Maternal and Child Health Nursing 7th Edition By Pillitteri – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Maternal and Child Health Nursing 7th Edition By Pillitteri – Test Bank

 

Sample  Questions

 

1. For which patient assessment finding would an intrauterine device (IUD) be contraindicated?
A) Misshapen uterus
B) Multiple sexual partners
C) Diagnosis of hypertension
D) History of thromboembolic disease
Ans: A
Feedback:
Use of an IUD may be contraindicated for a woman whose uterus is distorted in shape because the device might perforate the uterine wall. The device is not contraindicated for multiple sexual partners, hypertension, or history of thromboembolic disease. Infection is no longer a concern because the vaginal string no longer conducts fluid. The device does not impact hormone levels and will not influence blood pressure or blood flow.

 

 

2. A male patient is considering a vasectomy. Which information should the nurse instruct the patient about this procedure? (Select all that apply.)
A) Sexual intercourse can resume in a week.
B) The procedure can be done as an outpatient.
C) An opioid analgesic will be prescribed for pain control.
D) Use a birth control method until a negative sperm reports occur.
E) Spermatozoa present in the vas deferens will be viable for 2 weeks.
Ans: A, B, D
Feedback:
After a vasectomy, sexual intercourse can resume after 1 week. The procedure can be completed as an outpatient. The patient may experience a small amount of local pain afterward, which can be managed by taking a mild analgesic and applying ice to the site. An additional birth control method should be used until two negative sperm reports at about 6 and 10 weeks have been obtained. Spermatozoa, which were present in the vas deferens at the time of surgery, can remain viable for as long as 6 months.

 

 

3. A patient comes into the family planning clinic and requests a prescription for birth control pills. Which assessment finding indicates that an ovulation suppressant would not be the best contraceptive method for the patient?
A) Age 30 years
B) Allergy to foreign protein
C) Irregular menstrual cycles
D) History of thromboembolism
Ans: D
Feedback:
Combination oral contraceptives are not routinely prescribed for patient with a history of thromboembolic disease. The patients’ age would not be a contraindication for this type of contraceptive. An allergy to foreign protein would impact the patient’s ability to use condoms. Irregular menstrual cycles would be an indication for combination oral contraceptives.

 

 

4. A female patient has forgotten to take an ovulation suppressant for two mornings in a row.  What should the nurse advise the patient to do?
A) Take two pills a day for the rest of the month.
B) Take three pills immediately and avoid coitus for the remainder of the month.
C) Start a new cycle of 21 pills immediately plus additional estrogen for the next 3 days.
D) Take two pills now and use a second method of contraception for the remainder of the month.
Ans: D
Feedback:
If two consecutive active pills are missed, the patient should be advised to take two pills immediately. Then the patient should continue the following day with the usual schedule. Missing two pills may allow ovulation to occur, so an added contraceptive such as a spermicide should be used for the remainder of the month. The patient does not need to take two pills every day for the rest of the month, take three pills and abstain from coitus, or start a new cycle of 21 pills.

 

 

5. The nurse is planning an educational session on contraceptives for a group of adolescent high school students. What does the nurse need to do when planning this session?
A) Argue that encouraging abstinence is unrealistic during the teenage years.
B) Discuss that the application of a condom should occur after penile-vulvar contact.
C) Explain that the combination oral contraceptive approach is the best for adolescents.
D) Teaching about contraceptive options while avoiding indirect encouragement of sexual activity.
Ans: D
Feedback:
The nurse can help the nation achieve the 2020 National Health Goals by teaching adolescents about contraceptive options while being cautious to avoid indirectly encouraging sexual activity among teens. A 2020 National Health Goal is to increase the number of adolescents being instructed on abstinence. A condom should be applied before penile-vulvar contact. Oral contraceptives are not the contraceptive of choice for adolescents.

 

 

6. The nurse is teaching a patient on the use of a diaphragm for contraception. Which patient statement indicates that instruction has been not been effective?
A) “I need to use my finger to remove the diaphragm.”
B) “I should remove the diaphragm 6 hours after intercourse.”
C) “I should stop using a diaphragm if I get an infection of my cervix.”
D) “I need to have the diaphragm checked if my weight changes by 30 lb.”
Ans: D
Feedback:
The patient should be instructed to have the size of the diaphragm checked if weight changes by 15 lb. The patient does need to use the finger to remove the diaphragm. The diaphragm should be removed 6 hours after intercourse. The diaphragm should not be used if the patient is experiencing a cervical infection.

 

 

7. A 40-year-old woman who smokes desires a reliable contraceptive method. Which should the nurse recommend to this patient?
A) An ovulation suppressant
B) A condom and spermicide
C) A spermicidal suppository
D) The rhythm (calendar) method
Ans: B
Feedback:
Women who are 40 years of age and smoke should not take ovulation suppressants. Irregular menstrual cycles make natural methods difficult. Women older than the age of 40 may have vaginal dryness, so a spermicidal suppository would not be effective. The best option is for the patient to use a condom and spermicide.

 

 

8. An adolescent female who has recently started menstruating asks for a highly reliable birth control method. Which method should the nurse discuss with the patient?
A) Postcoital douching
B) An intrauterine device
C) An ovulation suppressant
D) Vaginal foam for her and a condom for her partner
Ans: D
Feedback:
For many adolescent couples, use of a dual method, such as a vaginally inserted spermicide by the girl and a condom by her partner, is a preferred method of birth control. Postcoital douching is not a method of birth control. Intrauterine devices are rarely used for early adolescents because the uterus may still be small. Ovulation suppressants are not recommended until a female has been menstruating for at least 2 years.

 

 

9. A patient wants to calculate fertile days using the calendar method. What will the nurse instruct the patient to subtract when making this calculation?
A) 14 from 28
B) 18 from the shortest period and 11 from the longest
C) 18 from the longest period and 11 from the shortest
D) The length of the average period from the ideal of 28
Ans: B
Feedback:
To calculate “safe” days, the patient should subtract 18 from the shortest cycle. This number predicts the first fertile day. Then subtract 11 from the longest cycle. This represents the last fertile day. The other calculations are incorrect to determine fertile days.

 

 

10. The nurse instructs a patient on cervical mucus changes that occur during ovulation. Which statement indicates that teaching has been effective?
A) “During ovulation, the mucus is thick.”
B) “Ovulation makes the mucus more acidic.”
C) “The mucus is white because of more white blood cells.”
D) “When the mucus is thin and watery, then ovulation is occurring.”
Ans: D
Feedback:
On the day of ovulation, the cervical mucus becomes copious, thin, watery, and transparent. During ovulation, the mucus is not thick, not acidic, and not white.

 

 

11. The nurse is planning instruction for a patient desiring to have a tubal ligation. Which information should the nurse emphasize when teaching the patient?
A) She must think of the procedure as irreversible.
B) The procedure will reduce her menstrual flow in amount.
C) She should schedule it to be done just before a menstrual flow.
D) She will have lessened dysmenorrhea following the procedure.
Ans: A
Feedback:
People considering tubal ligation should think of this procedure as permanent before having it done. Although reversal of the procedure can be done, the success rate is between 70% and 80%. Tubal ligation does not alter the menstrual flow or affect dysmenorrhea. Ectopic pregnancy could result if it is done following ovulation.

 

 

12. A patient asks the nurse if a cervical cap is better than a diaphragm for contraception. What should explain as the advantages of a cervical cap?
A) No initial fitting is required.
B) It can be left in place longer.
C) It needs no spermicidal jelly.
D) It does not need to be refitted after pregnancy.
Ans: B
Feedback:
Caps can be kept in place longer—up to 48 hours—because they do not put pressure on the vaginal walls or urethra. A fitting is needed for a cervical cap. They are used with spermicidal jelly, and they do need to be refitted after pregnancy.

 

 

13. The nurse instructs a patient on the use of a vaginal estrogen/progestin rings (NuvaRing) for contraception. Which patient statement indicates that additional instruction is needed?
A) “I am to take the ring out overnight.”
B) “I will leave the ring in place for 3 weeks.”
C) “I leave the ring in place during intercourse.”
D) “I am to use other birth control if I take the ring out for 4 hours.”
Ans: A
Feedback:
If the ring is removed for 4 hours for any purpose, it should be replaced with a new ring and a form of barrier protection is to be used for the next 7 days. The ring is not removed overnight. The ring is left in place for 3 weeks and then removed for menstruation during the ring-free week. The ring does not need to be removed for intercourse.

 

 

14. When should the nurse instruct a female patient using the basal body temperature method of contraception to refrain from having sexual intercourse?
A) Four days after noticing a temperature rise
B) Fourteen days after the last day of the menstrual period
C) Three days after recording a slight drop in temperature followed by an increase
D) Three to 4 days after recording a slight increase followed by a dip in the temperature
Ans: C
Feedback:
As soon as a woman notices a slight dip in temperature followed by an increase that lasts for at least 72 hours, this indicates that ovulation has occurred. The patient should not be instructed to refrain from sexual intercourse 4 days after a temperature rise, 14 days after the last menstrual period, or 3 to 4 days after a slight increase followed by a dip in the temperature.

 

 

15. The nurse completes instructing a patient on the use of the contraceptive patch. Which patient response indicates that teaching has been effective?
A) The patch is immediately effective after application.
B) The patch should be applied to the breasts, hips, or back.
C) The patch should be applied to the abdomen, buttocks, or back.
D) The patch should be covered when swimming because of chlorine’s effect on the adhesive.
Ans: C
Feedback:
The patch should be applied only to the buttocks, back, abdomen, or torso and never on the breasts. The patch is safe for wearing during swimming and bathing. The patch requires application for 1 week before becoming effective.

 

 

16. A patient who has unprotected intercourse has obtained the morning after pill but has not yet taken the prescribed dosage. What nursing diagnosis should the nurse identify as appropriate for the patient at this time?
A) Powerlessness
B) Spiritual distress
C) Decisional conflict
D) Readiness for enhanced knowledge
Ans: C
Feedback:
The patient has the morning after pill but has not yet taken the prescribed dosage. This indicates that the patient has not yet made a decision. Powerlessness would be applicable if the patient’s planned contraceptive was ineffective. Spiritual distress would be appropriate if there were a conflict regarding contraceptive methods. Readiness for enhanced knowledge would be applicable if the patient was asking about different contraceptive types.

 

 

17. An Rh-negative patient of 6 weeks gestation is scheduled for a medically induced termination. Which outcomes should the nurse identify as appropriate for this patient? (Select all that apply.)
A) Attended contraceptive counseling
B) Received Rho (D) immune globulin
C) Scheduled postprocedure sonogram
D) Avoided strenuous activity for 3 weeks
E) Experienced menstrual cycle in 2 months
Ans: A, B, C
Feedback:
A medically induced termination should be performed within 63 days of gestation. Once the termination medication has been provided, the patient should receive Rho (D) immune globulin, schedule a postprocedure sonogram, and attend contraceptive counseling. The patient should avoid strenuous activity for 3 days and have a return of a menstrual cycle within 2 to 4 weeks.

 

 

18. A patient recovering from a surgical pregnancy termination returns for a postprocedure examination. The patient tells the nurse that she is relieved that the procedure is over however is feeling sad. What should the nurse do to assist the patient at this time?
A) Suggest the patient talk with a counselor.
B) Ask the patient to identify the source of the sadness.
C) Recommend the patient attend contraceptive counseling sessions.
D) Discuss the need for an antidepressant with the health care provider.
Ans: A
Feedback:
After a surgical pregnancy termination, most women report to be relieved with the decision; however, those who express sadness and guilt may need to be referred for professional counseling so they can integrate and accept this event in their lives. Asking the patient to identify the source of the sadness will not help the patient work through feelings caused by the procedure. Recommending the patient attend contraceptive counseling sessions does not focus on the source of the patient’s sadness. Discussing antidepressant use may be premature for this patient.

 

 

19. A patient received a scheduled dose of depot medroxyprogesterone acetate (DMPA) 6 weeks ago. Today, the patient reports that a regular menstrual cycle is 2 weeks late. What is the first thing that should be done for this patient?
A) Perform a pregnancy test.
B) Provide prenatal counseling.
C) Discuss pregnancy termination options.
D) Explain side effects of the contraceptive.
Ans: A
Feedback:
Because the patient is receiving a contraceptive that could cause amenorrhea, and the patient’s menstrual cycle is 2 weeks late, the first thing that should be done is a pregnancy test to determine if the patient is pregnant. The results of this test will determine the next course of action. Depot medroxyprogesterone acetate (DMPA) is a pregnancy category X medication, which means it should not be administered to someone who is pregnant. It is unclear if the patient was already pregnant when the last dose was provided 6 weeks prior to the current situation. It is premature to provide prenatal counseling. Depending on the results of the pregnancy test, the nurse may need to explain side effects of the contraceptive which include amenorrhea.

 

 

20. A postpartum patient asks the nurse when the subdermal hormone implant for contraception can be inserted. What should the nurse respond to this patient?
A) In 6 weeks
B) In 1 month
C) 1 week after your next menstrual cycle
D) Before being discharged after this delivery
Ans: A
Feedback:
The subdermal hormone implant can be placed 6 weeks after the birth of a baby. One month is too soon for the implant to be placed after the birth of a baby. Typically, the rod is inserted during menses or no later than day 7 of a menstrual cycle to be certain that the patient is not pregnant at the time of insertion. The implant will not be placed immediately after the delivery of a baby.

 

1. A female patient learns that she is the carrier of the X-linked recessive disease hemophilia A. Her spouse is free of the disease. What should the nurse teach the patient about the frequency of this disease in future children?
A) All male children will inherit it.
B) All female children will be carriers like she is.
C) All male children will have a 50% risk to inherit the disease.
D) All female children will have a 50% risk to inherit the disease.
Ans: C
Feedback:
In X-linked recessive diseases such as hemophilia A, females who inherit the affected gene will be heterozygous, and, because a normal gene is also present, the expression of the disease will be blocked. But because males have only one X chromosome, the disease will be manifested in any male children who receive the affected gene from their mother. If the mother has the affected gene on one of her X chromosomes and the father is disease free, the chances are 50% a male child will manifest the disease and 50% a female child will carry the disease gene. All male children will not inherit the disease. All female children will not be a carrier of the disease. Females will not inherit the disease.

 

 

2. A married couple is beginning genetic counseling. What should the nurse instruct the couple regarding expectations from this process? (Select all that apply.)
A) The results will be provided to the couple only.
B) The results will be provided as quickly as possible.
C) The married couple makes the decision to participate in the process.
D) Medically recommended procedures will be immediately scheduled.
E) The married couple will sign informed consent forms for procedures.
Ans: A, B, C, E
Feedback:
Legal responsibilities of genetic testing, counseling, and therapy include the results will not be withheld and given to the persons directly involved; the results will be provided as quickly as possible; participation in genetic screening is elective; and those desiring genetic screening must sign an informed consent for the procedures. After genetic counseling, persons are not to be coerced to undergo procedures; therefore, medically recommended procedures will not be immediately scheduled.

 

 

3. Both people in a married couple carry the recessive gene for cystic fibrosis. When asked about the incidence of any children developing the disorder, what should the nurse respond?
A) “There is no chance.”
B) “There is a 1 in 4 chance.”
C) “There is a 2 in 4 chance.”
D) “There is a 3 in 4 chance.”
Ans: B
Feedback:
In autosomal recessive inheritance, the disease will not occur unless both parents have recessive genes for the disorder. There is a 25% chance a child born to the couple will be disease and carrier free; a 50% chance the child will be, like the parents, free of disease but carrying the unexpressed disease gene; and a 25% chance the child will have the disease, or a 1 in 4 chance. With the recessive gene carried by both parents, the chances of children developing the disease are not 2 in 4, 3 in 4, or 0 in 4.

 

 

4. The nurse is visiting a family who has a child with a genetic disorder. The oldest daughter in the family is planning marriage within the next few months. Which intervention should the nurse include that would support the 2020 National Health Goals for genetic disease?
A) Counsel the daughter to have no children.
B) Encourage the daughter to have genetic counseling.
C) Discuss voluntary sterilization options prior to marriage.
D) Explain that the chance of genetic anomalies in children is slim.
Ans: B
Feedback:
To support the 2020 National Health Goals for genetic anomalies, the nurses can help achieve these goals by being sensitive to the need for and educating parents about genetic screening in preconceptual settings. This means that the nurse should encourage the daughter to have genetic counseling. It is outside of the nurse’s scope of practice to counsel the daughter to remain childless or undergo voluntary sterilization. The nurse would not know the daughter’s chances of having a child with a genetic disorder unless genetic testing is performed.

 

 

5. A pregnant patient has been counseled to have an amniocentesis. For which genetic conditions should the nurse instruct the patient that this diagnostic test will detect?
A) Impetigo
B) Trisomy 21
C) Diabetes mellitus
D) Phenylketonuria
Ans: B
Feedback:
Trisomy 21 or Down syndrome is the most common genetic disorder that can be detected through examination of amniotic fluid obtained through amniocentesis. Impetigo, diabetes mellitus, and phenylketonuria cannot be diagnosed through examination of amniotic fluid.

 

 

6. The nurse is making a home visit to a family with a child born with a genetic abnormality. Which observation in the home indicates to the nurse that the parents are adjusting to the newborn’s health problems?
A) The father walks by the bassinet.
B) The father leaves during the visit.
C) The mother holds the baby during the visit.
D) The mother sits on the sofa while the baby cries.
Ans: C
Feedback:
Evidence that the parents are adjusting to the newborn with the genetic abnormality is the mother holding the baby during the visit. The father walking by the bassinet or leaving during the visit does not indicate adjustment. The mother sitting on the sofa while the baby cries does not indicate that the mother is adjusting to the newborn’s health problems.

 

 

7. A young married woman says that she is planning a tubal ligation because mental retardation runs in her husband’s family and she does not want any children with this problem. Which nursing diagnosis would best apply to this couple?
A) Anxiety related to marital issues
B) Deficient knowledge of genetically inherited disorders
C) Spiritual distress related to inappropriate approach to the issue of having children
D) Sexual dysfunction related to the possibility of having a cognitively impaired child
Ans: B
Feedback:
The young woman is making a decision to not have children without having information about her husband’s family and the people who have mental retardation. This is a knowledge deficit and is the most appropriate diagnosis for this couple. This situation does not support the diagnoses of anxiety, spiritual distress, or sexual dysfunction.

 

 

8. After an assessment, a couple planning marriage decides to schedule an appointment for genetic counseling in several months. Which information from the assessment would support this couple’s decision? (Select all that apply.)
A) The male and female are second cousins.
B) The male has a friend who has hemophilia.
C) The female has a foster brother with sickle-cell anemia.
D) The male and female are both of Mediterranean descent.
E) The female’s sister gave birth to a baby with Down syndrome.
Ans: A, D, E
Feedback:
Couples who are most apt to benefit from a referral for genetic testing or counseling include a closely related couple, are of ethnic backgrounds in which specific illnesses are known to occur, and those whose close relatives have a child with a genetic disorder. Having a friend with hemophilia and a foster brother with sickle-cell anemia would not support the couple’s decision to have genetic counseling.

 

 

9. A patient becomes concerned upon learning for the need to have a karyotype performed. What should the nurse explain to this patient about this test? (Select all that apply.)
A) It photographs and displays chromosomes.
B) It is procedure done on all pregnant women.
C) It reveals diseases present on chromosomes.
D) It can only be done during the first trimester of pregnancy.
E) It guarantees that a fetus will not be ill from a genetic disorder.
Ans: A, C
Feedback:
A karyotype photographs and displays chromosomes and is done to reveal diseases on chromosomes only. A karyotype is not performed on all pregnant women, but only those in which a genetic anomaly is suspected. The karyotype can be performed at any time during gestation and does not guarantee that a fetus will not be ill from a genetic disorder.

 

 

10. The nurse is beginning an assessment to determine a couple’s chances of having offspring with genetic anomalies. What should the nurse include in this assessment? (Select all that apply.)
A) Age of the female member of the couple
B) Diseases in the family that span three generations
C) Ethnic background of both members of the couple
D) Minimal expression of a previously undiagnosed disorder
E) Employment status of the male member of the couple
Ans: A, B, C, D
Feedback:
When conducting a health history assessment in anticipation of genetic counseling, the nurse will assess the age of the female member of the couple because some genetic anomalies are more common in older female patients. The nurse will also assess the couple for diseases that span three generations in both of the families and will assess the couple’s individual ethnic backgrounds. Physical assessment can identify minimal expression of a disorder that has gone previously undiagnosed. Employment status is not typically a part of the health history in preparation for genetic counseling.

 

 

11. During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby?
A) Short neck
B) Bowed legs
C) Low-set ears
D) Slanting of the palpebral fissure
Ans: C
Feedback:
Ears that are low-set ears is a common assessment finding in newborns with the trisomy chromosome abnormalities. Short neck, bowed legs, and slanting of the palpebral fissure are less common findings in a newborn with a chromosomal disorder.

 

 

12. A pregnant patient learns that her fetus has a genetic anomaly that will affect cognitive and musculoskeletal development. The patient is meeting with her spouse and the nurse and wants to know what options are available to them. What is the first thing that the nurse needs to do to help this couple with decision making?
A) Suggest routes to terminate pregnancy.
B) Assist the couple in identifying their values.
C) Analyze the opinions of extended family members.
D) Explain health care options for the baby going forward.
Ans: B
Feedback:
A useful place to start counseling is with values clarification to be certain a couple understands what is most important to them. Routes to terminate the pregnancy should be the last option. Analyzing the opinions of extended family members should occur after the couple identifies their own values. Explaining health care options for the baby going forward can occur after the couple identifies their values.

 

 

13. A child is diagnosed with an X-linked dominant inheritance disorder. What should the nurse explain to the parents about this disorder?
A) It only affects male offspring.
B) It appears in every generation.
C) All children of the couple will be affected.
D) Diseases caused by this disorder are not life threatening.
Ans: B
Feedback:
X-linked dominant inheritance disorders appear in every generation. The pattern of inheritance is through the X chromosome and affects female offspring. All children will not be affected. It is unclear if the diseases caused by this disorder are life threatening.

 

 

14. What should the nurse include when counseling potential parents about genetic disorders?
A) Environmental influences may affect multifactorial inheritance.
B) Genetic disorders primarily follow Mendelian laws of inheritance.
C) All genetic disorders involve a similar number of abnormal chromosomes.
D) The absence of genetic disorders in both families eliminates the possibility of having a child with a genetic disorder.
Ans: A
Feedback:
Not all genetic disorders follow Mendelian laws of inheritance. Diseases caused by multiple factors do not follow Mendelian laws because more than a single gene or HLA is involved. Environmental influences may be instrumental in determining whether the disorder is expressed. All genetic disorders do not involve a similar number of abnormal chromosomes. A family history may reveal no set pattern so an absence of genetic disorders in both families does not necessarily eliminate the possibility of having a child with a genetic disorder.

 

 

15. The results of a pregnant patient’s quadruple screen were positive, and an amniocentesis was performed. The amniocentesis report states no genetic anomalies present. What should the nurse do to assist this patient understand the test results?
A) Reassure that the report of the amniocentesis is valid.
B) Suggest that additional testing be performed on the fetus.
C) Explain that most of quadruple screens are falsely positive.
D) Remind that 30% of amniocentesis screens are falsely positive.
Ans: A
Feedback:
Receiving a false-positive report is unfortunate because it can potentially interfere with the mother’s bonding with her infant. Women may need some “debriefing” time after false-positive reports and may need to be reassured several times that the report of a possible chromosomal deviation was not true. The patient does not need additional testing done on the fetus. It is documented that 30% of quadruple screens are falsely positive. It is not true that 30% of amniocentesis screens are falsely positive.

 

1. During a prenatal examination, the nurse learns that a pregnant patient has a supernumerary nipple. What should the nurse teach the patient about this finding?
A) Such growths fade with menopause.
B) Bleeding from such growths is not uncommon.
C) Such growths deepen in color during pregnancy.
D) The tendency for supernumerary nipples is genetic.
Ans: C
Feedback:
Breast changes may be one of the first things women notice in pregnancy. Any supernumerary nipples may become darker and enlarge in size. There is no information to support that supernumerary nipples fade with menopause or bleed. There is also no information to support that supernumerary nipples are genetic in origin.

 

 

2. While conducting the first prenatal health history visit, the nurse learns that a pregnant patient is taking various herbal remedies and over-the-counter medications for minor ailments. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time?
A) Risk for injury to fetus related to lifestyle choices
B) Deficient knowledge regarding exposure to teratogens during pregnancy
C) Health-seeking behaviors related to strong cultural desire to have a healthy child
D) Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy
Ans: B
Feedback:
The patient is taking herbal remedies and over-the-counter medications, many of which can be teratogenic to the developing fetus. This is the most appropriate nursing diagnosis for the nurse to select for this assessment finding. There is no enough information to determine if the fetus is at risk because of the patient’s lifestyle choices. The patient has not asked for specific information so health-seeking behavior diagnoses would not be appropriate for the patient at this time.

 

 

3. When explaining what will occur during the first prenatal visit physical examination, a pregnant patient asks why a Papanicolaou smear is being done at this time. What should the nurse respond to the patient?
A) It helps to date the pregnancy.
B) It detects if uterine cancer is present.
C) It predicts whether cervical cancer will occur.
D) It detects cancer cells of the cervix, vulva, or vagina.
Ans: D
Feedback:
A Pap smear is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not present. A Pap smear is not used to date a pregnancy, detect uterine cancer, or predict if cervical cancer will occur.

 

 

4. The nurse in a community clinic is identifying ways to achieve the 2020 National Health Goals to support prenatal care. Which nursing actions would support the achievement of these goals? (Select all that apply.)
A) Urge female patients to ingest an adequate intake of folic acid.
B) Recommend pregnant patients attend developmental childbirth classes.
C) Discuss strategies to avoid intimate partner violence with every pregnant patient.
D) Provide a play area in the waiting room for the children of patients waiting to be seen.
E) Support pregnant patients to achieve the recommended weight gain during pregnancy.
Ans: A, B, D, E
Feedback:
A number of 2020 National Health Goals speak directly to the importance of prenatal care to include increasing the proportion of pregnant women who attend a series of prepared childbirth classes, increasing the proportion of women of childbearing potential who have an intake of at least 400 mcg of folic acid from fortified foods or dietary supplements before pregnancy, increasing the proportion of mothers who achieve a recommended weight gain during their pregnancies, and making sites for prenatal care “family friendly” or maximally receptive to women and families. Strategies to avoid intimate partner violence will not help the nurse achieve the 2020 National Health Goals for prenatal care.

 

 

5. Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit?
A) “Do you have a peptic ulcer?”
B) “Have you ever had a heart attack?”
C) “Have you had any neurologic diseases?”
D) “Have you had any urinary tract infections?”
Ans: D
Feedback:
Urinary tract infections are associated with preterm birth. If the patient has a history of this type of infection, then interventions can be directed to help the patient avoid a urinary tract infection while pregnant. Although a part of the review of systems, asking about peptic ulcers, heart attacks, and neurologic diseases may not have as significant an impact on the developing fetus as having urinary tract infections.

 

 

6. The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which patient statement indicates that the nurse’s efforts have been successful?
A) “It was so nice to not have to wait long in the waiting room.”
B) “I really hate having my weight and blood pressure measured around other people.”
C) “Why does everyone push breastfeeding and natural childbirth? What about what I want?”
D) “I thought you would have more reading material on labor and delivery in the waiting room.”
Ans: A
Feedback:
Strategies to individualize prenatal care include trying to schedule appointments so there won’t be a long wait time, providing privacy for weight and blood pressure assessments, educating on care options and encouraging participating in decisions about care, and providing materials on pregnancy in the waiting room.

 

 

7. The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit. For what will the nurse test this patient’s urine? (Select all that apply.)
A) Protein
B) Glucose
C) Bacteria
D) Drug levels
E) White blood cells
Ans: A, B, C, E
Feedback:
Urine is tested for proteinuria, glycosuria, nitrites, and pyuria. All of these can be done by means of test strips. The nurse will not test the patient’s urine for drug levels as part of a routine prenatal visit.

 

 

8. At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk during the pregnancy. Which data from the patient’s past illness history does the nurse use to make this decision? (Select all that apply.)
A) Seizure disorder
B) Previous cesarean birth
C) Hypertension for 10 years
D) History of abnormal Pap smear
E) Previous treatment for gonorrhea
Ans: A, C, E
Feedback:
Past illness history criteria that place a patient at risk during pregnancy include a seizure disorder, a chronic disease such as hypertension, and sexually transmitted infections. A previous cesarean birth and a history of abnormal Pap smears are criteria for the obstetrical history, which can place the patient at risk during pregnancy.

 

 

9. How should the nurse record the obstetric history for a pregnant patient who previously delivered two live infants at term and had one abortion at 12 weeks’ gestation?
A) Gravida 3, para 2
B) Gravida 3, para 3
C) Gravida 4, para 2
D) Gravida 4, para 3
Ans: A
Feedback:
Gravida is defined as a woman who has been pregnant. Para is defined as the number of pregnancies that have reached viability, regardless of whether the infants were born alive. The patient was pregnant three times. The patient delivered two live births. The aborted fetus is not included in the para count. The patient was not pregnant four times.

 

 

10. A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient?
A) Transverse narrow
B) Ideal for childbearing
C) Similar in shape to a male
D) Has weaker bones than normal
Ans: A
Feedback:
In an anthropoid pelvis, the transverse diameter is narrow. A gynecoid pelvis has an inlet that is well rounded forward and backward and has a wide pubic arch. This pelvic type is ideal for childbirth. An android pelvis is similar in shape to that of a male. The shape of the pelvis does not determine the strength of the bones.

 

 

11. The nurse is preparing to measure the diagonal conjugate of a pregnant patient’s pelvis. Which anatomic landmarks will the nurse use to make this measurement?
A) Medial surface of the ischial tuberosities
B) Posterior surface of sacrum and the axis of the ischial tuberosities
C) Interior surface of the sacral prominence and the posterior surface of the symphysis pubis
D) Anterior surface of the sacral prominence and the posterior surface of the symphysis pubis
Ans: D
Feedback:
The diagonal conjugate is the measurement between the anterior surface of the sacral prominence and the posterior surface of the symphysis pubis. The ischial tuberosity diameter measurement is the distance between the ischial tuberosities or the transverse diameter of the outlet and is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus. Measurements are not made from the posterior surface of the sacrum and the axis of the ischial tuberosities or the interior surface of the sacral prominence and the posterior surface of the symphysis pubis.

 

 

12. The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed?
A) “Pain with urination is expected during pregnancy.”
B) “I should call the doctor if I have any vaginal bleeding.”
C) “A sudden rush of fluid means that my membranes ruptured.
D) “I should not worry if I vomit once a day for the first 12 weeks.”
Ans: A
Feedback:
Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional patient teaching is needed. The patient should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy.

 

 

13. A patient having an examination to check the placement of an intrauterine device (IUD) is diagnosed as being pregnant. For which action should the nurse prepare the patient at this time?
A) Removal of the IUD
B) Surgery to abort the fetus
C) Potential for a spontaneous abortion
D) Nothing since the IUD can remain in place
Ans: A
Feedback:
A patient may become pregnant with an intrauterine device (IUD) in place. If this occurs, it needs to be removed to prevent infection during pregnancy. The fetus does not need to be aborted, and the patient will not spontaneously abort because the IUD is in place. The IUD cannot remain in place because of the risk for infection.

 

 

14. How should the nurse document a pregnant patient’s gestational status using the GTPAL system after collecting the following data?

Currently 18 weeks pregnant

Patient’s fourth pregnancy

Delivered one nonviable fetus at 26 weeks

Experienced one miscarriage

Delivered one viable fetus at 38 weeks’ gestation

A) 3, 2, 1, 2, 1
B) 4, 2, 2, 1, 1
C) 3, 2, 1, 1, 1
D) 4, 1, 1, 1, 1
Ans: D
Feedback:
GTPAL is a more comprehensive system for classifying pregnancy status. By this system, the gravida classification remains the same, but para is broken down into T: the number of full-term infants born (infants born at 37 weeks or after), P: the number of preterm infants born (infants born before 37 weeks), A: the number of spontaneous miscarriages or therapeutic abortions, and L: the number of living children. The patient has been pregnant four times. The patient delivered one viable infant at 38 weeks. The patient delivered one nonviable fetus at 26 weeks. The patient had one miscarriage. The patient has one living child.

 

 

15. The nurse is visiting the family of a newly pregnant patient whose spouse was ambivalent about the pregnancy during the first prenatal visit. Which observation indicates that the spouse is accepting the pregnancy?
A) Spouse leaves the house when the nurse arrives.
B) Spouse sits with the pregnant patient during the nurse’s visit.
C) Spouse shouts down the stairs about the location of clean laundry.
D) Spouse tells the patient what needs to be obtained from the grocery store.
Ans: B
Feedback:
If childbearing is to be a family affair, it is important to determine a partner’s degree of acceptance of the pregnancy and how well prepared the spouse is of assuming a new parenting role. After confirmation of pregnancy, include the partner in health care information or suggestions. The spouse sitting with the pregnant patient during the nurse’s visit indicates that the spouse is accepting the pregnancy. Leaving the house, shouting down the stairs about laundry, and giving a list of grocery items could indicate indifference or no interest in the pending pregnancy. These actions do not support acceptance of the pregnancy.

 

1. The nurse is preparing to assess the nutritional status of a patient who is 8 weeks pregnant. What is the most effective way for the nurse to assess the patient’s food intake thus far in the pregnancy?
A) Assess skin status for hydration and color.
B) Ask the patient to describe total intake for a week.
C) Assess a list that the patient describes as a good diet.
D) Ask the patient to describe intake for the last 24 hours.
Ans: D
Feedback:
The best method for assessing a woman’s nutritional intake during pregnancy is to ask the patient to list all the food eaten within the past 24 hours, starting with waking up until going to sleep. This method of history taking yields much more accurate information than asking a patient how often a specific food is eaten. Assessing skin status may provide more information about hydration that nutritional status. Assessing a total intake for a week would be too extreme for the patient to recall. Assessing the patient from a list of foods does not identify what the patient has most recently eaten.

 

 

2. The nurse is instructing a pregnant patient to consume a diet high in complete proteins. Which food item should the nurse recommend as an example of a complete protein?
A) A boiled or fried egg
B) Green, leafy vegetables
C) A slice of whole grain toast
D) Applesauce or a whole apple
Ans: A
Feedback:
The protein in meat, poultry, fish, yogurt, eggs, and milk contain all nine essential amino acids required and are considered complete proteins. The protein in nonanimal sources does not contain all essential amino acids and are considered incomplete proteins. Green, leafy vegetables; whole grain toast; and apples or applesauce are carbohydrate sources.

 

 

3. A pregnant patient asks if an over-the-counter vitamin can be taken during pregnancy instead of the prescribed prenatal vitamin. What should the nurse explain as the chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition?
A) Folic acid
B) Vitamin C
C) Potassium
D) Vitamin B12
Ans: A
Feedback:
Folic acid is added to maternal prenatal vitamins because of the threat of developing anemia. The pregnant patient should take a prenatal vitamin that contains a folic acid supplement of 0.4 to 0.6 mg, which may or may not be a part of an over-the-counter vitamin supplement. Vitamin C, potassium, and vitamin B12 are important; however, do not have the same risk of developing a health problem if not present in a prenatal vitamin supplement.

 

 

4. The nurse is determining the effectiveness of nutritional teaching with a pregnant patient. Which food item that the patient selects indicates that additional teaching on good sources of iron is needed?
A) Milk
B) Beef
C) Grains
D) Legumes
Ans: A
Feedback:
The foods richest in iron include organ meats; eggs; green, leafy vegetables; whole grains; enriched breads; or dried fruits. Milk is not a good source of iron and indicates that additional teaching is needed.

 

 

5. A pregnant patient tells the nurse that drinking enough fluids has always been a problem for her. What should the nurse counsel the patient as being an adequate daily amount of fluid to drink while pregnant?
A) Two glasses
B) Four glasses
C) Eight glasses
D) Ten glasses
Ans: C
Feedback:
Extra amounts of water are needed during pregnancy to promote kidney function because a woman must excrete waste products for two. Eight glasses of fluid daily is a common recommendation. Two or four glasses of fluid would not be an adequate amount. Ten glasses of fluid might be too much for the patient to consume each day.

 

 

6. A pregnant patient tells the nurse that saturated fats are avoided by using vegetable oil. What additional information about vegetable oil can the nurse use to reinforce this patient’s decision?
A) Aids in fluid balance
B) Contains linoleic acid
C) Stimulates kidney function
D) Has a high-potassium content
Ans: B
Feedback:
Linoleic acid is a fat that is essential for new cell growth but cannot be manufactured by the body. Vegetable oils such as safflower, corn, olive, peanut, and cottonseed; fatty fish; omega-3–infused eggs; and omega-3–infused spreads are all good sources of linoleic acid. Vegetable oil does not aid in fluid balance, stimulate kidney function, or have high potassium content.

 

 

7. During a previous prenatal visit, the nurse focused on the importance of adequate nutritional intake with a pregnant patient. Which assessment findings indicate that this teaching has been effective? (Select all that apply.)
A) Shiny hair
B) Smooth tongue
C) Conjunctiva pale
D) Chipped finger nails
E) Normal muscle reflexes
Ans: A, B, E
Feedback:
Evidence of an adequate nutritional intake while pregnant includes shiny hair, smooth tongue, and normal muscle reflexes. Pale conjunctiva could indicate iron deficiency. Chipped fingernails could indicate inadequate protein intake.

 

 

8. The nurse is planning care for several pregnant patients. Which patient is at the greatest risk for nutritional deficiency while pregnant?
A) Patient who rarely eats fruit
B) Patient with a 1-year-old son
C) Patient with 10-year-old twins
D) Patient who never follows a weight-reduction diet
Ans: B
Feedback:
A pregnant woman with high parity or a short interval between pregnancies such as having a 1-year-old son may enter pregnancy with depleted nutritional reserves that she has little to draw on during the first part of pregnancy. The other pregnant patients may have nutritional deficiencies that can be corrected with vitamin supplementation or adjustments in the diet.

 

 

9. A woman who is 6 weeks pregnant is concerned because she is nauseated every morning. Which measure should the nurse suggest the patient use to help relieve nausea?
A) Take two aspirin on arising.
B) Delay toothbrushing until noon.
C) Delay breakfast until midmorning.
D) Take a teaspoon of baking soda before breakfast.
Ans: C
Feedback:
The traditional solution for preventing nausea is for the pregnant patient to keep dry crackers, such as saltines, by the bedside and eat a few before rising because increasing carbohydrate intake seems to relieve nausea better than any other nutrition remedy. The patient can then eat a light breakfast or delay breakfast until 10 or 11 AM, which is past the time nausea seems to persist. Aspirin is irritating to the stomach and should not be taken. Delaying toothbrushing does not affect nausea. A teaspoon of baking soda should not be suggested because this could adversely affect the patient’s electrolyte status.

 

 

10. A pregnant patient asks the nurse what can be done for constipation. What should the nurse recommend to the patient?
A) Mineral oil
B) Increased fiber intake
C) Eating more meat products
D) Stopping prenatal vitamins temporarily
Ans: B
Feedback:
Eating fiber-rich foods is a natural way to prevent constipation because the bulk of the fiber left in the intestine aids evacuation. Eating fiber-rich foods this way is a better choice for preventing constipation than taking a fiber laxative because it allows a pregnant patient to receive nutrients from the food as well as prevent constipation. The pregnant patient should not use mineral oil to relieve constipation because it can prevent absorption of fat-soluble vitamins A, D, K, and E, vitamins necessary for both good fetal and maternal health. Eating more meat products can add to the constipation. The patient should not be advised to stop prescribed prenatal vitamins.

 

 

11. A woman of normal weight learns that she is pregnant and asks the nurse how much weight she should gain until delivery. What should the nurse respond to this patient?
A) Do not gain over 20 lb.
B) Any gain over 30 lb is ideal.
C) Twenty-five to 35 lb is ideal.
D) The amount of weight gain is not important.
Ans: C
Feedback:
A weight gain of 25 to 35 lb encourages fetal growth yet does not lead to a maternal weight gain postpregnancy. A patient who is overweight might be encouraged to limit weight gain to 20 lb while pregnant. A weight gain over 30 lb might be recommended for the patient that is underweight. The amount of weight gain is important to ensure adequate growth and health of the developing fetus and mother.

 

 

12. Which nutritional information should the nurse suggest to a pregnant patient who follows a vegetarian eating plan?
A) Include at least one serving of meat daily.
B) Be careful not to eat more than four servings of fruit daily.
C) Discontinue a vegetarian diet for the remainder of pregnancy.
D) Anticipate needing a vitamin B12 supplement during pregnancy.
Ans: D
Feedback:
Vitamin B12 is found almost exclusively in animal protein, so if animal protein is excluded from the diet, vitamin B12 deficiency can occur unless this is supplemented. The patient should anticipate needing a vitamin B12 supplement while pregnant. The patient is a vegetarian and will not add meat to the diet. The intake of fruit will not adversely affect the patient or the development fetus. The patient may or may not want to discontinue the vegetarian diet while pregnant.

 

 

13. The nurse is planning nutritional instructions for a pregnant patient who is a Mexican immigrant. On which areas should the nurse focus when preparing teaching for this patient? (Select all that apply.)
A) Add fruits rich in vitamin C.
B) Consume potatoes at every meal.
C) Increase the intake of dairy products.
D) Reduce the cooking time of vegetables.
E) Limit the amount of added animal fat in foods.
Ans: A, C, D, E
Feedback:
In the Mexican culture, most vegetables are cooked for a long time so they lose most of their nutritional value. Diet is high in fiber and starch. Animal fat is frequently added during food preparation. The diet may be inadequate in calcium, iron, vitamin A, and vitamin C. The nurse should instruct the patient to add fruits rich in vitamin C, increase dairy product intake, reduce cooking times of vegetables, and limit the amount of animal fat in the diet.

 

 

14. A patient who is 4 months pregnant is experiencing pyrosis. Which suggestion should the nurse make to the patient to help with this health problem?
A) Try to include complex carbohydrates in meals.
B) Eat small meals and do not lie down after meals.
C) Increase vitamin intake by adding more citrus fruit.
D) Take 30 ml of milk of magnesia after every meal.
Ans: B
Feedback:
Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the stomach causes regurgitation into the esophagus. Eating small meals and remaining upright limits the possibility of regurgitation. The patient should be instructed to avoid fatty and fried foods, coffee, carbonated beverages, tomato products, and citrus juices. Complex carbohydrates will not help with the problem. Milk of magnesia is not recommended to be taken for pyrosis.

 

 

15. During a prenatal appointment, a patient who is 3 months pregnant states she ingests starch because of a craving. What should the nurse respond to this patient?
A) Suggest a hemoglobin assessment be done.
B) Kindly encourage the patient to discontinue the habit.
C) Emphasize the protein, vitamin, and iron needs of pregnancy nutrition.
D) Plan another appointment to discuss the hazards of ingesting nonfood substances.
Ans: A
Feedback:
Pica is a symptom that often accompanies iron-deficiency anemia, and the primary care provider might need to assess the patient’s serum iron level because correcting this underlying problem with an iron supplement may correct the pica. Stopping eating the nonfood substance may be difficult because the habit may be deeply ingrained. Emphasizing the importance of other nutrients while pregnant will not correct the problem. The nurse does not need to make another appointment to discuss the hazards of ingesting nonfood substances. The teaching can be conducted during the current appointment.

 

 

16. The nurse is planning a prenatal educational program for a community health center. What information should the nurse include that supports the 2020 National Health Goals for nutrition in pregnancy? (Select all that apply.)
A) Avoid foods high in fats and calories.
B) Take prenatal vitamins as prescribed.
C) Ensure a daily intake of foods with folic acid.
D) Limit the intake of foods high in simple carbohydrates.
E) Maintain adequate nutrition before becoming pregnant.
Ans: B, C, E
Feedback:
Information that the nurse should include that supports the 2020 National Health Goals for nutrition in pregnancy include taking prenatal vitamins as prescribed because these will contain iron and folic acid. The nurse should also teach the participants to have a daily intake of foods with folic acid and to maintain adequate nutrition before becoming pregnant so that those entering pregnancy will have adequate nutritional stores. There are no specific foods that a pregnant patient should avoid such as those high in fat and calories. All pregnant patients do not need to limit the intake of foods high in simple carbohydrates.

 

 

17. The nurse has identified the diagnosis of imbalanced nutrition for a pregnant patient. Which assessment data did the nurse use to identify this diagnosis for the patient?
A) Patient eats salads at least twice a day.
B) Patient does not like potatoes or bread.
C) Patient eats red meat several times a week.
D) Patient does not want to gain any weight while pregnant.
Ans: D
Feedback:
Not wanting to gain weight while pregnant could lead to imbalanced nutrition for both the mother and developing fetus. Eating salads and red meat will not lead to imbalanced nutrition. Avoiding potatoes and bread will not lead to imbalanced nutrition.

 

 

18. The nurse provides instructions to a patient with hyperemesis gravidarum. Which outcome indicates that teaching has been effective?
A) Patient has vomiting episodes only in the morning.
B) Patient is able to tolerate soft foods after episodes of vomiting.
C) Patient is able to ingest clear liquids between episodes of vomiting.
D) Patient is able to ingest a regular diet after progressing through clear liquids and soft foods.
Ans: D
Feedback:
The pregnant patient with hyperemesis gravidarum may be hospitalized and treated with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started, and the woman discharged home. If able to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed to ensure she receives adequate nutrition. Vomiting episodes in the morning or tolerating clear liquids or soft foods between vomiting episodes indicates that teaching has not been effective.