occurs in response to increased oxygen levels. Decrease in
pulmonary vascular resistance occurs. Increase in systemic vascular resistance occurs.
Increased pressure in the left heart occurs.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
20. Which infant is at greater risk to develop cold stress?
a. Full-term infant delivered vaginally without complications.
b. 36-week infant with an Apgar score of 7 to 9.
c. 38-week female infant delivered via cesarean birth because of cephalopelvic
disproportion.
d. Term infant delivered vaginally with epidural anesthesia.
ANS: B
Preterm infants are at greater risk to develop cold stress because of thin skin, decreased
subcutaneous fat, and poor muscle tone.
DIF:
Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Health Promotion and Maintenance
21. A reported hematocrit level for a newborn delivered by vaginal birth is 75%. Based on this
lab value, which complication is the newborn least likely to develop?
a. Hypoglycemia
b. Respiratory distress
c. Infection
d. Jaundice
ANS: C
The presence of polycythemia as indicated by this lab result could result in the infant being
at risk to develop hypoglycemia, respiratory distress, and jaundice. Possible infection would
be unrelated to this diagnostic value.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
MULTIPLE RESPONSE
1. In the newborn nursery, you are reviewing the maternal medication list to ascertain if there
is any significant risk to the newborn. Which medications would pose a potential risk to the
newborn in terms of clotting ability? (Select all that apply.)
a. Carbamazepine
b. Phenytoin (Dilantin)
c. Phenobarbital
d. INH (Isoniazid)
NURSINGTB.COM
e. Prenatal vitamins with iron
ANS: A, B, C, D
Carbamazepine, phenytoin (Dilantin), phenobarbital, and isoniazid (INH) when taken by the
mother can affect the newborn’s clotting ability. Anticonvulsant usage can cause bleeding
problems. Prenatal vitamins with added iron should have no effect on the newborn’s clotting
ability.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
2. The nurse is teaching the postpartum patient about newborn transitional stools. Which
should the nurse include in the teaching session with regard to transitional stools? (Select all
that apply.)
a. They are a greenish brown color.
b. They are of a looser consistency.
c. They have a tarlike consistency.
d. They have a consistency of mustard.
e. They are seedy, with a sweet-sour smell.
ANS: A, B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Meconium stools are followed by transitional stools, a combination of meconium and milk
stools. They are greenish brown and of a looser consistency than meconium. Stools that are
tarlike are meconium stools. Infants fed with breast milk are seedy, with a sweet-sour smell;
the meconium has the consistency of mustard.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
3. Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.)
a. Post-term newborn
b. 38 weeks’ gestation newborn
c. Small-for-gestational-age newborn
d. Large-for-gestational-age newborn
e. Term newborn delivered by cesarean birth
ANS: A, C, D
Many newborns are at increased risk for hypoglycemia. In the preterm, late preterm (born
between 34 weeks and 36 6/7 weeks of gestation), and small-for-gestational-age infant,
adequate stores of glycogen or even fat for metabolism may not have accumulated. Stores
may be used up before birth in the post-term infant because of poor intrauterine nourishment
from a deteriorating placenta. Large-for-gestational-age infants and those with diabetic
mothers may produce excessive insulin that consumes available glucose quickly. The
newborn born at 38 weeks and the newborn born by cesarean at term have lower risk for
hypoglycemia.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: PhysNioUloRgS
icIInNteGgT
riB
ty.COM
COMPLETION
1. The postpartum nurse is administering vitamin K (phytonadione) to a newborn. The
prescribed order is to administer one dose of 0.5 mg of vitamin K via the intramuscular (IM)
route within 1 hour after birth. The ampule of vitamin K sent from the pharmacy is 1 mg/0.5
mL. How many milliliters does the nurse draw up to administer the correct dose? Record
your answer to two decimal points.
mL
ANS:
0.25
Use the medication calculation formula to calculate the correct dose.
Formula:
Desired/available  volume = milliliters per dose
0.5 mg/1 mg  0.5 mL = 0.25 mL
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 20: Assessment of the Normal Newborn
Foundations of Maternal-Newborn & Women's Health Nursing, 7th Edition
MULTIPLE CHOICE
1. The hips of a newborn are examined for developmental dysplasia. Which clinical finding
indicates an incomplete development of the acetabulum?
a. Negative Barlow test
b. Equal knee heights
c. Negative Ortolani sign
d. Thigh and gluteal creases are asymmetric.
ANS: D
Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip
is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a
clunking sensation and indicates a dislocated femoral head moving into the acetabulum.
During a positive Barlow test, the examiner can feel the femoral head move out of the
acetabulum.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. Which newborn reflex is elicited by stroking the lateral sole of the infant’s foot from the
heel to the ball of the foot?
a. Babinski
b. Stepping
NURSINGTB.COM
c. Tonic neck
d. Plantar grasp
ANS: A
The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The
stepping reflex occurs when infants are held upright, with their heel touching a solid surface,
and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex)
refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is
similar to the palmar grasp reflex; when the area below the toes is touched, the infant’s toes
curl over the nurse’s finger.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. Infants who develop cephalohematoma are at an increased risk for
a. infection.
b. jaundice.
c. caput succedaneum.
d. erythema toxicum.
ANS: B
NURSINGTB.COM
Cephalohematomas are characterized by bleeding between the bone and its covering, the
periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants
are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections.
Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum
is a benign rash of unknown cause that is sometimes referred to as “fleabite rash.”
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which statement best explains why a newborn with a congenital defect of the penis should
not be circumcised?
a. There is increased risk of infection.
b. The foreskin might be needed for future repairs.
c. A circumcision will make the defect more visible.
d. There is no medical rationale for a circumcision.
ANS: B
The foreskin may be used to correct a defect. There is no significant increase in infection. A
circumcision would not make the defect more noticeable. A circumcision is a decision made
by the parents; however, in this case the foreskin might be needed to correct a defect. Such
defects include epispadias and hypospadias.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
5. A maculopapular rash with a red base and a small white papule in the center is commonly
known as
NURSINGTB.COM
a. milia.
b. Mongolian spots.
c. erythema toxicum.
d. Café-au-lait spots.
ANS: C
A maculopapular rash with a red base and a small white papule in the center is a description
of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the
face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned
newborns, usually on the sacrum. Café-au-lait spots are pale tan (the color of coffee with
milk) macules. Parents should be reassured that occasional spots occur normally in most
newborns.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
6. A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for
weight?
a. Below the 90th
b. Less than the 10th
c. Greater than the 90th
d. Between the 10th and 90th
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
The LGA rating is based on weight and is defined as greater than the 90th percentile in
weight. An infant between the 10th and 90th percentiles is average for gestational age. An
infant in less than the 10th percentile is small for gestational age.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. A new patient asks, “Why are you doing a gestational age assessment on my baby?” The
nurse’s best response is
a. “It was ordered by your physician.”
b. “This must be done to meet insurance requirements.”
c. “It helps us identify infants who are at risk for any problems.”
d. “The gestational age determines how long the infant will be hospitalized.”
ANS: C
The nurse should provide the mother with accurate information about various procedures
performed on the newborn. Assessing gestational age is a nursing assessment and does not
have to be ordered. It is not necessary for insurance needs. Gestational age does not dictate
hospital stays. Problems that occur because of gestational age may prolong the stay.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
8. Which nursing action is designed to avoid unnecessary heat loss in the newborn?
a. Maintain room temperature at 21°C (70°F).
caRleSbIeN
foG
reTwBe.
igC
hiO
ngMthe infant.
b. Place a blanket over theNsU
c. Take the rectal temperature every hour to detect early changes.
d. Undress the infant completely for assessments so that they can be finished quickly.
ANS: B
Padding the scale prevents heat loss from the infant to a cold surface by conduction. The
room temperature should be appropriate to prevent heat loss from convection. Also, if the
room is warm enough, radiation will assist in maintaining body heat. Hourly assessments
are not necessary for a normal newborn with a stable temperature. Undressing the infant
completely will expose the child to cooler room temperatures and cause a drop in body
temperature by convection.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
9. The nurse is performing a gestational age assessment on a newborn. Which characteristic
indicates the greatest gestational maturity?
a. The infant’s arms and legs are extended.
b. There is some peeling and cracking of the skin.
c. There are few rugae on the scrotum and the testes are high in the scrotum.
d. The arm can be positioned with the elbow beyond the midline of the chest.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the
newborn. Extended arms and legs are a sign of preterm infants. Few rugae on the scrotum
indicate a younger age in the newborn. The arm being able to be positioned with the elbow
beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a
younger age.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. A new mother states, “My baby is so thin and wrinkled. It looks like he has too much skin.”
Which is the most therapeutic response by the nurse in response to the patient’s statement?
a. “You sound disappointed about how your infant looks.”
b. “All mothers are concerned about how their babies look.”
c. “Don’t worry. In no time he’ll fill out his skin and look just fine.”
d. “You know, all the cigarettes you smoked interfered with the nourishment he
needed.”
ANS: A
The nurse should clarify the patient’s statement and allow her to verbalize her feelings. “All
mothers are concerned about how their babies look” generalizes her concerns and does not
answer the mother’s question. “Don’t worry. In no time he’ll fill out his skin and look just
fine” does not directly answer the mother’s question and could leave her feeling like she
asked an unacceptable question. “You know, all the cigarettes you smoked interfered with
the nourishment he needed” is condescending and hurtful and would not allow for further
conversation between the nurse and mother.
DIF: Cognitive Level: AN
ppU
liR
caS
tiI
onNGTB.OCBO
J:M Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
11. Which assessment finding of a newborn requires prompt action by the nurse?
a. Respiratory rate of 50 breaths per minute
b. Cyanosis of the extremities
c. Pause in breathing lasting 20 seconds
d. Pause in breathing for 15 seconds followed by rapid respirations
ANS: C
Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis,
pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt
intervention. A respiratory rate of 50 breaths per minute is still within the normal range.
Tachypnea is considered to be 60 breaths per minute or more. Cyanosis of the extremities or
acrocyanosis is normal during the first day after birth and if the infant becomes cold.
Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes
followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants
during the first few days but is more common in preterm infants.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
12. The nurse is receiving shift report on her mother-baby couplet assignment. Which infant
should the nurse evaluate first?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
38-weeks’ gestation female newborn with a blood sugar level of 60 mg/dL
Term male newborn with a noted axillary temperature of 37.2°C (99°F)
40-weeks’ gestation female newborn with reported poor feed at last attempt
39-weeks’ gestation male newborn who has been crying prior to initial bath
ANS: C
Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this
newborn should be assessed first at the start of the shift. Although the newborn is term, and
it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is
asymptomatic. Blood sugar results are within normal range and the newborn is considered to
be term. Temperature is within normal range and the newborn is term. This newborn is
considered to be term, and crying alone does not increase risk stratification.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment
13. Inspection of a newborn’s head following birth reveals a hard ridged area and significant
molding. The anterior and posterior fontanels show no sign of depression. Delivery history
indicates that the mother was pushing for over 3 hours and had epidural anesthesia. A
vacuum extraction was necessary. Based on this information the nurse would
a. continue to monitor newborn and anticipate that molding will subside.
b. inspect and document location of fontanels to complete the head assessment.
c. contact the pediatric provider.
d. note findings as being within normal limits as a result of the strenuous birth
process.
ANS: C
NURSINGTB.COM
Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis
(premature closing of sutures) and therefore should contact the pediatric provider
immediately. Even though the birth process was difficult and vacuum extraction was used,
this does not account for the physical findings. Continuing to monitor is not a prudent action
at this time. Although it is important to note the presence of fontanels, the immediate action
would be to make the appropriate referral for medical intervention.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
14. The nurse is performing the initial assessment of a newborn and notes retractions, nasal
flaring, and tachypnea. The nurse will continue to perform a focused assessment on which
system?
a. Respiratory
b. Cardiovascular
c. Gastrointestinal
d. Musculoskeletal
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Tachypnea, a respiratory rate of more than 60 breaths per minute, is the most common sign
of respiratory distress. Retractions occur when the soft tissue around the bones of the chest
is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions
occur when the area under the sternum retracts each time the infant inhales. When the
muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are
present. A reflex widening of the nostrils occurs when the infant is receiving insufficient
oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air
entering the lungs.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
15. The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery.
On review of the newborn’s chart, the nurse sees a notation of caput succedaneum. What
will the nurse expect to find in the mother’s chart?
a. Race: non-White
b. A longer than usual labor
c. Administration of an epidural
d. Delivery by cesarean birth
ANS: B
A caput succedaneum is an area of localized edema that appears over the vertex of the
newborn’s head as a result of pressure against the mother’s cervix during labor. The
pressure interferes with blood flow from the area, causing localized edema at birth. The
edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the
more pronounced the caput. Mongolian spots are associated with infants born to non-White
parents. An epidural may bN
eU
aR
coS
ntI
riN
buGtiT
ngBf.
acCtoOrM
to a prolonged labor, but it is the pressure
of the head against the cervix that gives rise to the caput. If labor is prolonged without
descent of the head, a cesarean birth may follow but is not the cause of the caput.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
16. The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way
to evaluate for this finding?
a. Depress the tip of the nose.
b. Stroke the outer aspect of the foot.
c. Place a finger in the palm of the hand.
d. Rotate the hips in an upward and outward direction.
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful
when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing
the infant’s skin over a firm surface, such as the end of the nose or the sternum. The skin
blanches as the blood is pressed out of the tissues, making it easier to see the yellow color
that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice
begins at the head and moves down the body, and the areas of the body involved should be
documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The
Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is
determined by placing a finger in the newborn’s palm. The Barlow and Ortolani tests are
methods of assessing for hip instability in the newborn period. Both legs should abduct
equally in normal infants. Abducting the affected hip may be difficult. A hip click may be
felt or heard but is usually normal and is different from the clunk of hip dysplasia when the
femoral head moves in the hip socket.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
17. An infant at term was born at 0105 hours. The nurse is developing a plan of care for the
newborn. During which time range will the nurse plan on performing the assessment to
determine a Ballard score?
a. 0115 to 0130
b. 0200 to 0600
c. 1400 to 1800
d. 2000 to 2300
ANS: B
The new Ballard score is ofNteU
nR
uS
seI
dN
toGdT
etB
er.
mC
inO
eM
gestational age based on neuromuscular
and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks.
The assessment is most accurate when performed within 12 hours of birth. The Ballard
score is accurate within a 2-week window of gestational age.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
18. The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the
following figures depicts this birthmark?
a.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
b.
c.
NURSINGTB.COM
d.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A nevus flammeus (port wine stain) is a permanent, flat, pink to dark reddish-purple mark
that varies in size and location. Erythema toxicum is a red blotchy area that may have white
or yellow papules or vesicles in the center; it is not a birthmark. Mongolian spots are
bluish-black marks that resemble bruises. They usually occur in the sacral area but may
appear on the buttocks, arms, shoulders, and other areas. A nevus simplex is also called
salmon patch, stork bite, or telangiectatic nevus. It is a flat pink or reddish discoloration
from dilated capillaries that occur over the eyelids, just above the bridge of the nose, or at
the nape of the neck.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse is conducting a body system assessment of the newborn. Which are abnormal
findings that the nurse should report? (Select all that apply.)
a. Low-set ears
b. Yellow sclera
c. A doll’s eye sign
d. Edema of the eyelids
e. Absence of the grasp reflex
ANS: A, B, E
Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish
white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious
neurologic problem. The doll’s eye sign is a normal finding in the newborn; when the head
NUthe
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INs GmT
B.C
M the other side. Edema of the eyelids and
is turned quickly to one side,
ove
towOard
subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head
during birth, which causes capillary rupture in the sclera.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
2. To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse
would consider the following clinical information. (Select all that apply.)
a. These are both normal presentations because of the birth process and will resolve
within 24 to 48 hours.
b. Cephalohematoma manifests as a localized area of swelling as compared with
caput succedaneum, which appears as a general swelling of the head.
c. A cephalohematoma can develop several hours or days after the birth event,
whereas caput succedaneum is noted shortly before or immediately after the birth
event.
d. Edema that crosses suture lines is observed with caput succedaneum.
e. With a cephalohematoma, bleeding occurs between the bone and skull.
ANS: C, D, E
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical
condition is caused by bleeding between the periosteum and skull and is a serious medical
condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on
the fetal head during the birth process. Swelling is localized and crosses the suture line,
whereas with cephalohematoma the swelling is more generalized and crosses the suture line.
Caput resolves within 12 to 48 hours after the birth event.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
3. Which clinical findings are early signs of hypoglycemia in the newborn? (Select all that
apply.)
a. Jitteriness
b. Poor feeding
c. Respiratory difficulty
d. An increase in temperature
e. A capillary refill of 2 seconds
ANS: A, B, C
Early signs of hypoglycemia include jitteriness and other central nervous system signs and
signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill
of 2 seconds is a normal finding in the newborn.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
staRtiS
onIaN
l aGgT
eB
as.
seC
ssO
mMent on a newborn. Which characteristics
4. The nurse is performing a gNeU
indicate a preterm newborn? (Select all that apply.)
a. Translucent skin
b. Extended limp arms and legs
c. The ear springs back when folded
d. Square window angle of 45 degrees or less
e. Large clitoris and labia minora in the female newborn
ANS: A, B, E
The very preterm infant’s skin is translucent because it is thin and has little subcutaneous fat
beneath the surface. Preterm neonates have immature flexor muscles and little energy or
muscle tone. Therefore they have extended and limp arms and legs that offer little resistance
to movement by the examiner. In the preterm female infant, the labia majora are small and
separated, and the clitoris and labia minora are large by comparison. In the term neonate, the
ear springs back to its original position immediately. The more mature the neonate, the
smaller the angle of the square window assessment until the palm folds flat against the
forearm at term, the result of maternal hormones at the end of pregnancy.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 21: Care of the Normal Newborn
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. A yellow crust has formed over the circumcision site. The mother calls the hotline at the
local hospital 5 days after her son was circumcised. She is very concerned. Which response
by the nurse is most appropriate?
a. The yellow crust should not be removed.
b. This yellow crust is an early sign of infection.
c. Discontinue the use of petroleum jelly to the tip of the penis.
d. After circumcision, the diaper should be changed frequently and fastened snugly.
ANS: A
Crusting is a normal part of healing. The normal yellowish exudate that forms over the site
should be differentiated from the purulent drainage of infection. The only contraindication
for petroleum jelly is the use of a PlastiBell device. The diaper should be fastened loosely to
prevent rubbing or pressure on the incision site.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
2. Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is
optimal for the newborn?
a. Deltoid muscle
b. Gluteal muscle
NURSINGTB.COM
c. Rectus femoris muscle
d. Vastus lateralis muscle
ANS: D
The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels.
Gluteal muscles are not used until a child has been walking for at least 1 year to develop
these muscles. The rectus femoris is used only if absolutely necessary because this muscle is
located closer to the sciatic nerve and blood vessels, which poses a greater danger. The
deltoid is not a recommended site for newborn injections.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
3. Which information should the nurse teach to new parents regarding the use of a bulb
syringe?
a. Use it only once per day.
b. Suction the back of the throat vigorously.
c. Insert the syringe into the sides of the mouth.
d. Always suction the mouth before suctioning the nose.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The syringe should be inserted into the sides of the mouth rather than the back of the throat
to avoid a vagal response and bradycardia. Suction can occur as needed. Vigorous suction of
the back of the throat may stimulate the vagal nerve and produce bradycardia. The mouth
should be suctioned first to prevent aspiration.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
4. In providing and teaching cord care, which guidance is most appropriate?
a. Cord care is done only to control bleeding.
b. Alcohol is the only agent used for cord care.
c. It takes a minimum of 24 days for the cord to separate.
d. Keeping the cord dry will decrease bacterial growth.
ANS: D
Bacterial growth increases in a moist environment; therefore keeping the umbilical cord dry
impedes bacterial growth. Evidence-based practice guidelines show that cleaning the cord
with water when necessary and keeping it clean and dry is the best method of care. No other
agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14
days.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
5. Which of the following guidelines should the nurse implement to prevent the abduction of a
newborn from the hospital?
ofUtR
imSeI
inN
faGnT
tsB
ar.
eC
ouOt M
of the nursery
a. Restricting the amount N
b. Questioning anyone who is seen walking in the hallways carrying an infant
c. Allowing no visitors in the maternity area except those who have identification
bracelets
d. Instructing the parents not to give the baby to anyone except the nurse assigned
that day
ANS: B
Infants should be transported in the hallways only in their cribs. In many facilities babies are
cared for in the mother’s room, rather than a well-baby nursery. Infants need to spend time
with the parents to facilitate the bonding process and facilitate learning. It is impossible for
one nurse to be on call for one mother and baby for the entire shift; therefore the parents
need to be able to identify all of the staff that will be caring for them. Most maternity units
have special identification badges unique to that area. All patients should be oriented to
these identification badges.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
6. A nursing student has been caring for a patient and newborn all morning. After taking the
newborn to the nursery for hearing screening, the student is returning the infant to his
mother. Which procedure is correct for identifying the newborn?
a. Ask the mother to state her name and the name of her infant.
b. Call out the mother’s full name before leaving the infant with her.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
c. Have the mother read her printed band number and verify that it matches the
infant’s number.
d. Return the infant with no special procedure because the student knows the mother
and infant.
ANS: C
The mother and infant should have identifying armbands with matching numbers. Both of
these bands should be reviewed to determine that the mother has the correct infant. The
other actions do not adequately verify the identities of mother and infant.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
7. The nurse is explaining the procedure of newborn screening to parents prior to discharge.
Which statement by the parents indicates a need for further teaching?
a. “We understand the tests are performed at 24 to 48 hours.”
b. “We’re glad all the tests can be done on one blood sample.”
c. “We wish the tests would screen for congenital hypothyroidism, it runs in our
family.”
d. “We know that if the tests are done before 24 hours, the tests will need to be
repeated at 1 to 2 weeks.”
ANS: C
Common disorders often included in newborn screening are phenylketonuria (PKU),
hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and
thalassemia, and congenital adrenal hyperplasia. The parents require further teaching if they
suggest that congenital hypothyroidism is not screened. The newborn screening tests are
N R I th.GNTewbor
B.CO
M
performed at 24 to 48 hours aUfterSbirN
n screening requires a blood sample taken
from the infant’s heel, and only one blood sample is needed for all tests. Tests performed
within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants
tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that
disorders are not missed because of early testing.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
8. Which newborn assessment finding requires the nurse to take immediate action?
a. Glucose level of 40 mg/dL
b. Axillary temperature of 37°C (98.6°F)
c. Mild yellow tinge to skin at 32 hours of age
d. Mild inflammation of conjunctiva after eye prophylaxis
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A glucose level of 40 mg/dL requires an action. The nurse should follow agency policy and
health care provider orders regarding feeding infants with low glucose levels. A common
practice is to feed the newborn breast milk or formula if the glucose screening reveals a
level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe
hypoglycemia may need intravenous feedings to provide glucose more rapidly. A normal
temperature for a newborn is 36.5 to 37.5°C (97.7 to 99.5°F). Mild jaundice at 32 hours of
age is physiologic jaundice and does not need an action by the nurse, just further
monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye
treatment.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
9. The nurse is evaluating a newborn’s circumcision 30 minutes after the procedure. The nurse
notes excessive bleeding coming from the circumcised area. Which priority intervention
should the nurse implement at this time?
a. Apply pressure to the site.
b. Continue to observe for another 30 minutes.
c. Apply the diaper tightly over the circumcised area.
d. Apply petroleum jelly to the site with a small piece of gauze.
ANS: A
If excessive bleeding occurs after a circumcision, pressure is applied to the site. The nurse
notifies the physician, who may apply Gelfoam or epinephrine or suture the small blood
vessels. A small amount of blood loss may be significant in an infant, who has a small total
blood volume. Continuing to observe could mean additional blood loss. Applying the diaper
tightly will not stop the bleN
edU
inRgS
. PIeN
troGleTuB
m.jeCllO
yM
is applied to keep the diaper from sticking
to the circumcised area. It will not stop the bleeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
10. In which position should the parents be instructed to place their newborn for sleep?
a. On the back
b. On the left side
c. On the right side
d. On the abdomen
ANS: A
The American Academy of Pediatrics (AAP) recommends that mothers and fathers be
taught to place infants consistently on the back for sleep. This position is associated with the
lowest rate of SIDS. The side-lying position is not advised because of the possibility that the
infant might roll to the prone position. The newborn should not be placed on the abdomen
except for short periods under supervision in order to prevent plagiocephaly.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
11. A 38 weeks’ gestation fetus is delivered via cesarean birth and transported to the newborn
nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an
initial assessment in the newborn nursery. Which is the priority nursing diagnosis?
a. Risk for injury related to potential equipment malfunction of radiant warmer
b. Altered tissue perfusion related to use of medications during delivery process
c. Ineffective airway clearance due to mode of delivery and use of anesthetics
d. Risk for ineffective thermoregulation related to gestational age
ANS: C
Delivery via cesarean birth may affect the newborn’s ability to remove excess fluid
secretions because the infant did not move down the birth canal and thus may be at risk for
airway concerns. There is no evidence to support that the equipment is malfunctioning.
Although the use of medications may affect the newborn in terms of respiratory, cardiac,
and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is
at term based on reported gestational age and therefore is not a risk for ineffective
thermoregulation because of this fact.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and
Newborn Care
12. An infant’s temperature is recorded at 36°C (96.8°F) during the morning assessment. Which
action should the nurse take?
a. Note the findings in the electronic health record (EHR).
b. Unwrap the infant and inspect for abnormalities.
glU
uR
coS
seIw
c. Provide the infant withN
NaGteTr.B.COM
d. Make sure that the infant is wrapped securely with a blanket and recheck
temperature in 15 minutes.
ANS: D
This temperature potentially indicates hypothermia, so the infant should be wrapped
securely in a blanket and reassessed after that intervention. Findings should be documented
in the EHR; however, this is not the priority intervention. Unwrapping the infant would lead
to further compromise and additional risk for the core temperature to drop. Feeding the
infant with glucose water may eventually be used as an intervention if the infant shows
additional signs of hypoglycemia, which may accompany hypothermia.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
13. When an infant’s temperature drops from (37 to 36.3°C) 98.7 to 97.4°F, the nurse should
a. instruct parents on the risks of cold stress.
b. determine the time and amount of last feeding.
c. increase the temperature in the mother’s room.
d. evaluate infant for the presence of a blood sugar level higher than 50 mg/dL.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Temperature instability in the neonate may be caused by a decrease in blood glucose levels.
Infants who do not maintain adequate intake will not have adequate energy to maintain
temperature; instructing parents on cold stress and increasing the temperature in the room
are interventions to maintain a stable temperature but will not correct the underlying
problem. A blood sugar level higher than 50 mg/dL is a normal finding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
14. Administration of medications after birth is the topic of discussion during a prenatal
education class. Which statement indicates to the nurse that the pregnant patient understands
the primary indication for the administration of vitamin K?
a. “The nurse will draw blood to determine if vitamin K is needed.”
b. “Vitamin K prevents the possibility of bleeding problems in my baby.”
c. “My baby will receive medication by mouth when the nurse administers the
vitamin K.”
d. “Vitamin K will be administered shortly after birth, generally within the first
hour.”
ANS: B
This indication is the reason for vitamin K administration. Vitamin K is given to neonates
because they cannot synthesize it in the intestines without bacterial flora. This places them
at risk for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of
vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to
produce vitamin K in sufficient amounts. Vitamin K is not routinely given by mouth.
Although the injection is usually given within the first hour after birth, it can be delayed
until the infant has finishedNbU
reR
asStfI
eeNdG
inT
gB
sh.
oC
rtlO
yM
after birth.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
15. An hour after birth, the nurse assesses a newborn’s temperature and notes that it is 36.2°C
(97.2°F). The next activity planned for the newborn is the bath, and the new mother and
father are invited to participate in the procedure. What is the nurse’s next action?
a. Take the infant’s temperature rectally.
b. Ask the father to test the water to determine if it is too hot.
c. Delay the bath until the newborn’s temperature is above 36.7°C (98°F).
d. Explain to the new parents that no soap should be used to cleanse the eyes.
ANS: C
A temperature of 36.7°C (98°F) or higher is often used to determine when to bathe the
infant. The infant can lose heat in the bath through the process of evaporation. Rectal
temperatures are avoided because they can traumatize the rectal mucosa. The water
temperature should be approximately 38 to 40°C (100.4 to 104°F). The nurse should
determine if the bath water is the correct temperature to avoid scalding the newborn. Explain
the process of giving a bath during the procedure. Informing the parents before the
procedure may result in loss of information.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
16. Which intervention will be most helpful to parents in identifying problems with an infant car
seat?
a. Questioning the parents about the instructions
b. Providing the parents with current laws on infant and child safety
c. Asking the parents to demonstrate how to secure the infant in the car seat
d. Allowing the parents to ask questions and express feelings about infant restraint
ANS: C
If the nurse observes the parents demonstrating the use of the car seat, any problems or
misunderstandings can be identified. Questioning the parents is not a helpful way to identify
problems with a car seat; a return demonstration is preferable. Providing information
without a return demonstration will not prove that the parents are comfortable with the car
seat for the infant. A return demonstration is the best way to ensure that the parents
understand car seat safety. Parents should also be encouraged to attend a local car seat
fitting station.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
17. Which statement made by a parent indicates a need for the nurse to provide instruction on
safety and accident prevention?
a. “I always take the phone off the hook when I give my baby a bath so I won’t be
disturbed.”
b. “I’m going to buy a backpack for my 2-week-old baby so I can carry her in it
whenever she gets fussy.”
wR
haSt I
neNwGtT
hiB
ng.sC
mO
yM
baby will be learning to do in the
c. “I’ve been reading abouNt U
next month or two, so I’ll know what to expect.”
d. “I make sure I always place the baby in her own crib after feeding her in my bed.”
ANS: B
Backpacks should be used only for infants old enough to support their heads well by
themselves. Ideally parents should obtain an infant carrier designed specifically for carrying
a baby. “I always take the phone off the hook when I give my baby a bath so I won’t be
disturbed,” “I’m going to buy a backpack for my 2-week-old baby so I can carry her in it
whenever she gets fussy,” and “I make sure I always place the baby in her own crib after
feeding her in my bed” are all appropriate statements regarding newborn safety.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
18. Which statement made by a new mother should be a cause of concern to the nurse?
a. “I will start my baby on solid foods at 5 months.”
b. “I usually keep the temperature in my house at 22.2°C (72°F).”
c. “I plan to position my infant on his back when sleeping.”
d. “I don’t intend to spoil my baby by picking him up every time he cries.”
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Infant crying often indicates an unmet need. Parents should be cautioned about ignoring
crying. Infants whose parents intervene appropriately for crying are less likely to cry
excessively as they grow older. Solid foods should be started no earlier than 4 to 6 months.
A house temperature of 22.2°C (72°F) is appropriate for a newborn. The appropriate
position for a baby is on his or her back.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
19. Which of the following is the appropriate treatment for miliaria?
a. Application of oil
b. Removal of wet clothing
c. Removal of excess clothing
d. Application of soothing lotion
ANS: C
Miliaria (heat rash) develops in infants who are too warmly dressed. Infants should be
dressed in the same amount of clothing as the parent plus a receiving blanket. Oils and
ointments should be avoided. Wet clothing is not the cause of miliaria. Lotion should be
avoided. Often a bath will assist in cooling the infant, especially in hot weather.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
20. An infant who eats very rapidly may experience problems with swallowing excessive air.
What should the mother be instructed to do?
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olI
e.NGTB.COM
a. Use a nipple with a smaNllU
b. Place the infant on the abdomen after feeding.
c. Provide the infant with water between feedings.
d. Begin the feeding before the infant becomes too hungry.
ANS: D
Infants eat rapidly when they are very hungry. If fed before becoming excessively hungry,
the infant will eat at a slower rate. Using a nipple with a smaller hole will not prevent
swallowing excessive air. Infants should be placed on their back; however, can be put on
their ‘front to play’ for short periods under supervision. Water should not be given in
between feedings. All infants should be burped frequently throughout the feeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
21. Which statement is true regarding growth and development during the first 6 months?
a. The infant will grow 1 cm in length per month.
b. The infant will gain about 2 lb per month.
c. The infant will regain weight lost after birth within 1 week.
d. The infant will have a 1-inch increase in head circumference per month.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Each month the average infant gains 2 lb. Infants grow about 3.5 cm each month. Birth
weight is usually regained in 14 days. An infant’s head circumference increases about 2 cm
a month.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
22. Infant immunizations should begin at which age?
a. Birth
b. 2 months
c. 3 months
d. 4 months
ANS: A
The schedule of infant immunizations calls for the initial dose of hepatitis B vaccine at birth.
The first set of immunizations is given at birth.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
23. Which clinical finding indicates a sign of illness in the newborn?
a. A yellow scaly lesion on the scalp
b. More than two soft stools per day
c. Regurgitating a small amount of feeding
d. An axillary temperature greater than 38°C (100.4°F)
ANS: D
NURSINGTB.COM
Infants commonly respond to a variety of illnesses with an elevation in temperature. Yellow
scaly lesions on the scalp are normal findings and are probably cradle cap. More than two
soft stools per day are appropriate for a newborn. Regurgitating a small amount of a feeding
is a normal variance.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
24. During the first 6 months of life, the infant should have well-baby checkups at which
interval?
a. 1 to 2 weeks
b. 2 to 4 weeks
c. 1 to 2 months
d. 3 to 4 months
ANS: C
Most pediatricians schedule well-baby checkups every 1 to 2 months (4 to 8 weeks) to
assess the infant’s growth and development, answer parental questions, observe for
abnormalities, and give immunizations. Checkups are scheduled for every 1 to 2 months.
Two to 4 weeks are too soon between visits, and 3 to 4 months are too long between
checkups.
DIF:
Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MSC: Patient Needs: Health Promotion and Maintenance
25. As the nurse assists a newly discharged patient and her infant to the waiting car, the nurse
notes that the infant seat is in the front seat of the car facing the front and secured by the seat
belt. The nurse should explain to the parents that the car seat should be placed
a. in an upright position.
b. at a 30-degree angle.
c. not secured by the seat belt.
d. in the back seat facing the rear of the car.
ANS: D
A car seat in the back seat facing the rear of the car provides the best protection by keeping
the infant from being hurled forward on impact. The car seat should be in the back seat,
facing the rear of the car. New recommendations suggest a rear facing car seat at a
45-degree angle for up to 2 years of age.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
26. Which statement by a parent suggests that the nurse intervene with further teaching?
a. “I put my newborn baby on her back when she goes to sleep. I understand this is
the best position.”
b. “Jennifer’s eyes sometimes cross, but I know that this is normal in 1-month-old
babies.”
c. “My 5-month-old infant has been drooling, biting, and running a fever for the past
few days. I think he’s teething.”
ivR
inS
gI
heNrG
baTbB
y.
soCliO
dsMsince he was 8 weeks old. I think
d. “My neighbor has beenNgU
I’ll wait until my baby is about 5 months old.”
ANS: C
Although drooling and biting are signs of teething, a fever should always be considered a
sign of illness. A back position is the appropriate position for an infant to sleep. Eye
crossing at this age is a normal deviation. Infants should not be started on solids until they
are 4 to 6 months old.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
27. A new mother asks what she can do to help her infant sleep through the night. Which should
the nurse suggest?
a. Bring the infant into a well-lit room for the feeding.
b. Avoid talking to the infant and keep the room quiet during night feedings.
c. Play with the infant after the feeding before putting the infant back into the crib.
d. Change the infant’s diaper after the feeding to prevent waking the infant later in
the night.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Decreasing stimulation of the infant during and after the bedtime feeding will assist the
infant in establishing a normal sleep pattern. Keeping the baby in a quiet, dimly lit room is a
better option for a feeding during the night. The baby should be put right back into the crib
after a feeding; it is not the time to play with the infant. The infant’s diaper should be
changed before the feeding is started or can be skipped so as not to disturb the infant too
much.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
28. A new mother asks, “Why should I bring my baby in for a checkup? He is not sick.” Which
is the nurse’s best response?
a. “Please ask your pediatrician to explain this to you.”
b. “He may have a problem that you haven’t identified.”
c. “These visits are required by law to identify communicable diseases.”
d. “Well-baby visits allow the doctor to determine whether your baby is growing and
developing normally.”
ANS: D
The pediatric provider utilizing well-baby checkups to observe for abnormalities, answer
parental questions, give immunizations, and observe the normal growth and development of
the infant. Checkups are done to allow for the provider to identify problems, not for the
mother to identify problems. The nurse can answer this question; it does not need to be
answered by the provider. Checkups are not required by law.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: HealN
thUPRroSmIoN
tiG
onTaB
nd.M
aiM
ntenance
CO
29. Which infant should be seen immediately by a health care provider?
a. A 1-week-old infant with a diaper rash
b. A 1-month-old infant with an axillary temperature of 37.7°C (99.8°F)
c. A 3-week-old breast-fed infant who has had two loose stools
d. A 2-week-old infant with nasal congestion and respirations of 64 breaths per
minute
ANS: D
Normal respiratory function is a high priority in the newborn. Any situation in which
respiratory function in the infant is impaired should be evaluated immediately by a
physician. Diaper rashes are a normal variant. A temperature of 37.7°C (99.8°F) is still
within normal limits. Breast-fed infants have loose stools, this is a normal finding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
30. Which intervention should be included in the home care of a high-risk infant?
a. Feeding the infant on a strict schedule
b. Keeping the infant in the supine or prone position
c. Providing continued respiratory support and oxygen
d. Cleaning the umbilical cord several times daily with alcohol
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
High-risk infants may continue to need assistance with respiratory function after discharge.
It is unnecessary for the infant does to be kept on a strict schedule so as not to disrupt the
sleeping patterns of the infant. A high-risk infant should be placed on the side or back as
appropriate positions. Cleaning the cord several times a day with alcohol prep is not
necessary for any infant.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
31. Which statement by the parents indicates the need for further education with regard to
pacifier use?
a. “We will discard the pacifier if it becomes torn.”
b. “We will replace the pacifier every 1 to 2 months.”
c. “We will be sure to cleanse the pacifier frequently.”
d. “We will keep track of the pacifier by tying it to a string around the baby’s neck.”
ANS: D
Pacifiers should never be placed on a string around the infant’s neck. The string could
become tangled tightly around the neck and cause strangulation. If parents make this
statement, they need further instruction. When infants use a pacifier, parents should be
instructed to examine it often to see if it is in good condition. Cracked, torn, or sticky
nipples or nipples that can be pulled away from the shield should be discarded. Pacifiers
should be replaced every 1 or 2 months because they may come apart as they deteriorate and
cause aspiration of parts. Pacifiers should be kept clean by frequent washing, and parents
should buy several so that one is always clean when needed.
NURSINGTB.COM
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
32. The nurse is calling a new mother to schedule a routine home visit planned for 48 to 72
hours after discharge. What is the nurse’s priority question to help determine the best time
for the visit?
a. “When will the baby’s father be home?”
b. “Do you plan on having any visitors in the day or two?”
c. “At approximately what time do you think you will be nursing your baby?”
d. “When will your home be presentable enough for me to come and visit?”
ANS: C
A feeding session should be observed, especially if the mother is breastfeeding.
Establishment of milk supply, adequacy of the breast milk, and general support are
important topics to discuss for the mother who is breastfeeding for the first time. During the
home visit, the nurse performs a physical examination of the mother and infant. Family
adaptation to the addition of a new member and the adequacy of the mother’s support
system is also assessed. Cleanliness of the home environment is only a concern when the
baby’s health is at risk.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
33. A new mother is preparing for discharge from the birthing center and relays to the nurse her
concerns about how she will handle the baby’s episodes of crying. What is the nurse’s best
response?
a. “I hear your concern. Is there someone in the household who cannot tolerate
hearing a baby cry?”
b. “It is okay to just let the baby cry from time to time. You don’t want to risk
spoiling the baby too soon.”
c. “Infants only cry when they are hungry or if they have gas. If you don’t eat any
gas-producing food, your baby will cry less.”
d. “Crying is the way your baby communicates with you. It is important for you to
meet your baby’s needs consistently and promptly.”
ANS: D
Infants cannot signal that they have unmet needs in any way other than crying and are not
spoiled when parents meet their needs. In fact, their needs must be met in a consistent,
warm, prompt manner for the development of trust to occur. Infants who are consistently
held when in distress cry less at 1 year and are less aggressive at 2 years of age. Therefore
parents should be taught the importance of consistently and quickly answering infant cries.
The response to the assessment of intolerance of crying is a leading question and
nontherapeutic communication. Infants cry for many reasons, including hunger, discomfort,
fatigue, overstimulation, and boredom. Parents can often identify the problem based on the
type of sound made during crying. Sometimes no specific cause can be determined. There is
no mention in the stem of the question that the new mother is breastfeeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
34. During a prenatal education class regarding infant home care, the nurse is reviewing the
simulated setting created by new mothers for putting the baby to bed. Which observation
indicates to the nurse that the new mothers understood the nurse’s teaching about infant
safety?
a. The crib is lined with a bumper pad.
b. Stuffed animals are placed in the crib.
c. The baby mannequin is in the supine position.
d. The baby mannequin is covered with a handmade quilt.
ANS: C
Infants should be positioned on the back for sleep. The nurse should explain that the prone
position has been associated with sudden infant death syndrome (SIDS). No pillows,
blankets, or soft stuffed animals should be allowed in the crib because they could cause
suffocation. Infants can be placed in a zippered blanket sleeper for warmth.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is teaching new parents strategies to help with newborn colic. Which
interventions should the nurse suggest? (Select all that apply.)
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
e.
Increase the number of feedings.
Feed the infant in an upright position.
Burp the infant frequently during feedings.
Allow the infant to cry for a period of time.
Increase carrying time by use of a front carrier pack.
ANS: B, C, E
Feeding the infant in an upright position and burping frequently may help relieve discomfort
from swallowed air, which can cause colic. Increasing the time spent carrying the infant
often produces some improvement for colic. Feeding techniques such as overfeeding may
contribute to colic, so the number of feedings should not be increased. Allowing the infant
to cry excessively will cause the infant to swallow more air and will exacerbate the colic.
White noise such as a fan in the background or car rides may also help reduce crying
episodes.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
2. Parents ask the nurse, “How many wet diapers a day should we expect and how will we
know the baby’s stools are normal?” Which response should the nurse make if the infant is
being formula fed? (Select all that apply.)
a. The stools should be watery.
b. The stools should be dry and hard.
c. The infant should have at least one stool a day.
d. The infant should have at least six wet diapers a day.
e. The infant will only have a bowel movement every other day.
N R I G B.C M
U S N T
O
ANS: C, D
Formula-fed infants generally pass at least one stool each day. The infant should have at
least six wet diapers by the fourth day of life. Stools that are dry, hard, and marble-like
indicate constipation. Watery stools indicate diarrhea.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
3. The nurse is teaching new parents how to avoid and treat newborn diaper rash. Which
should the nurse include in the teaching session? (Select all that apply.)
a. Keep the diaper area clean and dry.
b. Do not use talc-based powders in the diaper area.
c. Cleanse the diaper area with a scrubbing motion.
d. Apply a thick layer of zinc oxide to prevent further outbreaks.
e. Remove the diaper and expose the perineum to warm air if a rash develops.
ANS: A, B, E
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Diaper rash is primarily treated by keeping the diaper area clean and dry. Talc-based
powders should not be used because they can cause pneumonia if they get into the infant’s
lungs. Removing the diapers and exposing the perineum to warm air help healing. Parents
should gently wash the perineum with mild soap and warm water but should avoid excessive
washing or scrubbing. Applying a thin layer of zinc oxide or petrolatum may speed healing
and help prevent further outbreaks. The nurse should tell parents not to apply the ointment
too thickly because it may be difficult to remove.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
4. The nurse is preparing a newborn for a circumcision. Which prescribed interventions should
the nurse implement to alleviate pain? (Select all that apply.)
a. Oral sucrose during the procedure
b. Bright lights after the procedure
c. Adequate stimulation before and after the procedure
d. Acetaminophen (Tylenol) postprocedure, as needed
e. EMLA cream (eutectic mixture of local anesthetics) before the procedure
ANS: A, D, E
Nonpharmacologic pain relief methods during and after the circumcision include pacifiers,
oral sucrose, soothing music, recordings of intrauterine sounds, decreased lights, and talking
softly to the infant. Acetaminophen may be given throughout the first day for postprocedure
pain. EMLA cream (eutectic mixture of local anesthetics) may be applied to anesthetize the
skin before the procedure. Bright lights and stimulation would not be methods to reduce
circumcision pain.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
5. The nurse has just completed discharge teaching to parents on newborn bathing. Which
statement made by the parents indicates a further need for teaching? (Select all that apply.)
a. “We will clean the diaper area last.”
b. “We will use cotton-tipped swabs to clean the ears.”
c. “We will use an antibacterial soap during the sponge bath.”
d. “We can submerge the baby in a tub of water after the cord falls off.”
e. “We will shampoo the baby’s head using a football hold before unwrapping.”
ANS: B, C
Soap is not necessary for the young infant but if used, it should be gentle and nonalkaline to
protect the natural acids of the infant’s skin. Do not use cotton-tipped swabs in the infant’s
ears or nose because injury may occur if the baby moves suddenly. Clean the diaper area
last. The cord generally falls off in about 10 to 14 days. Some care providers suggest
waiting for the cord to fall off before tub bathing. Before fully undressing the baby, use the
football position to shampoo the baby’s head.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 22: Infant Feeding
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. The breastfeeding patient should be taught a safe method to remove her breast from the baby’s
mouth. Which suggestion by the nurse is most appropriate?
a. Break the suction by inserting your finger into the corner of the infant’s mouth.
b. A popping sound occurs when the breast is correctly removed from the infant’s
mouth.
c. Slowly remove the breast from the baby’s mouth when the infant has fallen asleep
and the jaws are relaxed.
d. Elicit the Moro reflex in the baby to wake the baby up, and remove the breast
when the baby cries.
ANS: A
Inserting a finger into the corner of the baby’s mouth between the gums to break the suction
avoids trauma to the breast. A popping sound indicates improper removal of the breast from
the baby’s mouth and may cause cracks or fissures in the breast. The infant who is sleeping
may lose grasp on the nipple and areola, resulting in chewing on the nipple, making it sore.
Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up
techniques are recommended.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
N R I G B.C M
2. Which woman is most likely toUcoS
ntinN
ue bT
reastfeeOding beyond 6 months?
a. A woman who avoids using bottles.
b. A woman who uses formula for every other feeding.
c. A woman who offers water or formula after breastfeeding.
d. A woman whose infant is satisfied for 4 hours after the feeding.
ANS: A
Women who avoid using bottles and formula are more likely to continue breastfeeding. Use of
formula decreases breastfeeding time and decreases the production of prolactin and,
ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the
infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The
new breastfeeding mother needs to nurse often to stimulate milk production.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. In which condition is breastfeeding contraindicated?
a. Triplet birth
b. Flat or inverted nipples
c. Human immunodeficiency virus infection
d. Inactive, previously treated tuberculosis
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Human immunodeficiency virus is a serious illness that can be transmitted to the infant via
body fluids. Because the amount of milk being produced depends on the amount of suckling
of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin
to be treated during pregnancy but may begin after birth. Many methods help flat or inverted
nipples to become more erect. Only active tuberculosis patients would be cautioned not to
breastfeed.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment
4. Which type of formula should not be diluted before being administered to an infant?
a. Powdered
b. Concentrated
c. Ready to use
d. Modified cow’s milk
ANS: C
Ready to use formula can be poured directly from the can into the baby’s bottle and is ideal
(although expensive) when a proper water supply is not available. Formula should be well
mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula
may cause malnutrition or sodium imbalances. Cow’s milk is more difficult for the infant to
digest and is not recommended, even if it is diluted.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed
infant need each day?
a. 50 to 75
b. 100 to 110
c. 120 to 140
d. 150 to 200
NURSINGTB.COM
ANS: B
The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional
needs each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are
too much. Requirements for breastfed infants are different.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
6. Which hormone is essential for milk production?
a. Estrogen
b. Prolactin
c. Progesterone
d. Lactogen
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce
milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from
being produced. Progesterone decreases the effectiveness of prolactin and prevents mature
breast milk from being produced. Human placental lactogen decreases the effectiveness of
prolactin and prevents mature breast milk from being produced.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. Which recommendation should the nurse make to a patient to assist in initiating the
milk-ejection reflex?
a. Wear a well-fitting firm bra.
b. Drink plenty of fluids.
c. Place the infant to the breast.
d. Apply cool packs to the breast.
ANS: C
Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation.
A firm bra is important to support the breast; however, will not initiate the let-down reflex.
Drinking plenty of fluids is necessary for adequate milk production; but, will not initiate the
let-down reflex. Cool packs to the breast will decrease the let-down reflex. For many mothers
simply thinking of her infant will result in the let-down reflex.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
8. Which is the first step in assisting the breastfeeding mother to nurse her infant?
NlUedRgS
a. Assess the woman’s know
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tf.
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diO
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b. Provide instruction on the composition of breast milk.
c. Discuss the hormonal changes that trigger the milk-ejection reflex.
d. Help her obtain a comfortable position and place the infant to the breast.
ANS: A
The nurse should first evaluate the woman’s knowledge and skill in breastfeeding to
determine her learning needs. Assessment should occur prior to instruction. Discussing the
hormonal changes and helping her obtain a comfortable position may be part of the
instructional plan; however, assessment should occur first to determine what instruction is
needed.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
9. Which of the following is an important consideration in positioning a newborn for
breastfeeding?
a. Placing the infant at nipple level facing the breast
b. Keeping the infant’s head slightly lower than the body
c. Using the forefinger and middle finger to support the breast
d. Limiting the amount of areola the infant takes into the mouth
ANS: A
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Positioning the infant at nipple level will prevent downward pulling of the nipple and
subsequent nipple trauma. Keeping the infant’s head slightly lower will pull the nipple down
and cause trauma. The forefinger and middle finger can be used to support the breast;
however, this is not an important consideration in positioning the newborn. The infant should
take in as much areola as possible to prevent trauma to the nipples.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
10. The patient should be taught that when her infant falls asleep after feeding for only a few
minutes, she should do which of the following?
a. Unwrap and gently arouse the infant.
b. Wait an hour and attempt to feed again.
c. Try offering a bottle at the next feeding.
d. Put the infant in the crib and try again later.
ANS: A
The infant who falls asleep during feeding may not have fed adequately and should be gently
aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast
milk production will decrease. The infant should be aroused and feeding continued.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
11. To prevent breast engorgement, what should the new breastfeeding mother be instructed to
do?
a.
b.
c.
d.
Feed her infant no more than every 4 hours.
B.
Limit her intake of fluidsNfoUrR
thS
eI
fiN
rsG
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ew
daC
yO
s. M
Apply cold packs to the breast prior to feeding.
Breast-feed frequently and for adequate lengths of time.
ANS: D
Engorgement occurs when the breasts are not adequately emptied at each feeding or if
feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2
hours, therefore waiting 4 hours to feed is too long. Frequent feedings are important to empty
the breast and establish lactation. Fluid intake should not be limited with a breastfeeding
mother; that would decrease the amount of breast milk produced. Warm packs should be
applied to the breast before feedings.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. As the nurse assists a new mother with breastfeeding, the mother asks, “If formula is prepared
to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” The
nurse’s best response is that it contains
a. more calcium.
b. more calories.
c. essential amino acids.
d. important immunoglobulins.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Breast milk contains immunoglobulins that protect the newborn against infection. Calcium
levels are higher in formula than breast milk. This higher level can cause an excessively high
renal solute load if the formula is not diluted properly. The calorie counts of formula and
breast milk are about the same. All the essential amino acids are in formula and breast milk.
The concentrations may differ.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
13. How should the nurse explain mild supply and demand when responding to the question,
“Will I produce enough milk for my baby as she grows and needs more milk at each feeding?”
a. Early addition of baby food will meet the infant’s needs.
b. The breast milk will gradually become richer to supply additional calories.
c. As the infant requires more milk, feedings can be supplemented with cow’s milk.
d. The mother’s milk supply will increase as the infant demands more at each
feeding.
ANS: D
The amount of milk produced depends on the amount of stimulation of the breast. Increased
demand with more frequent and longer breastfeeding sessions results in more milk available
for the infant. Solids should not be added until about 4 to 6 months, when the infant’s immune
system is more mature. This will decrease the chance of allergy formations. Mature breast
milk will stay the same. The amounts will increase as the infant feeds for longer times.
Supplementation will decrease the amount of stimulation of the breast and decrease the milk
production.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: PhysiologNicUIR
ntS
egI
ritN
y GTB.COM
14. Which technique should the nurse recommend to the postpartum patient in order to prevent
nipple trauma?
a. Assess the nipples before each feeding.
b. Limit the feeding time to less than 5 minutes.
c. Wash the nipples daily with mild soap and water.
d. Position the infant so the nipple is far back in the mouth.
ANS: D
If the infant’s mouth does not cover as much of the areola as possible, the pressure during
sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for
trauma is important; however, it will not prevent sore nipples. Stimulating the breast for less
than 5 minutes will not produce the extra milk the infant may need. Soap can be drying to the
nipples and should be avoided during breastfeeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
15. A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on
her right breast. What should the nurse’s first response be?
a. “This is a normal response in breastfeeding mothers.”
b. “Notify your doctor so he can start you on antibiotics.”
c. “Stop breastfeeding because you probably have an infection.”
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. “Try massaging the area and apply heat; it is probably a plugged duct.”
ANS: D
A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area.
Massage of the area followed by heat will cause the duct to open. This is a normal deviation
but requires intervention to prevent further complications. Tender hard areas are not the signs
of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise,
and headache are signs of mastitis. She may have a localized area of redness and
inflammation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
16. Which is an important consideration regarding the storage of breast milk?
a. Can be thawed and refrozen
b. Can be frozen for up to 6 months
c. Should be stored only in glass bottles
d. Can be kept refrigerated for 72 hours
ANS: D
If used within 72 hours after being refrigerated, breast milk will maintain its full nutritional
value. It should not be refrozen. Ideally frozen milk should be used within 6 months. Frozen
milk should be kept at the back of the freezer. Milk can be stored in glass or rigid
polypropylene plastic containers with a tight cap. Frozen milk should be thawed in the
refrigerator and need used within 48 hours.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and N
EffeR
ctivI
e CaG
re EB
nv.irC
onmMent
U S N T
O
17. What is the most serious consequence of propping an infant’s bottle?
a. Colic
b. Aspiration
c. Dental caries
d. Ear infections
ANS: B
Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs.
Colic can occur in any infant. Dental caries becomes a problem when milk stays on the gums
for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth
buds. However, this is not the most serious consequence. Ear infections can occur when the
warm formula runs into the ear and bacterial growth occurs.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
18. A new mother asks why she has to open a new bottle of formula for each feeding. What is the
nurse’s best response?
a. “Formula may turn sour after it is opened.”
b. “Bacteria can grow rapidly in warm milk.”
c. “Formula loses some nutritional value once it is opened.”
d. “This makes it easier to keep track of how much the baby is taking.”
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: B
Formula should not be saved from one feeding to the next because of the danger of rapid
growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This
will cause problems in a newborn with an immature immune system. The loss of some
nutritional value after the formula is opened is not the reason for using fresh bottles with each
feeding. The danger of bacterial growth is the primary concern.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and Effective Care Environment
19. A new mother asks whether she should feed her newborn colostrum because it is not “real
milk.” The nurse’s best answer includes which information?
a. Colostrum is unnecessary for newborns.
b. Colostrum is high in antibodies, protein, vitamins, and minerals.
c. Colostrum is lower in calories than milk and should be supplemented by formula.
d. Giving colostrum is important in helping the mother learn how to breast-feed
before she goes home.
ANS: B
Colostrum is important because it has high levels of the nutrients needed by the neonate and
helps protect against infection. Colostrum provides immunity and enzymes necessary to clean
the gastrointestinal system, among other things. Supplementation is not necessary. It will
decrease stimulation to the breast and decrease the production of milk. It is important for the
mother to feel comfortable in this role before discharge, but the importance of the colostrum
to the infant is top priority.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
N
R
I
G
MSC: Patient Needs: PhysiologicUIntS
egritN
y TB.COM
20. A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling
tender and full in between infant feedings. She asks if there are any suggestions that you can
provide to help alleviate this physical complaint. The ideal nursing response would be to
a. tell the patient to wear a bra at all times to provide more support to breast tissue.
b. have the patient put the infant to her breast more frequently.
c. place ice packs on breast tissue after infant feeding.
d. explain that this is a normal finding and will resolve as her breast tissue becomes
more used to nursing.
ANS: B
The patient may be experiencing the signs of engorgement. Intervention methods such as
placing the infant to feed more frequently may help prevent physical complaints of tenderness
to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but
can provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement
issues. Warm water compresses are more likely to provide comfort. Engorgement is not a
normal finding but is a common presentation in nursing mothers. These symptoms will not
dissipate with continuation of breastfeeding.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
21. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and
displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The
nurse has attempted to teach the mother positioning on one side, and now the mother wants to
place the infant to the breast on the other side. Based on LATCH scores, what score would the
nurse assign to this feeding session?
a. 10 and document findings in the chart.
b. 6 and further teach and assist the mother in feeding activities.
c. 5 and tell the mother to discontinue feeding attempts at this time because the infant
is too sleepy.
d. 8 and no further assistance is needed for feeding.
ANS: B
The LATCH assessment tool is used to identify whether mothers need additional instruction
in the area of breastfeeding. The LATCH categories are latch, audible
communication/swallowing, type of nipple, comfort of breasts, and holding position of infant.
The assessment data reveal a score of 6 (0 + 2 + 1 + 2 + 1). The mother will need additional
assistance during breastfeeding at this time.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
22. A mother conveys concern over the fact that she is not certain if her newborn is receiving
enough nutrients from breastfeeding. This is the baby’s first clinic visit after birth. What
information can you provide that will help alleviate her fears regarding nutrient status for her
newborn?
a. Monitor the infant’s output; as long as at least six or more diapers are changed in a
24-hour period, the baby is receiving sufficient intake.
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b. Tell the mother that if a bab
ed withO
she or he will be content
and not fussy.
c. Tell the mother that breast milk contains everything required for the infant and not
to worry about nutrition.
d. Provide nutrition information in the form of pamphlets for the mother to take home
with her so that she uses them as a point of reference.
ANS: A
The presence of wet diapers confirms that the infant is receiving enough milk. Recording
weight and seeing an increase in weight is also an objective finding that can be used to note
nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although
breast milk is potentially the perfect food for the newborn, not everyone’s breast milk has the
same nutrient quality, therefore recording of weight gain and output measurements (wet
diapers and stool production) confirm nutritional status. Providing the mother with
educational pamphlets may be advisable; however, does not address the immediate problem.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
23. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once
her breast milk comes in. What is the nurse’s most appropriate response?
a. “Are you concerned about your ability to adequately nurse your baby?”
b. “Do you eat a well-balanced diet, high in protein and carbohydrates?”
c. “Breast milk is low in vitamin D and supplementation with 400 IU is
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
recommended.”
d. “Your breast milk has all the vitamins and will adequately meet your baby’s
needs.”
ANS: C
Generally, nutrients provided in breast milk are present in amounts and proportions needed by
the infant. However, recent studies have shown that the vitamin D content of breast milk is
low, and daily supplementation with 400 IU of vitamin D is recommended within the first few
days of life. Breastfeeding infants who are not exposed to the sun and those with dark skin are
particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart
of vitamin D–fortified milk per day should also be supplemented. Although the fatty acid
content of breast milk is influenced by the mother’s diet, malnourished mothers’ milk has
about the same proportions of total fat, protein, carbohydrates, and most minerals as milk
from those who are well nourished. Levels of water-soluble vitamins in breast milk are
determined by the mother’s intake. It is important for breastfeeding women to eat a
well-balanced diet to maintain their own health and energy levels.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
24. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which
statement indicates to the nurse that the mom needs more information about bottle feeding?
a. “I should encourage my baby to consume the entire amount of formula prepared
for each feeding.”
b. “I can make up a 24-hour supply of formula and refrigerate the bottles so I am
ready to feed my baby.”
c. “I will hold my baby in a cradle hold and alternate sides from left to right when I
N R I G B.C M
U S N T
O
feed my baby.”
d. “I will generally feed my baby every 3 to 4 hours or more often as signs of hunger
are displayed.”
ANS: A
Infants will stop suckling when they are full. Encouraging them to overeat may lead to
problems with regurgitation and possible aspiration. The mother can prepare a single bottle or
a 24-hour supply if adequate refrigeration is available. Show the parents how to position the
infant in a semi-upright position, such as the cradle hold. This allows them to hold the infant
close in a face-to-face position. The bottle is held with the nipple kept full of formula to
prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding
provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but
avoid rigid scheduling and take cues from the infant.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
25. The nurse is teaching a postpartum patient different holds for breastfeeding. Which of the
following figures depicts the football hold frequently used for patients who have had a
cesarean birth?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
NURSINGTB.COM
c.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d.
ANS: B
For the football or clutch hold, the mother supports the infant’s head and neck in her hand,
with the infant’s body resting on pillows next to her hip. This method allows the mother to see
the position of the infant’s mouth on the breast, helps her control the infant’s head, and is
especially helpful for mothers with heavy breasts. This hold also avoids pressure against an
abdominal incision. For the cradle hold, the mother positions the infant’s head at or near the
antecubital space and level with her nipple, with her arm supporting the infant’s body. Her
other hand is free to hold the breast. The cross-cradle or modified cradle hold is helpful for
infants who are preterm or have a fractured clavicle. The mother holds the infant’s head with
the hand opposite the side on which the infant will feed and supports the infant’s body across
her lap with her arm. The othN
erUhR
anSdIhN
olG
dsTtB
he.bCreOaM
st. The side-lying position avoids pressure
on the episiotomy or abdominal incision and allows the mother to rest while feeding.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. Late in pregnancy, the patient’s breasts should be evaluated by the nurse to identify any
potential concerns related to breastfeeding. Which of the following nipple conditions make it
necessary to intervene prior to birth. (Select all that apply.)
a. Flat nipples
b. Cracked nipples
c. Everted nipples
d. Inverted nipples
e. Nipples that contract when compressed
ANS: A, D, E
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling
them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples
appear normal; however, they will draw inward when the areola is compressed by the infant’s
mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of
pregnancy and between feedings after birth. The shells are placed inside the bra, with the
opening over the nipple. The shells exert slight pressure against the areola to help the nipples
protrude. The helpfulness of breast shells has been debated. A breast pump can be used to
draw the nipples out before feedings after birth. Everted nipples protrude and are normal. No
intervention will be required. Cracked, blistered, and bleeding nipples occur after
breastfeeding has been initiated and are the result of improper latching on. The infant should
be repositioned during feeding. The application of colostrum and breast milk after feedings
will aid in healing.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. For which infant should the nurse anticipate the use of soy formula? (Select all that apply.)
a. Preterm infant
b. Infant with galactosemia
c. Infant with phenylketonuria
d. Infant with lactase deficiency
e. Infant with a malabsorption disorder
ANS: B, D, E
Soy formula may be given to infants with galactosemia or lactase deficiency or those whose
families are vegetarians. Soy milk is derived from the protein of soybeans and supplemented
with amino acids. The formulas are also used for infants with malabsorption disorders. The
N ore
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B.C M
preterm infant may require a mU
trated foOrmula, with more calories in less liquid.
Modifications of other nutrients are also made. Human milk fortifiers can be added to breast
milk to adapt it for preterm infants. Low-phenylalanine formulas are needed for infants with
phenylketonuria, a deficiency in the enzyme to digest phenylalanine found in standard
formulas.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
3. A new mother asks the nurse, “How will I know early signs of hunger in my baby?” The
nurse’s best response is which of the following? (Select all that apply.)
a. Crying
b. Rooting
c. Lip smacking
d. Decrease in activity
e. Sucking on the hands
ANS: B, C, E
Early signs of hunger in a baby are rooting, lip smacking, and sucking on the hands. Crying is
a late sign, and the baby’s activity will increase, not decrease.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 23: High-Risk Newborn: Complications Associated with Gestational Age and
Development
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which is the most useful factor in preventing premature birth?
a. High socioeconomic status
b. Adequate prenatal care
c. Aid to Families with Dependent Children
d. Women, Infants, and Children (WIC) nutritional program
ANS: B
Prenatal care is vital for identifying possible problems. People with higher socioeconomic
status are more likely to seek adequate prenatal care, which is the most helpful for prevention
of premature births. Lower socioeconomic groups do not seek out health care, which puts
them at risk for preterm labor. Aid to Families with Dependent Children and WIC assist in the
nutritional status of the pregnant woman; however, the most helpful intervention for the
prevention of premature births is adequate prenatal care.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. In comparison with the term infant, the preterm infant has
a. more subcutaneous fat.
b. well-developed flexor muscles.
N R INGTB.COM
c. few blood vessels visible thUrouS
gh the skin.
d. greater surface area in proportion to weight.
ANS: D
Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat,
well-developed flexor muscles, and few blood vessels visible through the skin are features
that are more characteristic of a term infant.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
3. Decreased surfactant production in the preterm lung is a problem because
a. surfactant keeps the alveoli open during expiration.
b. surfactant causes increased permeability of the alveoli.
c. surfactant dilates the bronchioles, decreasing airway resistance.
d. surfactant provides transportation for oxygen to enter the blood supply.
ANS: A
Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the
work of breathing. It does not affect the bronchioles. By keeping the alveoli open, surfactant
permits enhanced oxygen exchange. Infants treated with surfactant have higher survival rates.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
4. A preterm infant is on a ventilator, with intravenous lines and other medical equipment. When
the parents come to visit for the first time, what is the most important action by the nurse?
a. Encourage the parents to touch their infant.
b. Reassure the parents that the infant is progressing well.
c. Discuss the care they will give their infant when the infant goes home.
d. Suggest that the parents visit for only a short time to reduce their anxiety.
ANS: A
Touching the infant will increase the development of attachment. As the infant’s condition
improves the parents should be encouraged to provide Kangaroo care. It is important to keep
the parents informed regarding the infant’s progress; however, the nurse needs to be honest
with the explanations. Discussing home care is an important part of parent teaching, although
is not the most important priority during the first visit. Parents should be encouraged to visit
for as long as they are comfortable.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Psychosocial Integrity
5. Which preterm infant should receive gavage feedings instead of bottle feedings?
a. Sucks on a pacifier during gavage feedings
b. Sometimes gags when a feeding tube is inserted
c. Has a sustained respiratory rate of 70 breaths per minute
d. Has an axillary temperature of 36.9C (98.4F), an apical pulse of 149
beats/minute, and respirations of 54 breaths per minute
ANS: C
Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have
difficulty with bottle-feedingN
.G
agI
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feG
edTinBg.
sC
shO
ouMld be initiated if the respiratory rate is
UaRvS
above 60 breaths per minute. Providing a pacifier during gavage feedings gives positive oral
stimulation and helps the infant associate the comfortable feeling of fullness with sucking.
The presence of the gag reflex is important before initiating bottle-feeding. Axillary
temperature of 36.9C (98.4F), an apical pulse of 149 beats/minute, and respirations of 54
breaths per minute are within expected limits and an indication that the infant is not having
respiratory problems at that time.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
6. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing
intervention helps to avoid this problem?
a. Group all care activities together to provide long periods of rest.
b. Keep charts on top of the incubator so the nurses can write on them there.
c. While giving a report to the next nurse, stand in front of the incubator and talk
softly about how the infant responds to stimulation.
d. Teach the parents signs of overstimulation, such as turning the face away or
stiffening and extending the extremities and fingers.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Parents should be taught the signs of overstimulation so they will learn to adapt their care to
the needs of their infant. Grouping care activities may under stimulate the infant during those
long periods and overtire the infant during the procedures. Keeping charts on the incubator
and giving the report in front of the incubator may cause overstimulation. Any clip boards or
binders in use should be kept at the desk, never on top of the incubator.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
7. A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is
a. soft and supple skin.
b. a hematocrit level of 55%.
c. lack of subcutaneous fat.
d. an abundance of vernix caseosa.
ANS: C
This post-term infant has actually lost weight in utero, which is seen as loss of subcutaneous
fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the
expected range of all newborns. There is no vernix caseosa in a post-term infant.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. In caring for the preterm infant, which complication is thought to be a result of high arterial
blood oxygen level?
a. Necrotizing enterocolitis (NEC)
b. Retinopathy of prematurity (ROP)
c. Intraventricular hemorrhaNgU
eR
(IV
SHI)NGTB.COM
d. Bronchopulmonary dysplasia (BPD)
ANS: B
ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the
interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH
is caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often
associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.
BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
9. In caring for the post-term infant, thermoregulation can be a concern, especially in an infant
who also has a(n)
a. hematocrit level of 58%.
b. RBC count of 5 million/mcL.
c. WBC count of 15,000 cells/mm3.
d. blood glucose level of 25 mg/dL.
ANS: D
Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be
able to produce enough body heat. A hematocrit level of 58% is within the expected range for
newborns. WBC count may be as high as 30,000 cells/mm3. RBC count ranges from 3.9 to 5.5
million/mcL.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
10. Which statement regarding newborns classified as small for gestational age (SGA) is
accurate?
a. They weigh less than 2500 g.
b. They are born before 38 weeks of gestation.
c. They are below the tenth percentile on gestational growth charts.
d. Placental malfunction is the only recognized cause of this condition.
ANS: C
SGA infants are defined as below the tenth percentile in growth when compared with other
infants of the same gestational age. SGA is not defined by weight. Infants born before 38
weeks are classified as preterm. There are many factors that contribute to the development of
an SGA infant, not just placental malfunction.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
11. Which nursing action is especially important for an SGA newborn?
a. Promote bonding.
b. Observe for and prevent dehydration.
c. Observe for respiratory distress syndrome.
d. Prevent hypoglycemia with early and frequent feedings.
ANS: D
The SGA infant has poor glyN
cogR
en sI
toreG
s and.
isCsubMject to hypoglycemia. Promoting bonding
S specific
N TBto
O infants. Dehydration is a concern for all
is a concern for all infants and U
is not
SGA
infants and is not specific to SGA infants. Respiratory distress syndrome is most commonly
seen in preterm infants.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
12. What will the nurse note when assessing an infant with asymmetric intrauterine growth
restriction?
a. All body parts appear proportionate.
b. The extremities are disproportionate to the trunk.
c. The head seems large compared with the rest of the body.
d. One side of the body appears slightly smaller than the other.
ANS: C
In asymmetric intrauterine growth restriction, the head is normal in size; but, appears large
because the infant’s body is long and thin due to lack of subcutaneous fat. The left and right
side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body
appears smaller than normal compared to the head. The body parts are out of proportion, with
the body looking smaller than anticipated. The body, arms, and legs have lost subcutaneous
fat so they will look small compared with the head.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
13. Which data should alert the nurse caring for an SGA infant that additional calories may be
needed?
a. The latest hematocrit was 53%.
b. The infant’s weight gain is 40 g/day.
c. The infant is taking 120 mL/kg every 24 hours.
d. Three successive temperature measurements were 36.1C, 35.5C, and 36.1C (97,
96, and 97F).
ANS: D
Low body temperature indicates that additional calories are needed to maintain body
temperature. The hematocrit is within the expected range for a newborn. A weight gain of
about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity
14. Which statement regarding large-for-gestational age (LGA) infants is most accurate?
a. They weigh more than 3500 g.
b. They are above the 80th percentile on gestational growth charts.
c. They are prone to hypoglycemia, polycythemia, and birth injuries.
d. Postmaturity syndrome is the most common complication.
ANS: C
Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants
are determined by their weight compared to their age. They are above the 90th percentile on
gestational growth charts. Postmaturity syndrome is not an expected complication with LGA
infants.
NURSINGTB.COM
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
15. Following the vaginal birth of a macrosomic infant, the nurse should evaluate the infant for
a. hyperglycemia.
b. clavicle fractures.
c. hyperthermia.
d. an increase in red blood cells.
ANS: B
Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as
fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have
the potential to become hypoglycemic and would be at risk for hypothermia. An increase in
red blood cells would not be the priority assessment for a macrosomic infant.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
16. An infant delivered prematurely at 28 weeks’ gestation weighs 1200 g. Based on this
information the infant is classified as
a. SGA.
b. VLBW.
c. ELBW.
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. low birth weight at term.
ANS: B
VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below
the tenth percentile in growth charts. ELBW (extremely low-birth-weight) infants weigh 100 g
or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. This
option is incorrect because it specifies at term and the infant in question is designated as
preterm at 28 weeks’ gestation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
17. The nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of
apnea lasting approximately 10 seconds followed by a period of rapid respirations. The
infant’s color and heart rate remain unchanged. The nurse suspects that the infant
a. is exhibiting signs of RDS.
b. requires tactile stimulation around the clock to ensure that apneic periods do not
progress further.
c. is experiencing periodic breathing episodes and will require continuous monitoring
while in the nursery unit.
d. requires the use of CPAP to promote airway expansion.
ANS: C
Periodic breathing can occur in term or preterm infants; it consists of periods of breathing
cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths
per minute). It is not associated with any color or heart rate changes. Infants who exhibit this
pattern should continue to be observed. There is no clinical evidence that the infant is
exhibiting signs of respiratorN
yU
diR
stS
reI
ssNsyGnT
drB
o.
mC
eO
(RM
DS). There is no indication that a pattern
of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and
tactile stimulation would be indicated if the infant were to have apneic spells.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
18. Which nursing diagnosis would be considered a priority for a newborn infant who is receiving
phototherapy in an isolette?
a. Hypothermia because of phototherapy treatment
b. Impaired skin integrity related to diarrhea as a result of phototherapy
c. Fluid volume deficit related to phototherapy treatment
d. Knowledge deficit (parents) related to initiation of medical therapy
ANS: C
Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia
are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the
priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The
infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and
limited intake. Lack of knowledge is a pertinent nursing diagnosis for these parents; but,
physiologic needs take precedence at this time.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Patient Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
19. An infant presents with lethargy in the newborn nursery on the second day of life. On further
examination, vital signs are stable and muscle tone is slightly decreased, with sluggish
reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a
decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be
exhibiting signs and symptoms of
a. RDS.
b. PIVH.
c. BPD.
d. ROP.
ANS: B
IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during
the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically,
one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit,
hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more
respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms
related to the eyes. Other physical characteristics are reported as being normal.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
20. Following a traumatic birth of a 10-lb infant, the nurse should evaluate
a. gestational age status.
b. flexion of both upper extremities.
c. infant’s percentile on growth chart.
d. blood sugar to detect hyperglycemia.
ANS: B
NURSINGTB.COM
Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage
to the brachial plexus. Gestational age or the infant’s growth chart percentile will not provide
data about potential injuries from a traumatic birth. A large infant is at increased risk for
hypoglycemia.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
21. A newborn assessment finding that would support the nursing diagnosis of postmaturity
would be
a. loose skin.
b. ruddy skin color.
c. presence of vernix.
d. absence of lanugo.
ANS: A
Decreased placental function because of a prolonged pregnancy results in loss of
subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color,
presence of vernix, and absence of lanugo do not indicate a postmature infant.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
MULTIPLE RESPONSE
1. Because late preterm infants are more stable than early preterm infants, they may receive care
that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these
infants are at increased risk for which of the following? (Select all that apply.)
a. Sepsis
b. Hyperglycemia
c. Hyperbilirubinemia
d. Cardiac distress
e. Problems with thermoregulation
ANS: A, C, E
Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are
related to immaturity and warrant close observation. After discharge, the infant is at risk for
rehospitalization related to these problems. The Association of Women’s Health, Obstetric
and Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the
problem and determine ways to ensure that these infants receive adequate care. The nurse
should ensure that this infant is feeding adequately before discharge and that parents are
taught the signs and symptoms of these complications. These infants are at risk for respiratory
distress and hypoglycemia.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 24: High-Risk Newborn: Acquired and Congenital Conditions
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia
every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should
be used instead of water. The purpose of this plan is to
a. prevent hyperglycemia.
b. provide fluids and protein.
c. decrease gastrointestinal motility.
d. prevent rapid emptying of the bilirubin from the bowel.
ANS: B
Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the
excess bilirubin from the infant’s system. Feedings every 2 hours will help prevent
hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the
bilirubin from the bowel. Breast milk or formula is more effective in promoting stooling and
removal of bilirubin.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
2. Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic
mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action
has top priority?
a. Notify the clinician stat. NURSINGTB.COM
b. Test for the blood glucose level.
c. Start an intravenous line with D10W.
d. Document the event in the nurses’ notes.
ANS: B
These symptoms are indications of hypoglycemia in the newborn. Permanent damage can
occur if glucose is not constantly available to the brain. It is not common practice to
administer intravenous glucose to a newborn unless their condition does not allow for enteral
feedings. Feeding the infant is preferable as formula or breast milk will maintain glucose
stability. Determine the blood glucose level according to agency policy, treat symptoms with
standing orders protocol, and notify the physician with the results. Documentation can wait
until the infant has been tested and treated if a problem is present.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. Which newborn should the nurse recognize as being at the greatest risk for developing
respiratory distress syndrome?
a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin.
b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of
membranes.
c. A 36-week-gestation male baby born by cesarean birth to a mother with
insulin-dependent diabetes.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. A 35-week-gestation female baby born vaginally to a mother who has
pregnancy-induced hypertension.
ANS: C
Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant
at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a
mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born
vaginally 72 hours after the rupture of membranes is at risk for infection because of the
prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a
mother who has pregnancy-induced hypertension is at risk for hypoxia.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Transitory tachypnea of the newborn (TTN) is thought to occur as a result of
a. a lack of surfactant.
b. hypoinflation of the lungs.
c. inadequate absorption of fetal lung fluid.
d. a delayed vaginal birth associated with meconium-stained fluid.
ANS: C
Inadequate absorption of fetal lung fluid is thought to be the clinical reason for TTN. Lack of
surfactant in the premature infant is likely to result in respiratory distress syndrome. A
delayed vaginal birth will help prevent TTN. This condition usually resolves within 24 to 48
hours. TTN is the most common respiratory cause of admissions to the NICU.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: PhysiologNic IR
ntegI
rity G B.C M
U S N T
O
5. The nurse must continually assess the infant who has meconium aspiration syndrome for the
complication of
a. persistent pulmonary hypertension.
b. bronchopulmonary dysplasia.
c. transitory tachypnea of the newborn.
d. left-to-right shunting of blood through the foramen ovale.
ANS: A
Persistent pulmonary hypertension has been associated with hypoxemia and acidosis as a
result of the aspiration of meconium. Bronchopulmonary dysplasia is a complication of the
use of positive-pressure oxygenation, which stretches the immature lung membranes.
Transitory tachypnea of the newborn is the result of inadequate absorption of fetal lung fluid.
Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be
caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or
atrioventricular canal defects.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
6. The nurse present at the birth is reporting to the nurse who will be caring for the neonate after
the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant
presented with depressed respirations and weak muscle tone. Which information should be
included in the report for this infant?
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
a.
b.
c.
d.
The parents spent an hour bonding with the baby after birth.
An IV was started immediately after birth to treat dehydration.
The infant required warmed humidified oxygen.
The infant was placed skin to skin with the mother.
ANS: C
If the infant with meconium in the amniotic fluid is not breathing effectively after drying,
stimulation, and bulb syringe suctioning, they may require humidified O2 or positive-pressure
ventilation. Insertion of a laryngoscope and suctioning of the infant’s secretions below the
vocal chords has not been found to reduce the incidence of meconium aspiration syndrome
(MAS). Bonding after birth is an expected occurrence. There is no relationship between
dehydration and meconium fluid. Infants with this clinical presentation should be moved to a
radiant warmer rather than placed skin to skin, immediately after birth. This can be done when
the infant is stable.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
7. Which intervention will increase the effectiveness in reducing the indirect bilirubin in an
affected newborn?
a. Turn the infant every 2 hours.
b. Place eye patches on the newborn.
c. Wrap the infant in triple blankets to prevent cold stress.
d. Increase the oral intake of water between and before feedings.
ANS: A
Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye
patches is important to protecNt U
thR
eS
eyIes;
veC
r,OthMis is not what affects the bilirubin levels.
NGhoTwBe.
Wrapping the infant in blankets will prevent the phototherapy from accessing the skin and
being effective. The infant should be uncovered and unclothed. It is important to increase oral
feedings, although water should not necessarily be given. Breast milk or formula will increase
the reduction of bilirubin.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
8. Newborns whose mothers are substance abusers frequently exhibit which of the following
behaviors?
a. Hypothermia, decreased muscle tone, and weak sucking reflex
b. Excessive sleep, weak cry, and diminished grasp reflex
c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation
d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding
ANS: D
Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and
uncoordinated sucking and swallowing behaviors. These infants may also present with
hyperactive muscle tone, a high-pitched cry, and diarrhea.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
9. When a cardiac defect causes the mixing of arterial and venous blood in the right side of the
heart, the nurse might expect to find
a. cyanosis.
b. diuresis.
c. signs of congestive heart failure.
d. increased oxygenation of the tissues.
ANS: C
Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs
and pulmonary congestion and congestive heart failure. Cyanosis is seen more frequently with
right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased
oxygenation of the tissues is not seen with this type of cardiac defect.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. In an infant with cyanotic cardiac anomaly, the nurse should expect to see
a. feedings taken eagerly.
b. a consistent and rapid weight gain.
c. a decrease in the heart rate with activity.
d. little to no improvement in color with oxygen administration.
ANS: D
With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any
improvement in the oxygenation of the blood with the administration of oxygen. Infants with
cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an
increase in the heart rate with activity.
NURSINGTB.COM
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
11. The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic
jaundice is that nonphysiologic jaundice
a. may result in kernicterus.
b. appears during the first 24 hours of life.
c. begins on the head and progresses down the body.
d. results from the breakdown of excessive erythrocytes not needed after birth.
ANS: B
Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic
jaundice appears after the first 24 hours of life. This type of jaundice may lead to kernicterus;
however, screening and appropriate treatment needs to take place in a time sensitive manner
in order to prevent kernicterus. Jaundice proceeds from the head down. Both jaundices are the
result of the breakdown of erythrocytes. Nonphysiologic jaundice is caused by an underlying
condition, such as Rh incompatibility.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
12. Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring
and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit
(NICU) for closer observation, with a diagnosis of transient tachypnea of the neonate (TTN).
The parents are notified and become anxious because they have no understanding of what this
means for their infant. The best action that the nurse can take at this time is to
a. refer them to the neonatologist for more information.
b. reassure them not to worry. The infant will be monitored closely by trained staff.
c. explain to them that this often occurs following a birth and it will most likely
resolve in the next 24 to 48 hours.
d. tell them that they will be able to come and see their baby, which will help make
calm their anxiety.
ANS: C
The clinical diagnosis of TTN has been established, and the nurse should provide factual
information relative to the clinical condition. The RN should be able to provide information to
clarify the parents’ concern without referral to the pediatric provider. Telling parents not to
worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction
with the newborn and parents may help ease anxiety; however, this does not address the
parents’ knowledge deficit.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
13. While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis
takes priority for the newborn at birth?
a. Risk for infection related to release of meconium
b. Risk for injury related to high-risk birth interventions, such as amino infusion
INedGsTecretio
B.CO
c. Risk for aspiration relatedNtU
oR
reS
tain
nsM
d. Risk for thermoregulation because of high-risk labor status
ANS: C
Because the fetus has already passed meconium in utero, the labor and birth assume a
high-risk management perspective. The likelihood that the infant will develop meconium
aspiration syndrome (MAS) is increased, therefore airway complications take precedence in
terms of nursing diagnosis and medical management.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Nursing Diagnosis
MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities
14. Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant?
a. Direct Coombs test based on maternal blood sample
b. Indirect Coombs test based on infant cord blood sample
c. Infant bilirubin level
d. Maternal blood type
ANS: C
The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect
Coombs test is based on maternal blood samples. Although maternal blood type is important
in determining whether there is a potential ABO incompatibility, the infant’s bilirubin level
provides the best evidence of whether the infant has hyperbilirubinemia or pathologic
jaundice.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
15. Which of the following lab values indicates that an infant may have polycythemia?
a. Hct 50%
b. Hct 55%
c. Hct 62%
d. Hct 70%
ANS: D
The presence of polycythemia in an infant is characterized by a hematocrit value greater than
65%.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
16. The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse
should immediately assess for other signs of
a. hyperglycemia.
b. neonatal infection.
c. hemolytic anemia.
d. increased bilirubin levels.
ANS: B
Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability,
respiratory problems, and changes in feeding habits may be common. Hyperglycemia,
hemolytic anemia, and increaNsedRbiliI
rubG
in leBv.
elC
s areMnot associated with poor infant feeding.
U S N T
O
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
17. The priority assessment for the Rh-negative infant whose mother’s indirect Coombs test was
positive at 36 weeks is
a. skin color.
b. temperature.
c. respiratory rate.
d. blood glucose level.
ANS: A
An Rh-negative infant whose mother was sensitized during the current pregnancy will have
decreased red blood cells (RBCs) and exhibit skin pallor due to erythroblastosis fetalis. The
temperature, respiratory rate, and blood glucose level are not assessments associated
specifically to an infant with an Rh incompatibility issue.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Physiologic Integrity
18. The nurse should be alert to a blood group incompatibility if
a. both mother and infant are O-positive.
b. mother is A-positive and infant is A-negative.
c. mother is O-positive and infant is B-negative.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. mother is B-positive and infant is O-negative.
ANS: D
Blood group incompatibilities occur because O-positive mothers who have natural antibodies
to type A or B blood. When mother and infant both have blood group O or A, no
incompatibility exists. The mother with blood group B does not have any antibodies to group
O.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Analysis
MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Infection can be transmitted to the neonate from mother during the pregnancy or birth or from
the mother, family members, visitors, or agency staff after birth. Which viral infections are
most likely to be transmitted during the birth process? (Select all that apply.)
a. Hepatitis B
b. Rubella
c. Herpes
d. Varicella Zoster
e. Cytomegalovirus
ANS: A, C, E
Hepatitis B, herpes, cytomegalovirus, and HIV are usually transmitted during birth; however,
they can also be acquired through transplacental transfer or from breast milk. Rubella and
varicella zoster (Chickenpox) are acquired in utero and may result in fetal death or significant
abnormalities.
NURSINGTB.COM
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
2. The drug-exposed infant often presents with irritability, frantic crying, and is difficult to
console. Which nursing measures can be used to prevent this behavior in this high-risk infant?
(Select all that apply.)
a. Keep the room well lit.
b. Swaddle the infant.
c. Rock slowly and gently.
d. Coo softly and gently.
e. Avoid pacifier use.
ANS: B, C, D
Comfort measures that will assist in consoling this infant and prevent crying include:
swaddling, providing a pacifier, slow and smooth rocking in a vertical or horizontal position,
cooing, gently stroking the back, keeping the room fairly dark, and avoiding both auditory and
visual stimulation. These infants are particularly sensitive to light and should be placed in a
darker corner of the nursery or have the lights in their room kept low. Pacifier use will assist
the baby in meeting non-nutritive sucking needs and provide a method to self soothe.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 25: Family Planning
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which contraceptive method provides protection against sexually transmitted diseases?
a. Oral contraceptives
b. Tubal ligation
c. Male or female condoms
d. Intrauterine device (IUD)
ANS: C
Because latex condoms provide the best protection available, they should be used during
any potential exposure to a sexually transmitted disease (STD). Only the barrier methods
provide some protection from STDs. A tubal ligation is considered a permanent
contraceptive method; however, does not offer any protection against sexually transmitted
diseases. IUDs are inserted into the uterus and provide no protection from STDs.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. A nurse is leading a discussion regarding options for birth control. Which of the following
methods is considered the most reliable?
a. Coitus interruptus
b. Breastfeeding
NURSINGTB.COM
c. Natural family planning
d. Intrauterine device
ANS: D
IUDs are 99% effective. Although coitus interruptus is considered 78% effective, it requires
great control by the man and may be unsatisfying for both partners. Women who
exclusively breast feed (without formula or solid food supplementation) may avoid
ovulation. Another method of birth control should be used when the frequency of
breastfeeding decreases. At 6 months postpartum ovulation commences in most women,
even if exclusively breastfeeding. Couples must be highly motivated to use natural family
planning because they must abstain from sex for as much as half of the menstrual cycle.
Errors in the forbidden time carry a very high risk of pregnancy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. Which patient is a safe candidate for the use of oral contraceptives?
a. 39-year-old with a history of thrombophlebitis.
b. 16-year-old with a benign liver tumor.
c. 20-year-old who suspects she may be pregnant.
d. 43-year-old who does not smoke cigarettes.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: D
Heavy cigarette smoking is a contraindication to oral contraceptive use due to risk of stroke.
Oral contraceptives are contraindicated with a history of thrombophlebitis. Liver tumors,
benign or malignant, preclude the use of oral contraceptives. Pregnancy is also a
contraindication.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
4. The role of the nurse in family planning is to
a. refer the couple to a reliable physician.
b. decide on the best method for the couple.
c. advise couples on which contraceptive to use.
d. educate couples on the various methods of contraception.
ANS: D
The nurse’s role is to provide information to the couple so that they can make an informed
decision about family planning. The nurse can assist the couple; they do not need to be sent
to a physician for contraceptive education. The nurse’s role is to evaluate the couple’s
knowledge base and educate regarding birth control options, not to decide which is the best
contraceptive method for them to utilize.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
5. Informed consent concerning contraceptive use is important since some of the methods
a. may not be reliable.
b. require a surgical procedure to insert.
c. have potentially dangerous side effects.
d. are invasive procedures that require hospitalization.
ANS: C
It is important for couples to be aware of potential side effects in order for them to make an
informed decision regarding the use of contraceptives. Even if a method is less reliable, it
still carries with it side effects that require informed consent. A written consent is required if
the contraceptive choice involves a surgical procedure. Some contraceptive procedures are
invasive; however, do not require hospitalization for insertion.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
6. Which contraceptive method should be contraindicated in a patient with a history of toxic
shock syndrome?
a. Condom
b. Spermicide
c. Cervical cap
d. Oral contraceptives
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
The cervical cap should not be used in women with a history of toxic shock syndrome. A
condom, spermicide, or oral contraceptives are not contraindicated with a history of toxic
shock syndrome.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
7. When instructing a patient in the use of spermicidal foam or gel, it is important to include
the information that
a. effectiveness is about 85%.
b. douching should be avoided for at least 6 hours.
c. it should be inserted 1 to 2 hours before intercourse.
d. one application is effective for several hours.
ANS: B
Douching within 6 hours of intercourse would remove the spermicide and increase the risk
of pregnancy. Effectiveness of spermicidal foam or gel is only 72% when used alone. The
spermicidal foam or gel should be inserted 15 minutes before intercourse. One application is
effective for approximately 1 hour.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
N R I G B.C M
8. Which symptom in a patient U
usinS
g oN
ral cT
ontraceO
ptives should be reported to the physician
immediately?
a. 5-lb weight gain
b. Leg pain and edema
c. Decrease in menstrual flow
d. Increased pigmentation of the face
ANS: B
Oral contraceptives increase clotting factors, which place the woman at risk for
thrombophlebitis. Leg pain and edema are symptoms of thrombophlebitis. A 5-lb weight
gain can be expected. A decrease in menstrual flow is an expected finding. Increased
pigmentation of the face is a common finding.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
9. When using the basal body temperature method of family planning, the woman should
understand that
a. she will remain fertile for 5 days after ovulation.
b. she should take her temperature each night before going to bed.
c. her temperature will increase about 0.2 to 0.4°C (0.4 to 0.8°F) after ovulation.
d. her temperature is normally lower during the second half of her cycle.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
The basal body temperature will increase approximately 0.2 to 0.4°C (0.4 to 0.8°F) at the
same time ovulation occurs. The woman is fertile for up to 18 days. She should take her
temperature at the same time upon rising in the morning. A woman’s temperature is usually
higher in the second half of her cycle.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
10. The major difference between the diaphragm and the cervical cap is that the diaphragm
a. is more effective.
b. requires spermicide.
c. applies pressure on the urethra.
d. has no contribution to toxic shock syndrome.
ANS: C
The diaphragm is made to fit snugly in the vaginal area and contains a hard rim that may
exert pressure on the urethra. The cervical cap is smaller and fits around the cervix. The
cervical cap is not more effective than a diaphragm. The diaphragm does not require
spermicide. Both methods may contribute to the onset of toxic shock syndrome.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
ntR
raS
utI
erN
inG
eT
deBv.
icC
e (OIU
11. The patient who has had anNiU
MD) inserted should be instructed to
a. use a vinegar douche weekly for 4 weeks.
b. have the IUD replaced every 2 to 4 years.
c. check the placement of the string once a week for 4 weeks.
d. use another method of contraception for 2 weeks after insertion.
ANS: C
Checking the placement of the string is necessary to determine whether the IUD is still
correctly positioned. If the string is shorter or longer than when checked previously, the
patient should contact her physician. A vinegar douche weekly for 4 weeks is not necessary.
An IUD can be left in place for up to 10 years. A second method of contraception is not
required after insertion of the IUD; it is effective immediately.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
12. A male patient asks, “Why do I have to use another contraceptive? I had a vasectomy last
week.” The best response is
a. “A vasectomy is only 80% effective.”
b. “A vasectomy is not effective in all men.”
c. “Semen may contain sperm for 6 months following a vasectomy.”
d. “Complete sterilization doesn’t occur until all sperm have left the system.”
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: D
It may take a month or longer for all sperm to be removed from the system. During that
time, an additional method of contraception must be used. A vasectomy is 99% effective.
Vasectomies have a high success rate; however, it may take 1 month for all the sperm to be
removed from the system.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
13. A woman who has a successful career and a busy lifestyle will most likely look for which
type of contraceptive?
a. Requires extensive education to use
b. Is the easiest and most convenient to use
c. Costs the least
d. Is permanent
ANS: B
A woman who has a busy lifestyle will probably have less time to devote to contraceptive
use, therefore she requires something that is easy and convenient. Extra time for education
would not be acceptable for this woman. Cost would probably not be a problem. There is no
indication that a woman who has a successful career and a busy lifestyle wants
contraception to be permanent, simply convenient.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: HealN
thUPRroSmIoN
tiG
onTaB
nd.M
aiM
ntenance
CO
14. The method of contraception that is considered the safest for women is a(n)
a. IUD.
b. diaphragm.
c. male condom.
d. oral contraceptive.
ANS: C
A male condom does not have any side effects or risk factors for the woman. Oral
contraception, an IUD, and the diaphragm all have significant side effects or risk factors for
the woman.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
15. A patient is 27 years old and delivered her first baby yesterday. She and her husband do not
want to have another baby for at least 3 to 4 years. The most appropriate method of birth
control to meet their needs is
a. withdrawal.
b. fertility awareness method.
c. combination of condoms and foam.
d. vasectomy with a reversal in 3 years.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: C
Of the methods listed, condoms and foam would be the best for this couple. Withdrawal is
the least effective form of birth control. Fertility awareness is not that effective and an
unwanted pregnancy could result. They want another child, therefore a vasectomy with a
reversal would not be an appropriate option.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
16. The most appropriate statement for introducing the topic of family planning in the
postpartum setting is
a. “What are your plans for future pregnancies?”
b. “Do you plan on being sexually active in the future?”
c. “Let’s talk about birth control, because breastfeeding is not 100% effective for
preventing pregnancy.”
d. “Here are some pamphlets on available methods of birth control. I’ll come back
later and discuss them with you.”
ANS: A
Discussing future pregnancy plans opens the conversation to ways of preventing pregnancy
from occurring before the woman is ready to have another child. “Do you plan on being
sexually active in the future?” will only provide a yes or no answer and not allow for
conversation. The family needs to be ready to talk about birth control; the effect of
breastfeeding on birth control is applicable only to the woman. Pamphlets are not always the
best form of teaching. The patient is usually too tired and overwhelmed to read more
NUpos
RStpa
IN
GTB.C
information in the immediate
rtum
periodO
.M
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
17. In reviewing information related to the occurrence of pregnancies using a focus group
discussion with women, concern was expressed that many of them had problems using their
respective type of contraception. As a result of noncompliance issues several women
became pregnant. Based on this information, the nurse would incorporate which of the
following in a teaching plan for group members?
a. Provide information relative to product recalls of contraceptive devices.
b. Have the patients keep a contraceptive diary related to the consistency of using
methods because it is apparent that they forgot to use their preferred method as
directed.
c. Have the patients consider switching to a different form of contraception because
the contraception did not prevent pregnancy for them.
d. Plan for assessing the patients’ knowledge related to the contraception methods
and provide information to increase the knowledge base so that the effectiveness
rate would improve.
ANS: D
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
A typical effectiveness rate refers to the occurrence of pregnancy while using a specific
contraception method. If contraception is used correctly and consistently, pregnancy should
not occur. A decreased effectiveness rate is associated with incorrect usage in terms of
application or inconsistent use. Providing information relative to product recalls of
contraceptive devices refers to an ideal effectiveness rate; the implication is that the
contraception method, although used correctly, is at fault. There is no evidence to support
this finding. Having the patient keep a contraceptive diary does not address the primary
concerns related to the typical effectiveness rate. Having the patient switch methods may not
be necessary because the primary focus is to determine the knowledge base and identify
learning needs.
PTS: 1
DIF: Cognitive Level: Synthesis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
18. You are teaching a group of adolescents regarding myths and facts related to contraception.
Which statement indicates that additional teaching is needed for this group?
a. Adolescents are more likely to become pregnant even if they use available
contraception methods correctly.
b. The withdrawal technique provides a higher likelihood that a teen will not get
pregnant.
c. Pregnancy can occur in the presence or absence of orgasm.
d. Pregnancy can occur even if a teen is menstruating at the time of coitus.
ANS: B
The withdrawal technique does not decrease the likelihood of becoming pregnant for any
woman including a teen. WNitU
hdRraSwIaN
l iG
s aThBig.hC
lyOuM
nreliable method of birth control. Even
without penetration, ejaculation may result in pregnancy. Based on current clinical evidence,
adolescents are more likely to become pregnant even if they correctly use available
contraception methods. Pregnancy can occur in the presence or absence of orgasm, and also
if the teen is menstruating at the time of coitus.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
19. A patient presents to the Women’s Health Clinic for continuation of her contraceptive
method. She has been using Depo-Provera (medroxyprogesterone acetate) for 24 months. In
preparation for instituting a plan of care, the nurse would consider which option as a
priority?
a. Schedule the patient for follow-up baseline diagnostic testing to confirm that the
patient is not pregnant.
b. Obtain information for an alternate contraception method.
c. Ask the patient for additional information related to her menstrual cycle.
d. Inspect the skin for site selection of contraceptive method.
ANS: B
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
According to WHO (World Health Organization) guidelines, women should not be on
Depo-Provera for more than 2 years due to loss of bone density. Therefore, the nurse should
include assessments for other types of contraception methods for this patient. Although it
may prove to be important to rule out possible pregnancy, based on the provided
information, discontinuation of this method is the priority intervention. Depo-Provera can
cause menstrual irregularities, but this is not the priority intervention. The nurse can follow
up on this issue later. Because the current method of contraception should no longer be
used, this option is not necessary.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Safe and Effective Care Environment
20. Which of the following statements is correct regarding the use of contraception and the
occurrence of sexually transmitted diseases (STDs)?
a. As long as the oral contraception method is used correctly, there is no transmission
of STDs during sexual activity.
b. Oral contraceptives provide the greatest protection against getting STDs.
c. Barrier methods, if used correctly, are more likely to protect individuals from
STDs as compared with other contraceptive methods.
d. It is less likely to see transmission of STDs if patients engage in oral sex as
opposed to vaginal penetration.
ANS: C
The correct use of barrier methods helps protect against the transmission of STDs compared
with other methods of contraception. The use of oral contraceptives has no effect on the
transmission of STDs. TheN
efU
feRctiv
orC
alOcM
ontraceptives is increased related to the
SIene
NGssToBf .
prevention of pregnancy compared with other methods with the exception of abstinence.
The method of sexual activity does not affect the transmission of STDs.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
21. Which of the following is a potential disadvantage for the patient who wishes to use an
intrauterine device (IUD) as a method of birth control?
a. Insertion of the device prior to coitus resulting in decreased spontaneity
b. Ectopic pregnancy
c. Protection against STDs
d. Decrease in dysmenorrhea
ANS: B
The insertion of an IUD is performed in a health care provider’s office. An ectopic
pregnancy can occur as a possible complication of the IUD. An IUD does not offer
protection against STDs. A decrease in dysmenorrhea would be an advantage of using an
IUD.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
22. A patient is using Depo-Provera as her method of birth control. Which clinical finding
warrants immediate intervention by the nurse?
a. Mid-cycle bleeding
b. Nausea
c. Temperature of 37.8°C (100°F)
d. Irregular periods
ANS: A
When using Depo-Provera, the major side effect is irregular bleeding. The presence of
mid-cycle bleeding warrants further investigation at this time. Nausea, fever, and irregular
periods are not the result of Depo-Provera.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment
23. A patient has had a prior history of endometriosis and comes to the clinic asking about
which method of birth control might be helpful to alleviate her symptoms. Which birth
control method would provide the greatest benefit to this patient?
a. Withdrawal method
b. Oral contraceptives
c. Depo-Provera
d. Intrauterine device (IUD)
ANS: B
A patient who has a history of endometriosis may gain additional benefit from using an oral
N R I tho
GT
B.CseMhormone levels will be more uniformly
contraceptive as her birth conUtrolSmeN
d becauO
regulated with this type of treatment. The withdrawal method and Depo-Provera will not
provide any additional benefit relative to a history of endometriosis. An IUD may cause
further irritation to the endometrial lining so it would not be a prudent choice.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
24. You are evaluating a patient in the clinic setting who has been taking oral contraceptives for
several years, without side effects. Vital signs are stable and the patient denies any pain or
tenderness. On examination, you note a small erythematous area of approximately 2 cm on
her right lower leg. She denies any traumatic injury and says this is a recent onset of a few
days. Based on this information you would
a. instruct the patient to use warm compresses for several days and keep the leg
elevated as much as possible.
b. have the patient wear flats rather than heels to modify her gait and help alleviate
this issue.
c. refer the patient to the health care provider for additional diagnostic work up.
d. have the patient take an over-the-counter (OTC) nonsteroidal antiinflammatory
drug (NSAID) and return to the clinic if the problem persists.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Because the patient has a history of oral contraceptive use, the nurse must assess and
evaluate findings relative to ACHES (warning signs of oral contraceptives). Thus the patient
should be worked up for the possibility of a superficial or deep vein thrombosis (DVT).
Warm compresses and elevation of the leg, wearing flats, and taking an OTC NSAID may
lead to further problems if there is an underlying clot that is not addressed promptly.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Safe and Effective Care Environment
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 26: Infertility
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Large amounts of leukocytes in the seminal fluid suggest a clinical finding of
a. inadequate fructose.
b. inflammation of the testes.
c. an infection of the genital tract.
d. an obstruction in the vas deferens.
ANS: C
The presence of large amounts of leukocytes suggests an infection. Adequate fructose must be
present to supply energy for the sperm. An inflammatory process would be diagnosed by
abnormal consistency or chemical composition. If an obstruction is present, the total amount
of seminal fluid would be decreased.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
2. A couple who has not achieved a successful pregnancy is scheduled to meet with a fertility
specialist. Which simple evaluation is usually the first test to be performed?
a. Semen analysis
b. Testicular biopsy
c. Endometrial biopsy
d. Hysterosalpingography
ANS: A
NURSINGTB.COM
Semen analysis is usually the first test to be performed because it is least costly and
noninvasive. Endometrial biopsy determines whether the endometrium is responding to
ovarian stimulation. A testicular biopsy is an invasive examination using a local anesthetic.
Hysterosalpingography uses a contrast medium to evaluate the structure and patency of the
uterus and tubes.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
3. Which situation best describes secondary infertility in a couple?
a. Never conceived.
b. Had repeated spontaneous abortions.
c. Not conceived after 1 year of unprotected intercourse.
d. Has one child but cannot conceive a second time.
ANS: D
Secondary infertility occurs in couples that have conceived before; but, are unable to conceive
again. Primary infertility occurs when a couple has never conceived or who has not conceived
after 1 year of unprotected intercourse (6 months if the women is over age 35). Repeated
spontaneous abortions are considered primary infertility (pregnancy wastage).
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
4. A woman undergoing evaluation of infertility states, “At least when we’re through with all of
these tests, we will know what is wrong.” The nurse’s best response is
a. “I know the test will identify what is wrong.”
b. “I’m sure that once you finish these tests, your problem will be resolved.”
c. “Even with diagnostic testing, infertility remains unexplained in about 20% of
couples.”
d. “Once you’ve identified your problem, you may want to look at the option of
adoption.”
ANS: C
Problems with infertility must be approached realistically. Nurses should not make judgments
or provide false reassurance. Providing accurate information to the couple is the optimal
response. The nurse should not make statements indicating that problems will be resolved,
because this gives a false impression. The tests are not always definitive; therefore, the nurse
should not offer her view or opinion; rather, should state the facts.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
5. A newly married woman states, “My friend told me I would never have a baby because I had
pelvic inflammatory disease when I was younger. I don’t understand how that can affect
whether or not I get pregnant.” The nurse’s most appropriate response is
a. “Your friend may be right. The disease may affect your ability to conceive.”
b. “Pelvic inflammatory disease may damage the ovaries and prevent ovulation.”
c. “Your friend has been misinformed. Fallopian tube damage occurs only following
gonorrhea.”
NURSINGTB.COM
d. “Infection may cause scarring and obstruction of the fallopian tubes, which can
prevent the fertilized egg from reaching the uterus.”
ANS: D
Providing the patient with accurate complete information is the best response. If untreated,
pelvic inflammatory disease produces scarring and obstruction of the fallopian tube. Tubal
scarring and obstruction do not occur following gonorrhea.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
6. The procedure in which ova are removed by laparoscopy, mixed with sperm, and the
embryo(s) returned to the woman’s uterus is
a. in vitro fertilization (IVF).
b. tubal embryo transfer (TET).
c. therapeutic insemination (IUI).
d. gamete intrafallopian transfer (GIFT).
ANS: A
In vitro fertilization is a procedure used to bypass blocked or absent fallopian tubes. Tubal
embryo transfer places the conceptus into the fallopian tube. Therapeutic insemination, also
known as intrauterine insemination, uses the partner’s sperm or that of a donor and places it
directly into the uterus. Gamete intrafallopian transfer is when the sperm and ova are placed in
the fallopian tube.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. Chromosome analysis is a diagnostic test that should be offered to which couple?
a. Never conceived
b. Has long-standing infertility
c. Has had repeated pregnancy losses
d. Has a normal child but has not conceived again
ANS: C
Repeated failures to carry a pregnancy to term may indicate genetic defects in the fetus that
are incompatible with life. A couple that has never conceived would not be offered
chromosome analysis. Long-standing infertility is not an indicator for chromosome analysis.
Secondary infertility with an existing normal child would not be an indicator for chromosome
analysis.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. A woman who is undergoing infertility testing states, “My husband won’t discuss this with
me. I don’t think he cares about or wants a baby.” The nurse’s ideal response is
a. “You should confront him about this.”
b. “He probably doesn’t understand your concern.”
c. “Men are sometimes less eager to have children.”
d. “It may be harder for him to express his feelings.”
ANS: D
NURSINGTB.COM
Men often internalize their feelings, which may appear to women as lack of concern or
interest. Suggesting that the woman confront her husband suggests that the woman is at fault
and not communicating with her husband. “He probably doesn’t understand your concern”
does not explain to the woman why her husband won’t discuss the problem; it passes
judgment on the husband. “Men are sometimes less eager to have children” does not allow the
woman to express her feelings; it offers the nurse’s opinion, which is not appropriate.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Psychosocial Integrity
9. Which of the following medical conditions could possible affect a woman’s fertility status?
a. Past medical history of asthma during childhood that is presently under control
with the use of an inhaler
b. Recently diagnosed with polycystic ovarian syndrome
c. Past surgical history of removal of external polyps on labial tissue
d. History of frequent sinus headaches that is seasonal in nature treated with
over-the-counter medication
ANS: B
Women with polycystic ovarian syndrome (PCOS) often have challenges conceiving in
addition to other problems due to abnormal hormones and ovarian function. The use of inhaler
therapy for the treatment of asthma should not affect the patient’s fertility status. Removal of
external polyps on the labia should not affect the patient’s fertility. A history of sinus
headaches should not affect the patient’s fertility.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
10. A patient has been diagnosed with an incompetent cervix (the cervix will not remain closed).
What treatment option will be incorporated into the plan of care for this patient?
a. Bed rest throughout the pregnancy
b. Wait and see approach to determine if the patient goes into preterm labor
c. Preparation for cerclage procedure at 32 weeks’ gestation
d. More frequent ultrasounds to assess progression of pregnancy
ANS: D
An incompetent cervix would place the patient in a high-risk category, and more frequent
ultrasound monitoring would be included in her care plan. Although bed rest may be ordered,
there is conflicting evidence regarding the merits of this intervention. An incompetent cervix
is considered a clinical abnormality, therefore the standard of care requires appropriate
surgical intervention. A cerclage procedure is typically done much earlier in the pregnancy
period.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
MULTIPLE RESPONSE
1. Which factors would contribute to abnormalities of the fallopian tube associated with the
development of infertility? (Select all that apply.)
a. History of conization of tN
he cR
ervI
ix G B.C M
S
O
b. History of pelvic surgical pU
rocedurN
es T
c. Incompetent cervix
d. Past treatments of STD with follow-up test of cure
e. Endometriosis
ANS: B, D, E
Surgical procedures related to the cervix, along with an incompetent cervix, would not affect
the fallopian tubes in terms of infertility. It would affect fertility issues related to the cervix as
a result of potential scarring (conization) and an inability to maintain the pregnancy in the
presence of an incompetent cervix. A history of pelvic surgical procedures could result in the
development of pelvic adhesions, which would affect the fallopian tube. Also, the presence of
STDs, even with effective treatment, along with the clinical diagnosis, would affect the
fallopian tube and possibly result in infertility.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
2. Which adverse reactions are associated with the administration of clomiphene citrate
(Clomid)? (Select all that apply.)
a. Abdominal bloating
b. Diarrhea
c. Oliguria
d. Nausea and vomiting
e. Abnormal uterine bleeding
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: A, D, E
Some adverse reactions associated with Clomid are abdominal distension, frequent urination,
nausea and vomiting, and abnormal uterine bleeding. Diarrhea is not a common presentation.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
NURSINGTB.COM
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Chapter 27: Women’s Health
Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition
MULTIPLE CHOICE
1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test?
a. Lubricant
b. Speculum
c. Fixative agent
d. Gloves and eye protectors
ANS: A
Lubricants other than water or water-based lubricants on the cervix interfere with the accuracy
of the cytology report. A speculum is necessary to visualize the cervix. A fixative agent is
applied to the slide to prevent drying or disruption of the specimen. The examiner should
always use standard precautions including gloves and eye protection.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
2. A 45-year-old patient asks how often she should have a mammogram. The most appropriate
answer is
a. whenever she feels a lump.
b. every year beginning at age 40.
c. they are unnecessary until age 50.
d. every year if you have risk factors.
ANS: B
N R I G B.C M
U S N T
O
The American Cancer Society recommends that women have an annual mammogram after 40
years of age. Mammography should be done routinely following the American Cancer Society
guidelines. Mammograms are necessary when a woman is in her 40s. Women with high-risk
factors may require them more often.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
3. While performing a self-breast exam, the patient notes an area on the right breast that is
nodular, with some associated tenderness. This is a new onset finding because the exams were
not problematic in the past. The left breast examination is unremarkable. The patient calls to
report her findings to the clinical nurse because this is not her typical result. What action
should the nurse perform next?
a. Refer the patient to an oncologist because the results are suspicious.
b. Ask the patient to come in for an office visit so that the findings can be validated
but tell her that this information is within the normal range of presentation.
c. Have the patient wear a tight-fitting bra and tell her that the tenderness is
associated with ovulation and will pass.
d. Have the patient repeat the self-breast exam in 2 weeks and call back with findings
to provide a basis for comparison.
ANS: B
NURSINGTB.COM
Although these findings are within the normal range of presentation for breast tissue, they are
not in the normal presentation for this patient. The patient has called to express concern;
therefore, the nurse should have the patient schedule an appointment for assessment and
evaluation. There is no need for referral to a specialist at this time. Wearing a tight-fitting bra
may help provide support; however, does not address the physical findings and concern of the
patient. Repeating the self-breast exam may be required; however, it does not address the
patient’s current concerns.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
4. Findings of a Pap smear exam denote atypical cells of undetermined significance (ASCUS).
The Pap test is repeated at 6 months and the same finding of ASCUS is reported. Which
therapeutic treatment option would the nurse expect the practitioner to order?
a. Mammography
b. Bone scan
c. Transvaginal ultrasound
d. Biopsy
ANS: D
Based on the standard of care, a colposcopy or biopsy of the cervix is indicated. A Pap smear
is performed to evaluate the cervix. There is no indication that mammography, which is used
to assess and evaluate breast tissue, is required. There is no evidence to warrant a bone scan.
Although a transvaginal ultrasound might be included in the treatment plan, the Pap smear
indicates cervical pathology so a colposcopy or biopsy is indicated.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health PrN
om
onIaN
ndGM
UoRtiS
TaBin.teCnaOncMe
5. Which concern is included in the plan of care for the patient who receives HPV (human
papillomavirus) vaccine?
a. It is available in oral form.
b. It involves a series of two injections.
c. Injections should be given over a 3-month period.
d. The vaccine (Gardasil) should not be given to any patient with a sensitivity to
yeast.
ANS: D
The vaccine should not be administered to any woman who has a sensitivity to any component
of the yeast family. It is available only in injection form. It is given as a series of three
injections. The series of three injections should be given over a 6-month period according to
Centers for Disease Control and Prevention (CDC) recommendations. Side effects of the
vaccine include: headache, fever, nausea, and dizziness.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
6. Which are the most common sites of breast cancer metastasis?
a. Kidneys
b. Bones and liver
c. Heart and blood vessels
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
d. Skin
ANS: B
Metastasis occurs when the cancer cells spread by both blood and lymph system to distant
organs and to vascular sites, commonly the lungs, liver, bones, and brain. Kidney metastasis is
uncommon. Metastasis to the heart and blood vessels is uncommon. Skin cancer is not
associated with breast cancer metastasis.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
7. Which sexually transmitted disease can be treated and eradicated?
a. Herpes
b. AIDS
c. Chlamydia
d. Venereal warts
ANS: C
Treatment options chlamydial bacterial infection include: azithromycin, doxycycline,
ofloxacin, levofloxacin, or erythromycin. Concurrent treatment of all sexual partners is
necessary to prevent recurrence. Because no cure is known for herpes, treatment focuses on
pain relief and preventing secondary infections. Because no cure is known for AIDS,
prevention and early detection are the main focus. Condylomata acuminata is caused by the
human papillomavirus (HPV). No treatment eradicates the virus; however, there is a vaccine
available.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: PhysiologNic IR
ntegI
rity G B.C M
U S N T
O
8. A benign breast condition that includes dilation and inflammation of the collecting ducts is
known as
a. fibroadenoma.
b. ductal ectasia.
c. intraductal papilloma.
d. chronic cystic disease.
ANS: B
Generally occurring in women approaching menopause, ductal ectasia results in a firm
irregular mass in the breast, enlarged axillary nodes, and nipple discharge. Fibroadenoma is
evidenced by fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile
nodules. Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the
mass grows, it causes trauma or erosion within the ducts. Chronic cystic disease causes pain
and tenderness. The cysts that form are multiple, smooth, and well delineated.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
9. Which statement regarding primary dysmenorrhea is most accurate?
a. Primary dysmenorrhea is experienced by all women.
b. It is unaffected by oral contraceptives.
c. It occurs in young multiparous women.
d. It may be caused by excessive endometrial prostaglandin.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: D
Primary dysmenorrhea is menstrual pain without identified pathology. Some women produce
excessive endometrial prostaglandin during the luteal phase of the menstrual cycle.
Prostaglandin diffuses into endometrial tissue and causes uterine cramping. Contrary to
popular belief, primary dysmenorrhea is not experienced by all women. Oral contraceptives
can be a treatment choice if cramps associated with primary dysmenorrhea are debilitating. It
most often occurs in young nulliparous women.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
10. Which information should the nurse stress in teaching a patient how best to relieve the
symptoms of premenstrual syndrome (PMS)?
a. Decrease her consumption of caffeine.
b. Drink a small glass of wine with her evening meal.
c. Decrease her fluid intake to prevent fluid retention.
d. Eat three large meals a day to maintain glucose levels.
ANS: A
Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates
depression and should be avoided in the patient with PMS. The patient should drink at least
2000 mL of water per day. Six smaller meals a day will help maintain glucose levels and
reduce symptoms.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
N R I G B.C M
U nurse
S NthatT she has
O started experiencing pain with intercourse.
11.1 A patient, age 49, confides in the
1 The patient asks, “Is there anything I can do about this?” The nurse’s best response is
. a. “No, it is part of the aging process.”
b. “Water-soluble vaginal lubricants may provide relief.”
c. “You need to be evaluated for a sexually transmitted disease.”
d. “You may have vaginal scar tissue that is producing the discomfort.”
ANS: B
Loss of lubrication, with resulting discomfort in intercourse, is a symptom of estrogen
deficiency. It is part of the aging process; however, the use of lubrication will help relieve the
symptoms. This is a normal occurrence with the aging process and does not indicate an STD.
It is caused by loss of lubrication with the decrease in estrogen. Scar tissue problems would
have occurred earlier.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
12. Which patient is most likely to develop osteoporosis?
a. A 50-year-old patient on estrogen therapy
b. A 55-year-old patient with a sedentary lifestyle
c. A 65-year-old patient who walks 2 miles each day
d. A 60-year-old patient who takes supplemental calcium
ANS: B
NURSINGTB.COM
Risk factors for the development of osteoporosis include smoking, alcohol consumption,
sedentary lifestyle, family history of the disease, and a high-fat diet. A number of drug
therapies are available to reduce the progression of osteoporosis. Weight-bearing exercises
have been shown to increase bone density. Supplemental calcium will help prevent bone loss,
especially when combined with vitamin D.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
13. A patient with a history of a cystocele should contact the physician if she experiences
a. backache.
b. constipation.
c. urinary frequency and burning.
d. involuntary loss of urine when she coughs.
ANS: C
Urinary frequency and burning are symptoms of cystitis, a common problem associated with
cystocele. Back pain is a symptom of uterine prolapse. Constipation may be a problem for the
patient with a rectocele. Involuntary loss of urine during coughing is referred to as stress
incontinence and is not an emergency.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
14. Which specific instruction should the nurse teach to assist a patient to regain control of her
urinary sphincter?
a. Perform Kegel exercises.
NaUkeR. SINGTB.COM
b. Void every hour while aw
c. Drink 8 to 10 glasses of water each day.
d. Allow the bladder to become distended before voiding.
ANS: A
Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of
the urinary sphincter. A prescribed schedule may help; however, every hour is too frequent.
Restricting fluids will cause bladder irritation, which exacerbates the problem. Drinking
adequate fluids will decrease the concentration of urine; however, this intervention will not
improve sphincter control. Overdistention of the bladder will result in further stress
incontinence.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Health Promotion and Maintenance
15. The physician diagnoses a 3-cm cyst in the ovary of a 28-year-old patient. You expect the
initial treatment to include
a. initiating hormone therapy.
b. scheduling a laparoscopy to remove the cyst.
c. examining the patient after her next menstrual period.
d. aspirating the cyst and sending the fluid to pathology.
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
Most ovarian cysts regress spontaneously. Cysts in women of childbearing age may decrease
within one cycle, so treatment is not necessary at this point. It is too early to anticipate
removal of the cysts. Most ovarian cysts regress spontaneously within one cycle. A
transvaginal ultrasound examination will help determine if the cyst is fluid-filled or solid. The
cyst can then be removed if warranted.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
16. The drug of choice to treat a gonorrhea infection is
a. penicillin G (Pfizerpen).
b. tetracycline (Achromycin).
c. ceftriaxone (Rocephin).
d. acyclovir (Zovirax).
ANS: C
Additional drugs include cefixime (Suprate) or ciprofloxacin (Cipro). Ceftriaxone is effective
for treatment of all gonococcal infections. Penicillin G is used most commonly to treat
syphilis. Tetracycline is prescribed to treat chlamydial infections. Acyclovir is most
commonly used to treat herpes genitalis.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity
17. Which option could be used for the treatment and management of a patient who reports mild
pain associated with a clinical diagnosis of fibrocystic breast disease?
a. Chamomile tea as a relaxant therapy
NURSINGTB.COM
b. Danazol (Danocrine)
c. Tamoxifen (Nolvadex)
d. Over-the-counter nonsteroidal antiinflammatory drug (NSAID) therapy
ANS: D
Because the patient is reporting mild pain, NSAIDs may provide adequate pain relief and
comfort. It is recommended that tea, coffee, and/or other stimulants be limited or restricted for
patients with fibrocystic breast disease. Danazol is typically used for moderate to severe pain
for patients with fibrocystic breast disease because its use is associated with more serious side
effects. Danazol should not be used longer than 4 to 6 months. The patient reports mild pain
so this would not be warranted. Tamoxifen is a selective estrogen receptor modulator (SERM)
used for the treatment of breast cancers and also for moderate to severe pain in fibrocystic
breast disease. The patient reports mild pain, so this would not be warranted.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies
18. Which treatment option minimizes the development of lymphedema in the surgical
management of a patient with breast cancer?
a. Radical mastectomy procedure
b. Radiation therapy
c. Sentinel lymph node mapping
d. Ultrasound
ANS: C
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
The use of sentinel lymph node mapping identifies only those affected lymph node tissues that
require surgical removal and helps minimize the development of lymphedema in the surgical
management of a patient with breast cancer. Radical mastectomy is associated with
lymphedema in the postsurgical breast cancer patient because of the removal of lymph node
tissue. Radiation therapy is not associated with a decrease in lymphedema for the breast
cancer patient. Ultrasound as an intervention does not affect the development of lymphedema.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation
19. You are taking care of a patient who has had a colporrhaphy. Which option would indicate a
priority assessment during the postoperative period?
a. Documentation of a pessary in the operative procedure notes by the physician
b. Removal of vaginal packing as ordered by the physician
c. Use of a cell saver for transfusion therapy in the postoperative period
d. Order for removal of staples 2 to 3 days post-procedure
ANS: B
Vaginal packing is typically used in this type of pelvic surgery. The removal of the packing
should be verified and documented. This is the priority assessment. A pessary would be
utilized as a nonsurgical intervention for a patient who has had uterine prolapse and was not a
surgical candidate based on medical history. A cell saver is used in orthopedic surgeries that
are at risk for blood loss so that the patient’s own blood can be re-infused based on established
protocol. There are no staples used in this type of surgical procedure, which is also known as
an A & P (anterior and posterior) repair.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Safe and N
EfU
feR
ctS
ivI
eC
NaGreTEBnv.irConOmMent/Establishing Priorities
20. In reviewing genetic testing for a female patient, you note the presence of BRCA1, BRCA2,
and CHEK2. How should these findings be interpreted?
a. There is no increased likelihood that the patient will develop breast or ovarian
cancer.
b. There is an increased likelihood only for the development of breast cancer in a
woman.
c. More information is needed to interpret these findings based on the patient’s
family history and the patient’s current and past medical history.
d. A radical bilateral mastectomy is required as soon as possible, since the cancer
may have already undergone sub-metastasis.
ANS: C
The presence of genetic markers (BRCA1, BRCA2, and CHEK2) provides strong indicators of
the increased risk for the development of breast cancer in males and females as well as
ovarian cancer. It is important to obtain additional information in order that a treatment plan
can be developed and implemented to improve patient outcomes. There is an increased
likelihood that the patient will develop breast or ovarian cancer. Stating that there is an
increased likelihood only for the development of breast cancer in a woman fails to include that
men are also at risk of developing breast cancer. At this point, surgical intervention is
speculative because the presence of biomarkers does not indicate that sub-metastasis has
occurred or that the cancer has even developed.
NURSINGTB.COM
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
MULTIPLE RESPONSE
1. While interviewing a 48-year-old patient during her annual physical examination, the nurse
learns that she has never had a mammogram. The American Cancer Society recommends
annual mammography screening starting at age 40. Before the nurse encourages this patient to
begin annual screening, it is important for her to understand the reasons why women avoid
testing. These reasons include which of the following? (Select all that apply.)
a. Fear of x-ray exposure
b. Expense of the procedure
c. Reluctance to hear bad news
d. Having heard that the test is painful
e. Belief that lack of family history makes this test unnecessary
ANS: A, B, C, D
Fear of x-ray exposure, expense, reluctance to hear bad news, and fear of pain are reasons
women avoid having a mammogram done. Although the test is expensive, it is usually
covered by health insurance. Many communities offer low-cost or free screening to women
without insurance. It is important to acknowledge that some discomfort occurs with screening.
Scheduling the test immediately at the end of a period makes it less painful. The risk of
radiation exposure is minimal to none. Nurses play a vital role in providing information and
reassurance to help women overcome these fears. Even patients with no family history should
have a regular screening done. The nurse should emphasize that a combination of breast
self-examination and mammography needs to be performed at regular intervals. Women with
a family history may need toN
bU
egR
inSsI
crN
eeG
nT
inB
g.
atC
aO
yoMunger age and have additional testing
such as ultrasound performed.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance
2. Healthy People 2020 goals directed at women’s health issues focus on which areas? (Select
all that apply.)
a. Increased screening for cervical and colorectal cancers
b. Reduction of cancer survivor rate based on clinical management treatment
c. Decreased morbidity and mortality related to breast cancer
d. Reduction in hospitalization for hip fractures in the older female population
e. Reduction in deaths associated with cardiovascular causes such as stroke and
coronary artery disease (CAD)
ANS: A, C, D, E
Healthy People 2020 goals directed at women’s health focus on increased access to screening
for cervical and colorectal cancers, decreased deaths occurring from breast cancer and heart
disease, and decreased hospitalization for hip fractures. A reduction of the cancer survival rate
would reflect increased morbidity and mortality.
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
NURSINGTB.COM
3. A 38-year-old patient presents to the clinic office complaining of increased bilateral
tenderness of her breasts prior to the onset of menses. On questioning the patient, this
presentation has occurred off and on for several years; however, the pain has increased.
Physical examination reveals lumpy areas bilaterally on the upper outer quadrants of each
breast tissue. The areas of concern are approximately 2 cm in size. Based on this assessment,
which diagnostic testing would be necessary? (Select all that apply.)
a. Ultrasound examination
b. Open biopsy
c. Fine-needle aspiration (FNA) biopsy
d. CBC with differential
e. Mammogram
ANS: A, C, E
Based on the clinical presentation, the patient may have fibrocystic breast disease. Although
this condition is typically benign, the fact that the patient has noted a change in tenderness
should be evaluated. Ultrasound, FNA, and mammography may be indicated to provide a
baseline for comparison and rule out any malignancy. An open or surgical biopsy is not
indicated at the present time but may be needed if the other test results indicate any pathology.
Blood work is not indicated at this time relative to the diagnosis.
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential
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