Foundations Of Maternal Newborn And Women’s Health Nursing, 6th Edition by Sharon Smith Murray – Test bank

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Foundations Of Maternal Newborn and Women’s Health Nursing, 6th Edition by Sharon Smith Murray – Test bank

 

Sample  Questions

 

 

Chapter 07: Physiologic Adaptations to Pregnancy

 

MULTIPLE CHOICE

 

  1. A pregnant client’s mother is worried that her daughter is not “big enough” at 20 weeks of gestation. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman’s umbilicus. Which should the nurse report to the client and her mother?
a. “You’re right. We’ll inform the practitioner immediately.”
b. “Lightening has occurred, so the fundal height is lower than expected.”
c. “The body of the uterus is at the belly button level, just where it should be at this time.”
d. “When you come for next month’s appointment, we’ll check you again to make sure that the baby is growing.”

 

 

ANS:  C

At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks’ gestation is located at the level of the umbilicus. Lightening has not yet occurred. At 20 weeks, the uterus should be at the umbilical level. The descent of the fetal head (lightening) occurs in late pregnancy. Waiting until the next appointment avoids the direct question and might increase the anxiety of the mother and grandmother.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   94

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. While the vital signs of a pregnant client in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?
a. Have the client stand up and retake her blood pressure.
b. Have the client sit down and hold her arm in a dependent position.
c. Have the client turn to her left side and recheck her blood pressure in 5 minutes.
d. Have the client lie supine for 5 minutes and recheck her blood pressure on both arms.

 

 

ANS:  C

Blood pressure is affected by positions 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   96

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation 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 client 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 client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   97

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which suggestion is appropriate for the pregnant client 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 Alkamints to obtain relief, as directed by the health care provider.

 

 

ANS:  D

Antacids high in calcium (e.g., Tums, Alkamints) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the woman to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   114

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions?
a. These contractions may indicate preterm labor.
b. These are contractions that never cause any discomfort.
c. Braxton Hicks contractions only start during the third trimester.
d. 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   94

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the 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 the increased vascular volume. Renal plasma flow increases during pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   94

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Physiologic anemia often occurs during pregnancy because of:
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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   95

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which is a positive sign of pregnancy?
a. Amenorrhea
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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   105

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client is currently pregnant; she has a 5-year-old son and a 3-year-old daughter. She had one other pregnancy that terminated at 8 weeks. Which are her gravida and para?
a. 3, 2
b. 4, 3
c. 4, 2
d. 3, 3

 

 

ANS:  C

She has had four pregnancies, including the current one (gravida 4). She had two pregnancies that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she is classified as a gravida 4. Gravida 4 is correct, but she is para 2; the pregnancy that was terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she would be classified as a gravida 4, not 3.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   106

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client’s last menstrual period was June 10. What is her estimated date of birth (EDD)?
a. April 7
b. March 17
c. March 27
d. April 17

 

 

ANS:  B

To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 3 months (March 10), and adds 7 days (March 17). April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of adding 7 days. March is the correct month, but instead of adding 7 days, 17 days were added. April 17 is subtracting 2 months instead of 3.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   107

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Why should a woman in her first trimester of pregnancy 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

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, but they can be identified. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   112

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client in her first trimester complains of nausea and vomiting. She asks, “Why does this happen?” 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   113

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which advice to the client 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   119

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. A client notices that the health care provider writes “positive Chadwick’s sign” on her chart. She asks the nurse what this means. Which is the nurse’s best response?
a. “It means the cervix is softening.”
b. “That refers to a positive sign of pregnancy.”
c. “It refers to the bluish color of the cervix in pregnancy.”
d. “The doctor was able to flex the uterus against the cervix.”

 

 

ANS:  C

Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the cervix, vagina, and labia, called Chadwick’s sign. Softening of the cervix is Goodell’s sign. Chadwick’s sign is a probable sign of pregnancy. The softening of the lower segment of the uterus is Hegar’s sign, which can allow the uterus to be flexed against the cervix.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   102

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which is the gravida and para for a client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   106

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. To relieve a leg cramp, what should the client be instructed to perform?
a. Dorsiflex the foot.
b. Apply a warm pack.
c. Stretch and point the toe.
d. Massage the affected muscle.

 

 

ANS:  A

Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle contraction. Warm packs can be used to relax the muscle, but more immediate relief is necessary, such as dorsiflexion of the foot. Pointing the toes will contract the muscle and not relieve the pain. Because she is prone to blood clots, massaging the affected leg muscle is contraindicated.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   115

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A client, 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 expected at this date. It may be a complication, but it may also be because of incorrect dating of the pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   94

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which complaint made by a client 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 may indicate ectopic pregnancy (if early), worsening 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 stage of pregnancy. Shortness of breath is an expected finding at 35 weeks.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   121

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A gravida client 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
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 well-being, but the main concern with back pain is to assess posture and body mechanics.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   113

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant woman is the mother of two children. Her first pregnancy ended in a stillbirth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the five-digit system to describe this woman’s current obstetric history, what should the nurse record?
a. 4-1-2-0-2
b. 3-1-2-0-2
c. 4-2-1-0-1
d. 3-1-1-1-3

 

 

ANS:  A

Gravida (the first number) is 4 because this woman is now pregnant and was pregnant three times before. Para (the next four numbers) represents the outcomes of the pregnancies and would be described as follows:

  • T: 1 = term birth at 41 weeks of gestation (son)
  • P: 2 = preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter)
  • A: 0 = abortion; none
  • L: 2 = living children, her son and her daughter

She is currently pregnant so she is a gravida 4. She had one term infant, two preterm infants, no abortion, and three living children.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   107

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which laboratory result would be a cause for concern if exhibited by a client 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 expected range for pregnant women.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   110

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A client in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse give about 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 travelling by car is an inaccurate statement.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   119

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The client has just learned she is pregnant and overhears the gynecologist saying that she has a positive Chadwick’s sign. When the client asks the nurse what this means, how should 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 mucous 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 mucous plug protects from infection, it is not called Chadwick’s sign.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   94

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When a pregnant woman develops ptyalism, what should the nurse advise?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   97

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. A pregnant immigrant has an unknown immunization history. When she presents for routine vaccinations, which will the nurse administer?
a. Hepatitis B
b. Measles
c. Rubella
d. Varicella

 

 

ANS:  A

In general, immunizations with live virus vaccines (e.g., measles, mumps, rubella, varicella, smallpox) are contraindicated during pregnancy because they may have teratogenic effects on the fetus. Inactivated vaccines are safe and can be used in women who have a risk of developing diseases such as tetanus, hepatitis B, and influenza.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   119

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When the pregnant woman develops changes caused by pregnancy, the nurse recognizes that the darkly pigmented vertical midabdominal line is the:
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 a different kind of line caused by lineal tears that occur in connective tissue.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   99

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When documenting a client encounter, what 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 more. A primipara has delivered one pregnancy of at least 20 weeks. A multipara has delivered two or more pregnancies of at least 20 weeks.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   106

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. You are performing assessments for an obstetric client who is 5 months pregnant with her third child. Which finding would cause you to suspect that the client was at risk?
a. Client 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   111

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. What is the best explanation that you can provide to a pregnant client 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 and get a prescription for iron pills to correct this condition.

 

 

ANS:  C

Providing factual information based on physiologic mechanisms is the best option. Although having the client write down her concerns is reasonable, the nurse should not refer this conversation to the physician but rather address the client’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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   95

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. 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

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 client positioning. In response to increased metabolism, maternal vasodilation is seen during pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   96

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A pregnant client complains that since she has been pregnant, her nose is always stuffed and she feels like she has a cold. Past medical history is negative for respiratory problems such as hay fever, sinusitis, or other allergies. What is the most likely cause for the client’s presentation?
a. Increased effects of progesterone to maintain the pregnancy
b. Effects of estrogen on the respiratory tract
c. Development of allergies as a result of pregnancy because of altered immunity
d. Increase in fluid consumption during pregnancy leading to overhydration

 

 

ANS:  B

Increasing estrogen levels during pregnancy can affect the respiratory tract passages, leading to increased vascular responses that manifest as coldlike symptoms. Progesterone, as the hormone of pregnancy, maintains the pregnancy and does not have any direct effects on the maternal respiratory passages. Although it is possible for a client to develop allergies based on exposure to antigen triggers, it is not typically associated with pregnancy states. An increase in fluid may lead to potential edema, but it is not associated with coldlike symptoms.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   97

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A pregnant client complains of frequent heartburn. The client states that she has never had these symptoms before and wonders why this is occurring now. The best response that the nurse can provide is:
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 client 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 client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   113

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which physiologic event may lead to increased constipation during 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   98

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Which physiologic findings are seen with respect to gallbladder function that might 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
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 are seen as a result of hemodilution. Gallbladder tissue becomes hypotonic during pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   98

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. 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 are expected findings in pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   98

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. A pregnant client 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 client to a dermatologist for further examination.
b. Ask the client 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 client 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 client should be assured that this is a normal finding of pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   98

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

  1. Determine the obstetric history of a client in her fifth pregnancy who 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 client 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   107

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Use Nägele’s rule to determine the EDD (estimated day of birth) for a client 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 month – 3 = January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days = April 19), so the correct answer is January 19.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   107

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   118

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A client 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   120

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The patient reports that the first day of her last normal menstrual period was December 8. Using Nägele’s rule, what date will the nurse identify as the estimated date of birth?
a. March 1
b. March 15
c. September 1
d. September 15

 

 

ANS:  D

Nägele’s rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and adding 7 days. The incorrect responses add months instead of subtracting months and subtract days instead of adding days.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   107

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The client with an IUD 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 because 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 but it can occur and cause complications such as spontaneous abortion and infection. A therapeutic abortion is not indicated unless infection occurs.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   107

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. 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 client’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 non-nutritive 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 client’s hematocrit/hemoglobin, zinc, and iron levels.

 

PTS:   1                    DIF:    Cognitive Level: Synthesizing        REF:   112

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient at 24 week’ gestation reports to the clinic nurse that she is tired all the time. What is the nurse’s best response?
a. “Everyone has chronic anemia at this time in pregnancy.”
b. “I’ll make sure your health care provider is informed of your concern.”
c. “Your urine is clean of protein and sugar. You are doing well at this time.”
d. “Make sure you are drinking enough fluid to keep up with the demands of your body.”

 

 

ANS:  B

The patient is experiencing classic signs of physiologic anemia, or an increase in the amount of plasma resulting in a dilution of circulating red blood cells (RBCs). Red blood cell production will continue to increase throughout pregnancy, with a resulting resolution in physiologic anemia. The health care provider will likely order a complete blood count to verify this. The anemia is physiologic and not chronic because there is no decrease in circulating RBCs. The absence of proteinuria and glucosuria is reassuring, but these findings are not correlated with fatigue. Adequate fluid volume intake is essential in pregnancy but is not responsible for the development of physiologic anemia or the corresponding fatigue.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   95, 96

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. 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 best 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.
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 client 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. Ultrasounds must be prescribed by a health care provider and ordering one is not in the nurse’s scope of practice.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   102

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse is conducting a prenatal history with a patient who is new to the clinic. The woman reports that she had one healthy baby at term, and a miscarriage at 8 weeks. What will the nurse document as the patient’s GTPAL?
a. 21011
b. 20111
c. 30111
d. 31011

 

 

ANS:  D

Because this is a prenatal history, the client is pregnant. Gravida is the number of times the uterus has been pregnant, which in this case is three. The patient reported one Term birth, no Preterm births, one Abortion or miscarriage, and presumably one Live child.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   106

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The clinic nurse confirms that a patient is pregnant. She reports to the nurse that she has regular periods, and the first day of her last period was on January 20. Using Nägele’s rule, what due date will the nurse relay to the patient?
a. September 23
b. September 27
c. October 23
d. October 27

 

 

ANS:  D

Nägele’s rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and then adding 7 days.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   107

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   106

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing a patient during a routine prenatal visit. Her pregnancy has been unremarkable, and at her last visit her fundal height measurement was 23 cm. The nurse measures the patient’s fundal height at 24 cm. What is the next nursing action?
a. Ask the patient when she last felt fetal movement.
b. Palpate the patient’s bladder to determine if it is full.
c. Review the patient’s chart for her pattern of weight gain.
d. Assess the patient’s deep tendon reflexes (DTRs) bilaterally at the patella.

 

 

ANS:  A

Between 16 and 36 weeks, fundal height measurement corresponds with the weeks of gestation. The patient was last at the clinic at 23 weeks and would be rescheduled to return at 27 week, or in 4 weeks. The fundal height is 3 cm less than it should be, so the nurse is concerned about fetal well-being. Fetal movement is one of the first indicators of fetal well-being. If the patient’s bladder is full, the fundal height measurement will surpass the expected finding. Weight gain can be an indicator of well-being, nutritional status, and excess fluid volume. It is not as reliable an indicator as fetal movement for well-being. DTRs are assessed routinely to assess for hyperreflexia associated with gestational or pregnancy-induced hypertension.

 

PTS:   1                    DIF:    Cognitive Level: Synthesizing        REF:   111

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A pregnant client 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 client 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 virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   119

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching a pregnant client 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 mucous plug has been expelled. One of the earliest signs of labor may be bloody show, which consists of the mucous 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   121

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is planning care for a client in her first trimester of pregnancy who is experiencing nausea and vomiting. Which interventions should the nurse plan to teach this client? (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 client 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 client should check with her health care provider.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   114

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which 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, and Chadwick’s sign are presumptive signs of pregnancy. Ballottement and Goodell’s sign are probable signs of pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   102

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which factors contribute to the presence of edema in the pregnant client? (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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   101

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Physiologic Adaptation

 

SHORT ANSWER

 

  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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   93

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Calculate the estimated date of birth (EDD) in October using Nägele’s rule for a client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   107

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

Chapter 09: Nutrition for Childbearing

 

MULTIPLE CHOICE

 

  1. When planning a diet with a pregnant client, what should the nurse’s first action be?
a. Teach the client about MyPlate.
b. Review the client’s current dietary intake.
c. Instruct the client to limit the intake of fatty foods.
d. Caution the client to avoid large doses of vitamins, especially those that are fat-soluble.

 

 

ANS:  B

The first action should be to assess the client’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 client. Limiting intake of fatty foods is important in a pregnant client’s diet but not the first action. Cautioning about excessive fat-soluble vitamins is important but not the first action.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   144

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. A nurse is teaching a nutrition class to a group of pregnant clients. The nurse should include that the major source of nutrients in the diet of a pregnant woman should be composed of which?
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 mainly by the complex carbohydrates. The most common simple carbohydrate is table sugar, which is a source of energy but does not provide any nutrients.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   145

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. To increase the absorption of iron in a pregnant client, with what should an iron preparation be given?
a. Tea
b. Milk
c. Coffee
d. Orange juice

 

 

ANS:  D

A vitamin C source may increase the absorption of iron. 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   149

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   155

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. What is the recommended weight gain during pregnancy for a client who begins pregnancy at a normal weight?
a. 10 to 15 lb
b. 15 to 20 lb
c. 20 to 25 lb
d. 25 to 35 lb

 

 

ANS:  D

A weight gain of 25 to 35 lb is believed to reduce intrauterine growth restriction that may result from inadequate nutrition, and also allows for variations in individual needs. There is no precise weight gain appropriate for all women. A 10-lb weight gain is not sufficient to meet the needs of the pregnancy. A 15- to 20-lb weight gain is recommended for women who are overweight before the pregnancy. A 20- to 25-lb weight gain is recommended for women who are overweight before the pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   161

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client in her fifth month of pregnancy asks the nurse, “How many more calories should I be eating daily?” What should the nurse’s response be?
a. 180 more calories a day
b. 340 more calories a day
c. 452 more calories a day
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. 500 calories are more than the recommended calories for pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   145

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant client’s diet may not meet her need for folate. What is a good 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   147, 148

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant client asks the nurse if she can double her prenatal vitamin dose because she doesn’t like to eat vegetables. What is the nurse’s response about 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 shown to cause 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   154

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A nurse is conducting a prenatal nutritional education class for a group of nursing students. Which should the nurse include as the definition of pica?
a. Iron deficiency anemia
b. Intolerance to milk products
c. Ingestion of nonfood substances
d. Episodes of anorexia and vomiting

 

 

ANS:  C

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   155

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which is the common effect of both smoking and cocaine use on the pregnant client?
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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   156

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The breastfeeding client whose recommended prepregnancy caloric intake was 2000 calories per day would need how many calories per day to meet her current needs?
a. 2300
b. 2500
c. 2750
d. 3000

 

 

ANS:  B

The increase for a breastfeeding client is 500 calories above her recommended prepregnancy caloric intake. 2300 calories is not enough to meet her needs. 2750 calories may be too many calories and may lead to weight gain. 3000 calories is too many for this client and will lead to weight gain.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   151

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which is the most important reason for evaluating the pattern of weight gain in pregnancy?
a. Prevents excessive adipose tissue deposits
b. Determines cultural influences on the woman’s diet
c. Assesses the need to limit caloric intake in obese women
d. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   160

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A pregnant client would like to know a good food source of calcium other than dairy products. Which is the best answer that the nurse should give?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   154

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. To determine cultural influences on a client’s diet, what should the nurse do first?
a. Evaluate the client’s weight gain during pregnancy.
b. Assess the socioeconomic status of the client.
c. Discuss the four food groups with the client.
d. Identify the food preferences and methods of food preparation common to the client’s culture.

 

 

ANS:  D

Understanding the client’s food preferences and how she prepares food will assist the nurse in determining whether the client’s culture is adversely affecting her nutritional intake. Evaluating a client’s weight gain during pregnancy should be included for all clients, not just for those who are culturally different. The socioeconomic status of the clients may alter the nutritional intake, but not the cultural influence. Teaching the food groups to the client should come after assessing food preferences.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   160

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which pregnant adolescent is most at risk for a nutritional deficit during pregnancy?
a. A 16-year-old who is 10 lb overweight
b. A 17-year-old who is 10 lb underweight
c. A 15-year-old of normal height and weight
d. A 16-year-old of normal height and weight

 

 

ANS:  B

The adolescent who is pregnant and underweight is most at risk because she is already deficient in nutrition and must now supply the nutritional intake for both herself and her fetus. An overweight pregnant teen is at risk for deficiency but is not at the highest risk. Being underweight is the most risky because she is already deficient. A 15-year-old has special nutritional needs during pregnancy, but she is not at the highest risk for deficiency. A 16-year-old has special nutritional needs during pregnancy, but she is not at the highest risk for deficiency.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   151

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What should be the goal of a client with the nursing diagnosis “Imbalanced nutrition: Less than body requirements” (related to diet choices inadequate to meet the nutrient requirements of pregnancy)?
a. Gain a total of 30 lb.
b. Decrease intake of snack foods.
c. Take daily supplements consistently.
d. Increase intake of complex carbohydrates.

 

 

ANS:  A

A weight gain of 30 lb is one indication that the client has gained a sufficient amount for the nutritional needs of pregnancy. Decreasing snack food may be the problem and should be assessed. However, assessing the weight gain is the best method of monitoring intake for this pregnancy. A daily supplement is not the best goal for this client. It does not meet the basic need of proper nutrition during pregnancy. Increasing the intake of complex carbohydrates is important for this client, but monitoring the weight gain should be the end goal.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   157

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client who is in week 28 of gestation is concerned about her weight gain of 17 lb. Which is the nurse’s best response?
a. “You should not gain any more weight until you reach the third trimester.”
b. “You should try to decrease your amount of weight gain for the next 12 weeks.”
c. “You have not gained enough weight for the number of weeks of your pregnancy.”
d. “You have gained an appropriate amount for the number of weeks of your pregnancy.”

 

 

ANS:  D

A woman in her 28th week of gestation should have gained between 17 and 20 lb. The normal pattern of weight gain is about 3.5 lb total in the first trimester (by 13 weeks) and 1 lb per week after that. The client has gained the appropriate amount of weight. It would be inappropriate to have her decrease her weight gain. She has gained an appropriate amount of weight and should not increase the weight gain. Weight gain needs to be consistent during the last part of the pregnancy and should not be suppressed.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   162

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. In teaching a pregnant adolescent about nutrition, what should the nurse plan to do?
a. Determine the weight gain needed to meet adolescent growth and add 35 lb.
b. Suggest that she 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   162

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The traditional diet of Asian women includes little meat and few dairy products and may be low in calcium and iron. The nurse can help a client 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

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   152

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. When planning a diet for a pregnant client, which nutritional interventions should be implemented?
a. Fluids should be restricted to 6 glasses a day to minimize fluid retention and occurrence of edema.
b. Protein in the diet should be increased to meet growth and development needs.
c. Nutrient density should be used only if there are problems with weight gain during the course of the pregnancy.
d. Advise the client that the pattern of weight gain is not as important as the overall weight gained during the pregnancy.

 

 

ANS:  B

An increase in protein consumption is recommended as compared with prepregnancy diet recommendations. Fluid intake should be 8 to 10 glasses per day to maintain hydration. Nutrient density should be used throughout the pregnancy to meet increasing caloric needs. The pattern of weight gain is critical in helping identify potential risks associated with the development of fluid retention and preeclampsia.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   144

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. A pregnant client asks the nurse if she should take herbal supplements during pregnancy. What is the best response to her query?
a. “As long as you have had no reaction to them in the past, they would be safe to use during pregnancy.”
b. “Prenatal vitamins are the only things that should be taken during pregnancy.”
c. “Nutritional supplements will be prescribed by the health care provider based on individual needs.”
d. “During pregnancy, no supplementation is required because this is considered to be a healthy state.”

 

 

ANS:  B

Prenatal vitamins are noted as the standard of care in the medical treatment of pregnancy. A nurse should not encourage the use of herbal supplements to a pregnant client (or to any client) without obtaining information relative to constituent ingredients and assessment of potential interactions. This discussion should include the health care provider as a member of the interdisciplinary team. Nutritional supplements are not indicated during pregnancy, other than prenatal vitamins. During pregnancy, the client will not be able to meet their nutritional needs without the use of prenatal vitamins.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   150

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. Which client 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 section 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 client who is breastfeeding will require more calories and nutrients than individuals who are pregnant, delivered regardless of the type of birth, and whether they are bottle feeding.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   145

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Basic Care and Comfort

 

  1. A client post-delivery is concerned about getting back to her prepregnancy weight. She had only gained 15 pounds during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
a. Client has lost 35 pounds during the 6-week period prior to her scheduled checkup.
b. Client states that she is eating healthy and limiting intake of processed foods.
c. Client relates increased consumption of fruits and vegetables in her diet postbirth.
d. Client 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 client 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   143

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following is associated with inadequate maternal weight gain during pregnancy?
a. Prolonged labor
b. Preeclampsia
c. Gestational diabetes
d. Low-birth-weight infant

 

 

ANS:  D

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   161

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse is developing information to give to a group of pregnant women who are interested in nutritional management of their pregnancy with regard to expected weight gain. The nurse bases the amount of weight gain for pregnant women on calculation of their:
a. EDC (expected date of confinement).
b. prepregnancy weight.
c. BMI (body mass index).
d. basal energy expenditure (BEE).

 

 

ANS:  C

BMI takes into account height, weight, and body frame characteristics. Weight gain is not based on the EDC. Although the prepregnancy weight is important, it must be looked at in correlation to a calculated BMI. The calculation of BEE is used for clients who are at nutritional risk and are receiving enteral and/or parenteral nutrition therapies.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   143

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant client comes to the OB clinic and informs you that she is very concerned about the amount of weight gain associated with pregnancy. She then tells you that she wants to switch to a low-fat diet during pregnancy. BMI measurements indicate a BMI of 22.7. What would be the best nursing response to this client’s stated plan?
a. Tell the client that as long as she maintains a varied diet with regard to the other nutrients, there should be no problems.
b. Refer the client to a dietician for assistance in planning the low-fat diet.
c. Advise the client that it is important to maintain the intake of essential fatty acids during pregnancy.
d. Schedule the client for more frequent visits during the next few months to evaluate her weight pattern.

 

 

ANS:  C

It is important to teach the client that essential fatty acids are needed in the diet to assist fetal development (visual and cognitive). Dieting during pregnancy is not advised. Clients should maintain a regular diet that has a varied intake of nutrient sources. There is no need for referral at this time because dieting is not recommended during pregnancy. The client’s BMI indicates that she is within the normal weight range. There is no need to add additional appointments at this time.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   145

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant client arrives for her first prenatal visit at the clinic. She tells you that she has been taking an additional 400 mcg of folic acid prior to her pregnancy. Based on information obtained, she is at 8 weeks’ gestation. What recommendation would you give regarding folic acid supplementation?
a. Have the client continue to take 400 mcg folic acid throughout her pregnancy.
b. Tell the client that she no longer has to take additional folic acid because it will be included in her prenatal vitamins.
c. Have the client increase her folic acid intake to 1000 mcg throughout the rest of her pregnancy.
d. Schedule the client to go for an AFP (alpha-fetoprotein) test.

 

 

ANS:  B

Prenatal vitamins include adequate folic acid supplementation, so clients should not take additional supplementation as long 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 client is at 8 weeks’ gestation.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   146

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which food selections would lead to enhanced iron absorption during pregnancy?
a. Eating additional fiber and grains in the diet
b. Drinking coffee with meals
c. Drinking orange juice
d. Including spinach in the diet two to three times a week

 

 

ANS:  C

Drinking orange juice, which contains ascorbic acid, acts to enhance iron absorption. Foods that are high in fiber and grains contain phytates, which can decrease iron absorption. Coffee intake can affect iron binding and therefore decrease absorption. Spinach contains oxalates, which can interfere with iron absorption.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   150

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which client is most at risk for a low-birth-weight infant?
a. 22-year-old, 60 inches tall, normal prepregnant weight
b. 18-year-old, 64 inches tall, body mass index is <18.5
c. 30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm
d. 35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb

 

 

ANS:  B

The client 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; clients 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   144

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Changes in the diet of the pregnant client who has phenylketonuria would include:
a. adding foods high in vitamin C.
b. eliminating drinks containing aspartame.
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 client with phenylketonuria.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   145

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When explaining the recommended weight gain to your client, the nurse’s teaching should include which statement?
a. “All pregnant women need to gain a minimum of 25 to 35 pounds.”
b. “The fetus, amniotic fluid, and placenta require 15 pounds of weight gain.”
c. “Weigh gain in pregnancy is based on the client’s prepregnant body mass index.”
d. “More weight should be gained in the first and second trimesters and less in the third.”

 

 

ANS:  C

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 pounds. The combination of the fetus, amniotic fluid, and placenta averages about 11 pounds in the client 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   143

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Identify the appropriate weight gain at 28 weeks’ gestation for a client with a normal BMI (body mass index) before pregnancy.
a. 10 pounds
b. 19 pounds
c. 25 pounds
d. 30 pounds

 

 

ANS:  B

The woman with a normal BMI before pregnancy will gain approximately 4.4 pounds during the first trimester and 1 pound per week during the second and third trimesters. At 28 weeks, normal weight gain would be 4 pounds during the first trimester and 15 pounds in the second trimester. Ten pounds at 29 weeks gestation is adequate weight gain. Twenty-five and 30 pounds at 28 weeks is excessive weight gain.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   143

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   145

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The pregnant woman of normal weight enters her 13th week of pregnancy. If the client eats and exercises as directed, what will the nurse anticipate as the ongoing weight gain for the remaining trimesters?
a. 0.3 pound every week
b. 1 pound every week
c. 1.8 pounds every week
d. 2 pounds 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.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   157

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client with a BMI of 32 has a positive pregnancy test. What is the maximum number of pounds that the nurse will advise the client to gain during the pregnancy?
a. 20
b. 25
c. 28
d. 40

 

 

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 client as obese. The other options refer to minimal or maximal weight gain for clients in other BMI categories.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   143

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The pregnant client with significant iron deficiency anemia is prescribed iron supplements. The client confides to the nurse that she can’t 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, but it will also decrease absorption.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   149

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity: Pharmacologic Therapies

 

  1. What will the nurse advise when providing nutrition education to the pregnant client?
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 blindness in neonates.”
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.”
d. “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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   151

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. For the pregnant client 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

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 eaten by vegans. Fruits and vegetables alone will not provide the essential amino acids. Vitamin and mineral supplements do not provide amino acids.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   153

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant client has lactose intolerance. What recommendation will the nurse provide to best help the client 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, just like the nondehydrated varieties. Milk products can be avoided by those with lactose intolerance because adequate calcium may be obtained from food and supplements.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   149

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is reviewing the changes in nutrition related to pregnancy with a 17-year-old who is 12 weeks pregnant. They are specifically focusing on the dairy requirements. What is the nurse’s next action?
a. Ask, “Do you like milk, yogurt and cheese?”
b. Ask, “How many servings from the dairy group do you eat each day?”
c. Tell her, “You need to add no less than 3 cups of dairy-based foods each day.”
d. Inform her, “If you do not like to drink milk, you can eat a spinach salad every day”

 

 

ANS:  B

To individualize the patient’s teaching plan, the nurse must first assess the patient’s calcium intake. Then the nurse can modify the instructions for adequate calcium intake, based on the patient’s actual needs. Milk, yogurt, and cheese are calcium-rich foods but are inappropriate for the lactose-intolerant patient. The adolescent pregnant patient requires more daily calcium than the recommendation of 3 cups per day for the adult woman. Spinach is a source of calcium but it also contains oxalates, which decrease calcium availability.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   150

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The health care provider has recommended an iron supplement for the patient who is 20 weeks pregnant. The nurse is reviewing the recommendation with the patient. What fluid is best for the nurse to recommend when taking an iron supplement?
a. 8 ounces of milk
b. 8 ounces of water
c. 4 ounces of orange juice
d. 4 ounces of apple juice

 

 

ANS:  C

Iron absorption is enhanced when taken with a source of vitamin C. Calcium can block the absorption of vitamin C. Water and apple juice to not facilitate or block the absorption of iron.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   149

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   146

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. 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 advice to the 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.”
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 recommendation; four meals a day is not frequent enough. Consumption is not the patient’s stated concern—it is the nausea and vomiting.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   154

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The nurse is teaching a client 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, brown rice, and whole wheat pasta. Increased intake of fluids can help prevent constipation. A pregnant client should not take a daily laxative unless prescribed by her health care provider. Increased intake of dairy products, especially cheese, can increase constipation.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   162

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching a breastfeeding client 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

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   158

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is advising a lactose-intolerant pregnant client 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,   oz 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   149

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching a pregnant client about food safety during pregnancy and lactation. Which statements by the client 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 client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   151

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

MATCHING

 

Match each term with the correct definition.

a. Necessary for metabolism of calcium
b. Necessary for mineralization of fetal bones and teeth
c. Deficiency in first weeks of pregnancy may cause spontaneous abortion and neural tube defects

 

 

  1. Folic acid

 

  1. Vitamin D

 

  1. Calcium

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   146                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Folic acid deficiency in the first weeks of pregnancy may cause spontaneous abortion and neural tube defects in the fetus. Vitamin D is necessary for the metabolism of calcium. Calcium is necessary for mineralization of fetal bones and teeth.

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   147                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Folic acid deficiency in the first weeks of pregnancy may cause spontaneous abortion and neural tube defects in the fetus. Vitamin D is necessary for metabolism of calcium. Calcium is necessary for mineralization of fetal bones and teeth.

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   148                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Folic acid deficiency in the first weeks of pregnancy may cause a spontaneous abortion and neural tube defects in the fetus. Vitamin D is necessary for metabolism of calcium. Calcium is necessary for mineralization of fetal bones and teeth.

 

Match each term with the correct definition.

a. Important in cell growth and neuromuscular function
b. Important in thyroid function
c. Important in DNA and RNA synthesis

 

 

  1. Iodine

 

  1. Magnesium

 

  1. Zinc

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   148                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Iodine is important in thyroid function. Magnesium is important in cell growth and neuromuscular function. Zinc is important in DNA and RNA synthesis.

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   148                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Iodine is important in thyroid function. Magnesium is important in cell growth and neuromuscular function. Zinc is important in DNA and RNA synthesis.

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   148                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Iodine is important in thyroid function. Magnesium is important in cell growth and neuromuscular function. Zinc is important in DNA and RNA synthesis.

Chapter 13: Nursing Care During Labor and Birth

 

MULTIPLE CHOICE

 

  1. The nurse is preparing to perform Leopold’s maneuvers. Why are Leopold’s maneuvers used by practitioners?
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 Nitrazine or ferning 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   227

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which comfort measure should a nurse use to assist 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 client’s face and neck.
d. Keep the room lights lit so the client and her coach can see everything.

 

 

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 get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   236

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which assessment finding could indicate hemorrhage in the 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   224

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which is an essential part of nursing care for a laboring client?
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 client 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, but managing pain is a top priority.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   220

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client at 40 weeks’ gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:
a. 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 vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   221

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which client at term should go to the hospital or birth center the soonest 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   221

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:
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 her 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   222

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. 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 intact. The nurse should expect the client 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 client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   233

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?
a. Inform the mother that the 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. Tell the mother that she is going to have a boy because the heart rate is fast.

 

 

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.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   235

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which should the nurse recognize as being associated with fetal compromise?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   235

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?
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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   231

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which nursing assessment indicates that a woman 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

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 0 station indicates engagement.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   233

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   231, 233

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband’s hand away and shouts, “Don’t touch me!” This behavior is most likely:
a. abnormal labor.
b. a sign 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   223

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. 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, but the hands and feet are blue. The Apgar score for this infant is:
a. 7.
b. 8.
c. 9.
d. 10.

 

 

ANS:  C

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   249

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. If a woman’s fundus is soft 30 minutes after birth, the nurse’s first response 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   249

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   248

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse notes that a client 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

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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   251

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who 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 because of fear of the unknown. It would be important to recognize this because the client 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 clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   244

OBJ:   Nursing Process Step: Nursing Diagnosis

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?
a. Length of second-stage labor is 2 hours.
b. Client has received an epidural for pain control during the labor process.
c. Client is using breathing techniques during contractions to maximize pain relief.
d. Client is receiving parenteral fluids during the course of labor to maintain hydration.

 

 

ANS:  B

A client 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   244

OBJ:   Nursing Process Step: Diagnosis

MSC:  Client Needs: Safe and Effective Care Environment/Management of Care

 

  1. A gravida 1, para 0, 38 weeks’ gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?
a. Performing more frequent vaginal exams will not make the labor go any quicker.
b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.
c. Tell the client that she will check every 30 minutes.
d. Medicate the client as needed for anxiety so that the labor can progress.

 

 

ANS:  B

Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client’s anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   231, 233

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

 

  1. When using the second Leopold’s maneuver in fetal assessment, the nurse would palpate (the):
a. both sides of the maternal abdomen.
b. lower abdomen above the symphysis pubis.
c. both upper quadrants of the maternal abdomen .
d. lower abdomen for flexion of the presenting part.

 

 

ANS:  A

The second Leopold’s maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   230, 231

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nursing priority during admission of a laboring client 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 client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   223

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse has given the newborn an Apgar score of 5. She should then:
a. begin ventilation and compressions.
b. do nothing except place the infant under a radiant warmer.
c. observe the infant and recheck the score after 10 minutes.
d. gently stimulate by rubbing the infant’s back while administering O2.

 

 

ANS:  D

An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborn’s transition to extrauterine life.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   249

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client’s record?
a. Fetal heart rate
b. Pain level
c. Test results ensuring that the fluid is not urine
d. The client’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 client’s understanding of the event would only need to be documented if it presents a problem.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   222

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. At 5 minutes after birth, the nurse assesses that the neonate’s heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign?
a. 7
b. 8
c. 9
d. 10

 

 

ANS:  B

The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   248

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The gynecologist performs an amniotomy. What will the nurse’s role include immediately following the procedure?
a. Assessing for ballottement
b. Conducting a pH and/or fern test
c. Labeling of specimens for chromosomal analysis
d. Recording the character and amount of amniotic fluid

 

 

ANS:  D

An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   229

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   229

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?
a. To apply internal monitoring electrodes
b. To assess for Goodell’s sign
c. To determine cervical dilation and effacement
d. To determine strength of contractions

 

 

ANS:  C

The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodell’s sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   229

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?
a. Obtain a fetal heart rate.
b. Determine the estimated due date.
c. Auscultate anterior and posterior breath sounds.
d. Ask the client when she last had something to eat.

 

 

ANS:  C

On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   227

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse’s priority action with this procedure?
a. Perform Leopold’s maneuvers.
b. Determine the color of the amniotic fluid.
c. Assess the fetal heart rate immediately after the procedure.
d. Prepare the patient for a change in her pain level after the procedure.

 

 

ANS:  C

An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopold’s maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   229

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. 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
b. 20-gauge
c. 22-gauge
d. 24-gauge

 

 

ANS:  A

The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   229

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?
a. Place the catheter as quickly as possible.
b. Place a small pillow under the patient’s left hip.
c. Omit the use of a cleansing agent, such as Betadine.
d. Set up the catheter tray before positioning the patient.

 

 

ANS:  B

To promote placental function, the nurse can place a small pillow or rolled blanket under the patient’s left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   235

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse examines a primipara’s cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse’s priority action?
a. Palpate her bladder for fullness.
b. Assess the frequency and duration of her contractions.
c. Determine who will stay with the patient for the birth.
d. Encourage the patient to exhale in short breaths with contractions.

 

 

ANS:  D

Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient’s urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   237

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The labor nurse is reviewing the cardinal maneuvers 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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   247

OBJ:   Nursing Process Step: Planning       MSC:  Client needs: Health Promotion and Maintenance

 

  1. The nurse is performing Leopold’s maneuvers on a client. 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.
b.
c.
d.

 

 

ANS:  C

The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is done 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).

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   230

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. A laboring client is 10 cm dilated but 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
b. Less birth canal injuries
c. Decreased pushing time
d. Faster descent of the fetus
e. 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   238

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. 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 head helps prevent heat 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   248

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

 

  1. When taking care of a client in labor who is not considered to be at 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

Nursing care of the normal laboring client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   229

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

 

  1. Which interventions are required following an amniotomy procedure? (Select all that apply.)
a. Notation related to amount of fluid expelled
b. Color and consistency of fluid
c. Fetal heart rate
d. Maternal blood pressure
e. Maternal heart rate

 

 

ANS:  A, B, C

Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   229

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity/Reduction of Risk Potential

 

  1. The nurse is monitoring a client 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   234

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is caring for a client 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 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   249

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

SHORT ANSWER

 

  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

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

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   249

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

Chapter 21: Care of the Normal Newborn

 

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. On which rationale should the nurse base a reply?
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

Crust 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. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   427

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn?
a. Deltoid muscle
b. Gluteal muscles
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.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   416

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What should the nurse teach to parents about using a bulb syringe?
a. Use it only once a 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

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   417

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which principle is important in providing and teaching cord care?
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, so keeping the umbilical cord dry impedes bacterial growth. Cord care is done to prevent infection and aid in the drying of the cord. No agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14 days.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   422

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which is the purpose of state-required newborn screening?
a. Keep the state records updated.
b. Document the number of births.
c. Allow for accurate statistical information.
d. Recognize and treat newborn disorders early.

 

 

ANS:  D

Early treatment of disorders will prevent morbidity associated with some common newborn disorders. Keeping state records and documenting the number of births are not the purposes of newborn screening. The number of births is not indicated by the newborn screening test.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   432, 433

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which should the nurse implement to prevent the kidnapping of a newborn from the hospital?
a. Restricting the amount of time infants are out of the nursery
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 to not give the baby to anyone except the nurse assigned that day

 

 

ANS:  B

Infants should be transported in the hallways only in their cribs. Restricting the amount of time infants are out of the nursery will be difficult to monitor and will limit the mother’s support system from visiting. Infants need to spend time with the parents to facilitate the bonding process. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   423, 424

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. A nursing student has been caring for a client and her newborn all morning. After taking the newborn to the nursery for tests, the student is returning the newborn to the 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.
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 arm bands with matching numbers. The other actions do not adequately verify the identities of mother and infant.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   423

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse is explaining the procedure of newborn screening to parents before 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.”
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 need further teaching if they say that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   433

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which newborn assessment finding requires the nurse to take an 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

A glucose level of 40 mg/dL requires an action. Follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn if the glucose screening shows 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 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   419

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is assessing 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?
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 bleeding. Petroleum jelly is applied to keep the diaper from sticking to the circumcised area. It will not stop the bleeding.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   425

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. 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) in 2011 recommended that mothers and fathers be taught to place infants on the back for sleep, because 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   423, 430

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 38 weeks’ gestation fetus is delivered via cesarean section 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 section 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   417

OBJ:   Nursing Process Step: Nursing Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care

 

  1. An infant’s temperature is recorded at 36° C (96.8° F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement?
a. Note the findings in the electronic health record (EHR).
b. Unwrap the infant and inspect for abnormalities.
c. Provide the infant with glucose water.
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, but 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   420

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment/Establishing Priorities

 

  1. In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem?
a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours.
b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn.
c. Make sure that all emergency exits are accessible to staff and clients on the unit.
d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security.

 

 

ANS:  B

Requiring appropriate identification is the best method of preventing possible infant abduction. Evidenced-based practice has indicated that potentially “family and/or staff or someone representing themselves as such” is more likely to attempt an infant abduction. The unit should be a closed or locked unit and require admittance to maintain security. Limiting the visitors to two per client may cause increased stress to the new family because they want to share this experience. Preventing siblings from visiting by only allowing immediate adult family members may prevent beginning sibling attachment and cause separation and stress anxiety to the mother and children.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   423, 424

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. When an infant’s temperature drops from 98.7° to 97.4° F (37° to 36.3° C), the nurse should:
a. instruct parents on cold stress.
b. determine 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

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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   420

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. 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 a shot 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. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding shortly after birth.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   415

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The postpartum nurse is reviewing oral-nasal bulb suctioning with a first-time mom. Which statement will the nurse need to correct?
a. “Depress the bulb prior to inserting the tip.”
b. “Suction the nose first and then the mouth.”
c. “Keep a bulb syringe in the bassinet at all times.”
d. “Gradually release the pressure on the bulb while withdrawing it.”

 

 

ANS:  B

The mouth should be suctioned first because the infant may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth. Then the nose is suctioned gently and only if necessary. Suctioning is traumatic to the delicate tissues and may cause edema of the nasal passages. The remaining statements are correct.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   417

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. 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 and not the father needs to 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   421

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8° to 37° C (98.2° to 98.6° F), and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision?
a. Consent
b. Vitamin K
c. Heart rate
d. Temperature

 

 

ANS:  B

The administration of the vitamin K prevents excessive bleeding. The infant could be at risk for hemorrhage without the vitamin K. Other assessment measures can be used to fulfill the remaining assessments, such as a verbal consent can be obtained, the skin can be palpated to determine temperature, and overall color can give the health care provider information about the infant’s heart rate. The only replacement for vitamin K is time to allow for the development of vitamin K in the gastrointestinal (GI) system.

 

PTS:   1                    DIF:    Cognitive Level: Synthesis             REF:   426

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which newborn testing must be performed prior to discharge from the hospital? (Select all that apply.)
a. Pulse oximetry
b. Hearing
c. Guthrie
d. Hypothyroidism
e. Galactosemia

 

 

ANS:  A, C, D, E

The pulse oximetry test is used to identify potential cardiac anomalies, so it must be done prior to infant discharge. The Guthrie test is another name for the metabolic screening panel test that is done to identify a group of metabolic diseases that would have a significant impact on newborn infants. Included in this test are observations related to thyroid activity, PKU, and galactosemia. A hearing screening test is recommended during the first month of life.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   432, 433

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance/Health Screening

 

  1. Which are the reasons for having auditory screening on all newborns in the first month of life? (Select all that apply.)
a. Early identification and treatment
b. Reassurance for concerned new parents
c. To prevent or reduce developmental delay
d. To achieve one of the Healthy People 2020 goals

 

 

ANS:  A, C, D

Newborn auditory screening is done to identify hearing loss and begin treatment. Treatment can help to reduce developmental delay. Newborn auditory screening is a Healthy People 2020 goal. New parents are often anxious regarding this test and the impending results; however, it is not a reason for the screening to be performed.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   432, 433

OBJ:   Nursing Process Step: Diagnosis     MSC:  Client Needs: Physiologic Integrity

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   426

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. 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.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   431

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which nursing action is a priority to prevent infection in the newborn? (Select all that apply.)
a. Wearing gloves before touching neonates
b. Washing hands before and after handling any neonate
c. Washing hands and arms thoroughly at the beginning of the day
d. Sharing some equipment that will not transmit infection from one neonate to another

 

 

ANS:  B, C

At the beginning of their shift, nurses wash their hands and arms thoroughly. Throughout the day, handwashing is important before and after touching any infant. Gloves are not necessary unless personal protective equipment is required because of coming in contact with body fluids. To avoid cross-contamination, each infant’s supplies are kept separately from those used for other infants. Supplies in drawers or cupboards of each crib unit should be used only for that infant because they are likely to be touched by nurses giving care. Using them for another neonate could result in the transfer of infectious organisms.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   424

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity