Maternal Newborn Nursing The Critical Components Of Nursing Care 2nd Edition by Roberta Durham – Test Bank

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Maternal Newborn Nursing  The Critical Components Of Nursing Care 2nd Edition by Roberta Durham – Test Bank

 

Sample  Questions

 

 

Chapter 5: Psycho-Social-Cultural Aspects of the Antepartum Period

 

 

 

Multiple Choice

 

 

 

  1. Sally is in her third trimester and has begun to sing and talk to the fetus. Sally is probably exhibiting signs of:a. Mental illnessb. Delusionsc. Attachmentd. Crisis

 

ANS: c

Feedback
a. This is normal maternal–fetal adaptation.
b. Delusions are not real, and the fetus is real.
c. Correct, because talking to the fetus is a sign of positive maternal adaptation. All other answers indicate pathology.
d. Interacting with the fetus in utero represents normal development of attachment to the fetus.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

 

 

  1. What is the most common expected emotional reaction of a woman to the news that she is pregnant? a. Jealousyb. Acceptancec. Ambivalenced. Depression

 

ANS: c

Feedback
a. Others in the family may be jealous of the fetus, but that is not a common maternal response.
b. Acceptance of the pregnancy typically occurs later in the pregnancy.
c. Ambivalence is a normal expected reaction to the news of pregnancy, whether or not the pregnancy is planned or wanted.
d. This would represent an abnormal emotional response to pregnancy.

 

KEY: Integrated Process: Teaching and Learning | Nursing Process: Analysis | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy

 

 

 

  1. Which of the following information regarding sexual activity would the nurse give a pregnant woman who is 35 weeks’ gestation? a. Sexual activity should be avoided from now until 6 weeks postpartum.b. Sexual desire may be affected by nausea and fatigue. c. Sexual desire may be increased due to increased pelvic congestion.d. Sexual activity may require different positions to accommodate the woman’s comfort.

 

ANS: d

Feedback
a. There are no contraindications to sexual activity during this time for a normally progressing pregnancy.
b. Nausea and fatigue affect sexual desire during the first trimester, not the third.
c. Increased sexual desire r/t increased pelvic congestion is a characteristic of the second trimester, not the third.
d. Correct. An enlarging abdomen creates feelings of awkwardness and bulkiness and may require couples to modify intercourse positions for the pregnant woman’s comfort.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

 

 

  1. Which statement best exemplifies adaptation to pregnancy in relation to the adolescent?a. Adolescents adapt to motherhood in a similar way to other childbearing women.b. Social support has very little effect on adolescent adaptation to pregnancy. c. The pregnant adolescent faces the challenge of multiple developmental tasks.d. Pregnant adolescents of all ages can be capable and active participants in health-care decisions.

 

ANS: c

Feedback
a. Adolescents must cope with the conflicting developmental tasks of pregnancy and adolescence at the same time.
b. Social support has been associated with a more positive adaptation to mothering for adolescents.
c. Correct. Pregnant adolescents face conflicting and multiple developmental tasks of pregnancy and adolescence at the same time.
d. By late adolescence (ages 17 to 20) this can occur, but early adolescents are oriented toward the present and are self-centered, and often pregnancy at this age is a result of abuse or coercion.

 

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult

 

 

  1. Jane’s husband Brian has begun to put on weight. What is this a possible sign of? a. Culturalism syndromeb. Couvade syndromec. Moratorium phased. Attachment

 

ANS: b

Feedback
a. This is not related to culture.
b. Correct. Couvade syndrome has symptoms that mimic changes of pregnancy.
c. Moratorium phase represents one of the phases of the father’s responses to pregnancy.
d. Attachment is reflected in behaviors.

KEY: Integrated Process: Caring | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy

 

 

  1. Cathy is pregnant for the second time. Her son, Steven, has just turned 2 years old. She asks you what she should do to help him get ready for the expected birth. What is the nurse’s most appropriate response?a. Steven will probably not understand any explanations about the arrival of the new baby, so Cathy should do nothing.b. If Steven’s sleeping arrangements need to be changed, it should be done well in advance of the birth.c. Steven should come to the next prenatal visit and listen to the fetal heartbeat to encourage sibling attachment. d. Steven should be encouraged to plan an elaborate welcome for the newborn.

 

ANS: b

Feedback
a. This applies to very young children under the age of 2.
b. Children still sleeping in a crib should be moved to a bed at least 2 months before the baby is due, as this age group is particularly sensitive to disruptions of the physical environment.
c. This is not appropriate for a 2-year-old but may be appropriate for older age groups.
d. This is not appropriate for a 2-year-old but may be appropriate for older age groups.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult

 

 

  1. The nurse is interviewing a pregnant client who states she plans to drink chamomile tea to ensure an effective labor. The nurse knows that this is an example of:a. Cultural prescriptionb. Cultural tabooc. Cultural restrictiond. Cultural demonstration

 

ANS: a

Feedback
a. Correct. Cultural prescription is an expected behavior of the pregnant woman during the childbearing period.
b. Taboos are cultural restrictions believed to have serious supernatural consequences. Drinking chamomile tea would not be in this category.
c. Restrictions are activities during the childbearing period which are limited for the pregnant woman. Drinking chamomile tea would not be in this category.
d. Demonstration is not a term that is used in relation to cultural behaviors.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Basic Care and Comfort | Difficulty Level: Easy

 

 

 

  1. Which of the following would be a priority for the nurse when caring for a pregnant woman who has recently emigrated from another country?a. Help her develop a realistic, detailed birth plan.b. Identify her support system.c. Teach her about expected emotional changes of pregnancy.d. Refer her to a doula for labor support.

 

ANS: b

Feedback
a. A detailed birth plan may not be culturally appropriate and is not first priority.
b. Correct, because lack of social support has been correlated with an increased risk of pregnancy complications and difficult adaptation to pregnancy. Pregnant women who are recent immigrants face many challenges in obtaining needed social support, and the nurse should first identify her support system to plan further interventions and referrals.
c. There may be cultural variations in emotional changes of pregnancy.
d. The nurse should first identify her support system before planning further interventions and referrals.

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

 

 

  1. A pregnant client at 20 weeks’ gestation comes to the clinic for her prenatal visit. Which of the following client statements would indicate a need for further assessment? a. “I hate it when the baby moves.”b. “I’ve started calling my mom every day.”c. “My partner and I can’t stop talking about the baby.”d. “I still don’t know much time I’m going to take off work after the baby comes.”

 

ANS: a

Feedback
a. Experiencing quickening as unpleasant may be a sign of maladaptation to pregnancy and needs further assessment by the nurse.
b. This is an expected finding in maternal adaptation and development of the maternal role.
c. This is an expected finding in maternal adaptation and development of the maternal role.
d. At 20 weeks’ gestation, the client still has plenty of time to process this decision.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

 

 

  1. A pregnant client asks the nurse why she should attend childbirth classes. The nurse’s response would be based on which of the following information? a. Attending childbirth class is a good way to make new friends.b. Childbirth classes will help new families develop skills to meet the challenges of childbirth and parenting.c. Attending childbirth classes will help a pregnant woman have a shorter labor.d. Childbirth classes will help a pregnant woman decrease her chance of having a cesarean delivery.

 

ANS: b

Feedback
a. There may be a beneficial effect of childbirth classes, but this is not the primary goal of childbirth education.
b. Correct. These are the stated goals of childbirth education (ICEA, Lamaze).
c. Evidence remains inconclusive regarding linking attendance at childbirth classes with a decreased incidence of cesarean section and shorter labors.
d. Evidence remains inconclusive regarding linking attendance at childbirth classes with a decreased incidence of cesarean section and shorter labors.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy

 

 

  1. A woman presents for prenatal care at 6 weeks’ gestation by LMP. Which of the following findings would the nurse expect to see?
  2. Multiple pillow orthopnea
  3. Maternal ambivalence
  4. Fundus at the umbilicus
  5. Pedal and ankle edema

 

ANS: b

Feedback
a. Orthopnea is a common complaint of women during the third trimester.
b. Ambivalence is a common feeling of women during the first trimester.
c. The fundus should be at the umbilicus at 20 weeks’ gestation.
d. Dependent edema is a common complaint of women during the third trimester.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

 

 

 

  1. A first-time father is experiencing couvade syndrome. He is likely to exhibit which of the following symptoms or behaviors?
  2. Urinary frequency
  3. Hypotension
  4. Bradycardia
  5. Prostatic hypertrophy

 

ANS: a

Feedback
a. Urinary frequency is a common symptom of couvade.
b. The father’s blood pressure is not usually affected.
c. The father’s heart rate is not usually affected.
d. Prostatic changes are not related to couvade.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Family Dynamics | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

 

 

 

  1. When providing a psychosocial assessment on a pregnant woman at 21 weeks’ gestation, the nurse would expect to observe which of the following signs?
  2. Ambivalence
  3. Depression
  4. Anxiety
  5. Happiness

 

ANS: d

Feedback
a. Ambivalence is often seen during the first trimester.
b. The nurse would not expect to see depression at any time during the pregnancy.
c. The patient may express some anxiety near the time of delivery.
d. The nurse would expect the patient to exhibit signs of happiness at this time.

 

KEY: Integrated Process: Communication and Documentation; Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. An example of a cultural prescriptive belief during pregnancy is:
  2. Remain active during pregnancy
  3. Coldness in any form should be avoided
  4. Do not have your picture taken
  5. Avoid sexual intercourse during the third trimester

 

ANS: a

The belief that the patient should remain active during pregnancy is the only example of a cultural prescriptive belief. All of the other answers are examples of cultural restrictive beliefs.

 

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Cultural Respect | Difficulty Level: Easy

 

 

 

  1. Taboos are cultural restrictions that:
  2. Have serious supernatural consequences
  3. Have serious clinical consequences
  4. Have superstitious consequences
  5. Are functional and neutral practices

 

ANS: a

Taboos are believed to have serious supernatural consequences. Taboos are not known to have clinical or superstitious consequences and are not functional or neutral practices.

 

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Cultural Competence | Client Need: Cultural Respect | Difficulty Level: Moderate

 

 

 

  1. Jenny, a 21-year-old single woman, comes for her first prenatal appointment at 31 weeks’ gestation with her first pregnancy. The clinic nurse’s most appropriate statement is:
  2. “Jenny, it is late in your pregnancy to be having your first appointment, but it is nice to meet you and I will try to help you get caught up in your care.”
  3. “Jenny, have you had care in another clinic? I can’t believe this is your first appointment!”
  4. “Jenny, by the date of your last menstrual period, you are 31 weeks and now that you are finally here, we need you to come monthly for the next two visits and then weekly.”
  5. “Jenny, by your information, you are 31 weeks’ gestation in this pregnancy. Do you have questions for me before I begin your prenatal history and information sharing?”

ANS: d

Feedback
a. The initial interview time with the patient should be used to build a positive, nonthreatening relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care that is woman centered.
b. The initial interview time with the patient should be used to build a positive, nonthreatening relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care and not making assumptions about prior care. The prenatal nurse’s objective is to provide a user-friendly service that is efficient, effective, caring, and patient centered.
c. The initial interview time with the patient should be used to build a positive, nonthreatening, and nonjudgmental relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care.
d. The initial interview time with the patient should be used to build a positive, nonthreatening relationship and to gain her confidence by respecting her choices and advocating for continued prenatal care. The prenatal nurse’s objective is to provide a user-friendly service that is efficient, effective, caring, and patient centered.

 

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The clinic nurse visits with Wayne, a 32-year-old man whose partner is pregnant for the first time and is at 12 weeks. Wayne describes nausea and vomiting, fatigue, and weight gain. His symptoms are best described as:
  2. Influenza
  3. Couvade syndrome
  4. Acid reflux
  5. Cholelithiasis

 

ANS: b

Feedback
a. This cluster of symptoms is indicative of couvade syndrome, the experience of maternal signs and symptoms of pregnancy.
b. In preparation for parenthood, the male partner moves through a series of developmental tasks. During the first trimester, the father begins to deal with the reality of the pregnancy and may worry about financial strain and his ability to be a good father. Feelings of confusion and guilt often surface with the recognition that he is not as excited about the pregnancy as his partner, and couvade syndrome, the experience of maternal signs and symptoms, may develop.
c. This cluster of symptoms is indicative of couvade syndrome, the experience of maternal signs and symptoms of pregnancy.
d. This cluster of symptoms is indicative of couvade syndrome, the experience of maternal signs and symptoms of pregnancy.

 

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

Multiple Response

 

 

 

  1. The clinic nurse encourages paternal attachment during pregnancy by including the father in (select all that apply):
  2. Prenatal visits
  3. Ultrasound appointments
  4. Prenatal class information
  5. History taking and obtaining prenatal screening information

 

ANS: b, c, d

Pregnancy is psychologically stressful for men; some enjoy the role of nurturer, but others feel alienated and begin to stray from the relationship. The nurse can be instrumental in promoting early paternal attachment. Involvement of the father during examinations and tests and prenatal classes, along with thorough explanations of the need for them, can minimize the father’s feelings of being left out. A history and prenatal screening should be conducted at the first prenatal visit with the woman alone to ensure confidentiality and an open discussion of any problems or concerns she may have. The history should include information about the current pregnancy; the obstetric and gynecologic history; and a cultural assessment, and a medical, nutritional, social, and family (including the father’s) medical history.

 

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse screens all pregnant women early in pregnancy for maternal attachment risk factors, which include (select all that apply):
  2. Adolescence
  3. Low educational level
  4. History of depression
  5. A strong support system for the pregnancy

 

ANS: a, b, c

Maternal attachment to the fetus is an important area to assess and can be useful in identifying families at risk for maladaptive behaviors. The nurse should assess for indicators such as unintended pregnancy, domestic violence, difficulties in the partner relationship, sexually transmitted infections, limited financial resources, substance use, adolescence, poor social support systems, low educational level, the presence of mental conditions, or adolescence that might interfere with the patient’s ability to bond with and care for the infant. A strong support system can facilitate the patient’s ability to bond with and care for the infant.

 

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. Strategies for culturally responsive care include (select all that apply):
  2. Practicing ethnocentrism
  3. Applying stereotyping
  4. Examining one’s own biases
  5. Learning another language

 

ANS: c, d

The only actions among the choices that are culturally responsive are examining one’s own biases and learning another language. Ethnocentrism and stereotyping are not culturally responsive actions.

 

KEY: Integrated Process: Safe and Effective Care Environment | Cognitive Level: Application | Content Area: Cultural Competence | Client Need: Cultural Respect | Difficulty Level: Moderate

 

 

 

Fill-in-the-Blank

 

 

 

  1. The clinic nurse talks with Becky, a 16-year-old woman who is now 28 weeks’ gestation. Today’s visit is only the second prenatal appointment that Becky has kept. The nurse wonders if Becky’s failure to come for routine prenatal checks is, in part, related to an adolescent’s orientation to the __________, rather than to the __________.

 

ANS: present; future

The adolescent may not seek prenatal care unless pressured by authority figures or peers to do so. By nature, adolescents are not future oriented. Hence, the pregnant adolescent may not be able to readily accept the reality of the unborn child.

 

KEY: Integrated Process: Teaching/Learning | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult

 

 

 

  1. According to Rubin, the mother-to-be needs to accept the pregnancy and incorporate it into her own reality and __________. This process is known as “__________.”

 

ANS: self-concept; binding in

The mother-to-be needs to accept the pregnancy and incorporate it into her own reality and self-concept. This process is known as “binding in.” Acceptance of the child is critical to a successful adjustment to the pregnancy. Acceptance must come from the expectant woman as well as from others.

 

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level: Knowledge Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. The clinic nurse asks pregnant women about their acceptance and planning for this pregnancy as a component of domestic violence screening. The nurse is aware that a(n) __________ pregnancy __________ the risk for domestic violence.

 

ANS: unplanned; increases

Intimate partner violence (IPV) may occur for the first time during pregnancy, or the nurse may identify evidence during the physical examination that is suspicious of ongoing physical abuse. Acceptance of pregnancy may be delayed if it was unplanned or unwanted. As a women’s advocate, nurses have a duty to be observant, to actively listen, and to use communication skills to gain clarification and understanding.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

Chapter 7: High-Risk Antepartum Nursing Care

 

 

 

Multiple Choice

 

 

 

  1. A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure client safety.a. Assess uterine contractions continuously.b. Assess fetal heart rate continuously.c. Assess urinary output.d. Assess respiratory rate.

 

ANS: d

Feedback
a. Monitoring contractions does not indicate magnesium toxicity.
b. Magnesium sulfate will decrease fetal variability and not provide an accurate assessment of magnesium toxicity.
c. Urinary output does not correlate to decreased deep tendon reflexes.
d. Correct. Respiratory effort and deep tendon reflexes (DTRs) are involuntary, and a decrease in DTRs could indicate the risk of magnesium sulfate toxicity and the risk for decreased respiratory effort.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate

 

 

 

  1. A pregnant client with a history of multiple sexual partners is at highest risk for which of the following complications:a. Premature rupture of membranesb. Gestational diabetesc. Ectopic pregnancyd. Pregnancy-induced hypertension

 

ANS: c

Feedback
a. Multiple partners do not increase a woman’s risk of premature rupture of membranes.
b. Genetics and client diet and weight are contributing factors to gestational diabetes.
c. Correct. A history of multiple sexual partners places the client at a higher risk of having contracted a sexually transmitted disease that could have ascended the uterus to the fallopian tubes and caused fallopian tube blockage, placing the client at high risk for an ectopic pregnancy.
d. Multiple sexual partners are not a risk factor for pregnancy-induced hypertension.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

 

 

  1. Identify the hallmark of placenta previa that differentiates it from abruptio placenta.a. Sudden onset of painless vaginal bleedingb. Board-like abdomen with severe painc. Sudden onset of bright red vaginal bleedingd. Severe vaginal pain with bright red bleeding

 

ANS: a

Feedback
a. Correct. When the placenta attaches to the lower uterine segment near or over the cervical os, bleeding may occur without the onset of contractions or pain.
b. The hallmark for abruptio placenta is pain and a board-like abdomen.
c. Bright red bleeding could be related to abruptio placenta, placenta previa, or other complications of pregnancy.
d. Pain is not a hallmark of placenta previa.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

 

 

 

  1. Which of the following assessments would indicate instability in the client hospitalized for placenta previa?a. BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPMb. FHR moderate variability without accelerationsc. Dark brown vaginal discharge when voidingd. Oral temperature of 99.9°F

 

ANS: a

Feedback
a. A decrease in BP accompanied by bradycardia or tachycardia is an indication of hypovolemic shock.
b. FHR with moderate variability can be absent of accelerations during fetal sleep cycles or after maternal sedation.
c. Bright red vaginal bleeding is an indication of current bleeding.
d. Oral temperature may fluctuate based on the client’s hydration status. It should be reassessed. Cause for concern is a temperature of 100.4°F or more.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

 

 

 

  1. During pregnancy, poorly controlled asthma can place the fetus at risk for:a. Hyperglycemiab. IUGRc. Hypoglycemiad. Macrosomia

ANS: b

Feedback
a. Maternal asthma does not place the fetus at risk for hyperglycemia.
b. Compromised pulmonary function can lead to decompensation and hypoxia that decrease oxygen flow to the fetus and can cause intrauterine growth restriction (IUGR).
c. Asthma does not directly affect glycemic control.
d. A fetus experiencing hypoxia would be small for gestational age, not large for gestational age.

 

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: AnalysisContent Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

 

 

  1. Which of the following nursing diagnoses is of highest priority for a client with an ectopic pregnancy who has developed disseminated intravascular coagulation (DIC)?a. Risk for deficient fluid volumeb. Risk for family process interruptedc. Risk for disturbed identityd. High risk for injury

 

ANS: a

Feedback
a. Correct. The client is at high risk for hypovolemia which is life threatening and takes precedence over any psychosocial or less pressing diagnoses.
b. This is a psychosocial diagnosis and is not life threatening.
c. This is a psychosocial diagnosis and is not life threatening.
d. The client is at risk for injury; however, the diagnosis of deficient fluid volume is more descriptive and has clearly defined goals and interventions.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult

 

 

 

  1. Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension?a. Total urine protein of 200 mg/dLb. Total platelet count of 40,000 mm c. Uric acid level of 8 mg/dLd. Blood urea nitrogen 24 mg/dL

 

ANS: b

Feedback
a. The client’s urine protein is elevated. A urine protein of ≥300 mg/dL in a 24-hour collection is considered concerning.
b. Correct. A platelet count of £50,000 is a critical value and should be reported to the health-care provider immediately. This client is at increased risk of hemorrhage.
c. The uric acid level is only slightly elevated.
d. The BUN is only slightly elevated.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult

 

 

  1. Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client’s blood glucose levels?a. Nifedipineb. Betamethasone c. Magnesium sulfated. Indomethacin

 

ANS: b

Feedback
a. Nifedipine does not affect maternal blood glucose levels.
b. Beta-sympathomimetics may stimulate hyperglycemia which will require an increased need for insulin.
c. Magnesium sulfate does not affect blood glucose levels.
d. Indomethacin does not affect blood glucose levels.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Difficult

 

 

  1. While educating the client with class II cardiac disease, at 28 weeks’ gestation, the nurse instructs the client to notify the physician if she experiences which of the following conditions? a. Emotional stress at workb. Increased dyspnea while restingc. Mild pedal and ankle edemad. Weight gain of 1 pound in 1 week

 

ANS: b

Feedback
a. Emotional stress increases cardiac workload; however, without symptoms of cardiac decompensation, this is not immediately concerning.
b. Increasing dyspnea, at rest, can be a sign of cardiac decompensation leading to increased congestive heart failure.
c. Mild edema during the third trimester is normal. However, increasing edema and pitting edema should be reported as they can be a sign of increasing CHF.
d. A weight gain of 1 pound per week is expected during the third trimester.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

 

 

 

  1. The nurse working in a prenatal clinic is providing care to three primigravida patients. Which of the patient findings would the nurse highlight for the physician?
  2. 15 weeks, denies feeling fetal movement
  3. 20 weeks, fundal height at the umbilicus
  4. 25 weeks, complains of excess salivation
  5. 30 weeks, states that her vision is blurry

 

ANS: d

Feedback
a. This finding is normal. Quickening is usually felt between 16 and 20 weeks’ gestation.
b. This finding is normal. The fundal height at 20 weeks’ gestation is usually at the level of the umbilicus.
c. Excess salivation is a normal, albeit annoying, finding.
d. Blurred vision is a sign of pregnancy-induced hypertension (PIH). This finding should be reported to the woman’s health-care practitioner.

 

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks’ gestation in her first pregnancy. She is worried about having her baby “too soon,” and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be:
  2. Preterm labor
  3. Term labor
  4. Back labor
  5. Braxton-Hicks contractions

 

ANS: d

Feedback
a. Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the end of the 36th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.
b. Term labor occurs after 37 weeks’ gestation.
c. There is no indication in this scenario that this is back labor.
d. Braxton-Hicks contractions are regular contractions occurring after the third month of pregnancy. They may be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

 

 

 

  1. The perinatal nurse knows that the term to describe a woman at 26 weeks’ gestation with a history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is:
  2. Preeclampsia
  3. Chronic hypertension
  4. Gestational hypertension
  5. Chronic hypertension with superimposed preeclampsia

 

ANS: d

Feedback
a. Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, and renal and central nervous systems.
b. Chronic hypertension is hypertension that is present and observable prior to pregnancy or hypertension that is diagnosed before the 20th week of gestation.
c. Gestational hypertension is a nonspecific term used to describe the woman who has a blood pressure elevation detected for the first time during pregnancy, without proteinuria.
d. The following criteria are necessary to establish a diagnosis of superimposed preeclampsia: hypertension and no proteinuria early in pregnancy (prior to 20 weeks’ gestation) and new-onset proteinuria, a sudden increase in protein—urinary excretion of 0.3 g protein or more in a 24-hour specimen, or two dipstick test results of 2+ (100 mg/dL), with the values recorded at least 4 hours apart, with no evidence of urinary tract infection; a sudden increase in blood pressure in a woman whose blood pressure has been well controlled; thrombocytopenia (platelet count lower than 100,000/mmC); and an increase in the liver enzymes alanine transaminase (ALT) or aspartate transaminase (AST) to abnormal levels.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings?
  2. Patellar and biceps reflexes of +4
  3. Urinary output of 50 mL/hr
  4. Respiratory rate of 10 rpm
  5. Serum magnesium level of 5 mg/dL

 

ANS: c

Feedback
a. The magnesium sulfate has been ordered because the patient has severe pregnancy-induced hypertension. Patellar and biceps reflexes of +4 are symptoms of the disease.
b. The urinary output must be above 25 mL/hr.
c. The drop in respiratory rate may indicate that the patient is suffering from magnesium toxicity. The nurse should report the finding to the physician.
d. The therapeutic range of magnesium is 4 to 7 mg/dL.

 

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Adverse Effects/Contraindications; Antepartum Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Diagnostic Tests | Client Need: Health Promotion and Maintenance; Pharmacological and Parenteral Therapies; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother?
  2. Serum potassium level increases
  3. Diarrhea
  4. Urticaria
  5. Complaints of nervousness

 

ANS: d

Feedback
a. The nurse would not expect to see a rise in the mother’s serum potassium levels.
b. The beta agonists are not associated with diarrhea.
c. The beta agonists are not associated with urticaria.
d. Complaints of nervousness are commonly made by women receiving subcutaneous beta agonists.

 

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications and Side Effects | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate

 

 

 

  1. Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae?
  2. Increasing abdominal girth measurements
  3. Profuse vaginal bleeding
  4. Bradycardia with an aortic thrill
  5. Hypothermia with chills

 

ANS: a

Feedback
a. The nurse would expect to see increasing abdominal girth measurements.
b. Profuse vaginal bleeding is rarely seen in placental abruption and is never seen when the abruption is concealed.
c. With excessive blood loss, the nurse would expect to see tachycardia.
d. The nurse would expect to see a stable temperature.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate

 

 

 

  1. A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings?
  2. Pyelonephritis
  3. Pregnancy-induced hypertension
  4. Gestational diabetes
  5. Abruptio placentae

 

ANS: c

Feedback
a. Pyelonephritis does not lead to the development of hydramnios or macrosomia.
b. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia.
c. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies.
d. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

 

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult

 

 

 

  1. For the patient with which of the following medical problems should the nurse question a physician’s order for beta agonist tocolytics?
  2. Type 1 diabetes mellitus
  3. Cerebral palsy
  4. Myelomeningocele
  5. Positive group B streptococci culture

 

ANS: a

Feedback
a. Beta agonists often elevate serum glucose levels. The nurse should question the order.
b. Beta agonists are not contraindicated for patients with cerebral palsy.
c. Beta agonists are not contraindicated for patients with myelomeningocele.
d. Beta agonists are not contraindicated for patients with group B streptococci.

 

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption?
  2. The patient with placenta previa
  3. The patient whose vagina is colonized with group B streptococci
  4. The patient who is hepatitis B surface antigen positive
  5. The patient with eclampsia

 

ANS: d

Feedback
a. Patients with placenta previa are not especially high risk for placental abruption.
b. Patients colonized with group B streptococci are not especially high risk for placental abruption.
c. Patients who are hepatitis B surface antigen positive are not especially high risk for placental abruption.
d. Patients with eclampsia are high risk for placental abruption.

 

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Complications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. The nurse is caring for a woman at 28 weeks’ gestation with a history of preterm delivery. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis?
  2. Human relaxin levels
  3. Amniotic fluid levels
  4. Alpha-fetoprotein levels
  5. Fetal fibronectin levels

 

ANS: d

Feedback
a. Relaxin levels are rarely assessed. In addition, they are unrelated to the incidence of preterm labor.
b. Amniotic fluid levels are not directly related to the incidence of preterm labor.
c. Alpha-fetoprotein levels are not related to the incidence of preterm labor.
d. A rise in the fetal fibronectin levels in cervical secretions has been associated with preterm labor.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Laboratory Values | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate

 

 

 

  1. Which of the following statements is most appropriate for the nurse to say to a patient with a complete placenta previa?
  2. “During the second stage of labor you will need to bear down.”
  3. “You should ambulate in the halls at least twice each day.”
  4. “The doctor will likely induce your labor with oxytocin.”
  5. “Please promptly report if you experience any bleeding or feel any back discomfort.”

 

ANS: d

Feedback
a. This response is inappropriate. This patient will be delivered by cesarean section.
b. This response is inappropriate. Patients with placenta previa are usually on bed rest.
c. This response is inappropriate. This patient will be delivered by cesarean section.
d. Labor often begins with back pain. Labor is contraindicated for a patient with complete placenta previa.

 

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. A woman at 32 weeks’ gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome?
  2. Rise in serum creatinine
  3. Drop in serum protein
  4. Resolution of thrombocytopenia
  5. Resolution of polycythemia

 

ANS: c

Feedback
a. A rise in serum creatinine indicates that the kidneys are not effectively excreting creatinine. It is a negative outcome.
b. A drop in serum protein indicates that the kidneys are allowing protein to be excreted. This is a negative outcome.
c. Resolution of thrombocytopenia is a positive sign. It indicates that the platelet count is returning to normal.
d. Polycythemia is not related to HELLP syndrome. Rather one sees a drop in red cell and platelet counts with HELLP. A positive sign, therefore, would be a rise in the RBC count.

 

KEY: Integrated Process: Nursing Process: Evaluation | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Illness Management | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult

 

 

 

  1. A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following?
  2. High leukocyte count
  3. Explosive diarrhea
  4. Fractured pelvis
  5. Low platelet count

 

ANS: d

Feedback
a. High leukocyte count is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.
b. Explosive diarrhea is not associated with severe PIH or HELLP syndrome.
c. A fractured pelvis is not associated with severe PIH or HELLP syndrome.
d. Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Diagnostic Tests; Reduction of Risk Potential: Laboratory Data | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. A woman at 10 weeks’ gestation is diagnosed with gestational trophoblastic disease (hydatiform mole). Which of the following findings would the nurse expect to see?
  2. Platelet count of 550,000/ mm3
  3. Dark brown vaginal bleeding
  4. White blood cell count 17,000/ mm3
  5. Macular papular rash

 

ANS: b

Feedback
a. The nurse would not expect to see an elevated platelet count.
b. The nurse would expect to see dark brown vaginal discharge
c. The nurse would not expect to see an elevated white blood cell count.
d. The nurse would not expect to see a rash.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult

 

 

 

  1. After an education class, the nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed?
  2. “I could get an STI even if I just have oral sex.”
  3. “Girls over 16 are less likely to get STDs than younger girls.”
  4. “The best way to prevent an STI is to use a diaphragm.”
  5. “Girls get human immunodeficiency virus (HIV) easier than boys do.”

 

ANS: c

Feedback
a. This statement is true. Organisms that cause sexually transmitted infections can invade the respiratory and gastrointestinal tracts.
b. This statement is true. Young women are especially high risk for becoming infected with sexually transmitted diseases.
c. This statement is untrue. The young woman needs further teaching. Condoms protect against STDs and pregnancy. In addition, condoms can be kept in readiness for whenever sex may occur spontaneously. Using condoms does not require the teen to plan to have sex. A diaphragm is not an effective infection-control method. Plus, it would require the teen to plan for intercourse.
d. This statement is true. Young women are higher risk for becoming infected with HIV than are young men.

 

KEY: Integrated Process: Nursing Process: Evaluation; Teaching and Learning | Cognitive Level: Application | Content Area: Disease Prevention; High Risk Behaviors; Human Sexuality | Client Need: Health Promotion and Maintenance: High Risk Behaviors; Human Sexuality | Difficulty Level: Moderate

 

 

 

  1. A woman who is admitted to labor and delivery at 30 weeks’ gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour?
  2. Temperature
  3. Pulse
  4. Respiratory rate
  5. Blood pressure

 

ANS: c

Feedback
a. The temperature should be monitored, but it is not the most important vital sign.
b. The pulse rate should be monitored, but it is not the most important vital sign.
c. The respiratory rate is the most important vital sign. Respiratory depression is a sign of magnesium toxicity.
d. The blood pressure should be monitored, but it is not the most important vital sign.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Intrapartum Care; Potential for Complications from Pharmacological Therapies: Adverse Effects/Contraindications | Client Need: Health Promotion and Maintenance; Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate

 

 

 

  1. You are caring for a patient who was admitted to labor and delivery at 32 weeks’ gestation and diagnosed with preterm labor. She is currently on magnesium sulfate, 2 gm per hour. Upon your initial assessment you note that she has a respiratory rate of 8 with absent deep tendon reflexes. What will be your first nursing intervention?
  2. Elevate head of the bed
  3. Notify the MD
  4. Discontinue magnesium sulfate
  5. Draw a serum magnesium level

 

ANS: c

Initial nursing intervention needs to be discontinuing magnesium sulfate because the patient is exhibiting signs of magnesium toxicity with absent deep tendon reflexes and decreased respiratory rate.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application and Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Hard

 

 

 

  1. A 34-weeks’ gestation multigravida, G3 P1 is admitted to the labor suite. She is contracting every 7 minutes and 40 seconds. The woman has several medical problems. Which of the following of her comorbidities is most consistent with the clinical picture?
  2. Kyphosis
  3. Urinary tract infection
  4. Congestive heart failure
  5. Cerebral palsy

 

ANS: b

Feedback
a. Kyphosis is unrelated to preterm labor.
b. Urinary tract infections often precipitate preterm labor.
c. It is unlikely that the congestive heart failure precipitated the preterm labor.
d. Cerebral palsy is unrelated to preterm labor.

 

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance: Antepartum Care; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult

 

 

 

  1. A primiparous woman has been admitted at 35 weeks’ gestation and diagnosed with HELLP syndrome. Which of the following laboratory changes is consistent with this diagnosis?
  2. Hematocrit dropped to 28%.
  3. Platelets increased to 300,000 cells/mm3.
  4. Red blood cells increased to 5.1 million cells/mm3.
  5. Sodium dropped to 132 mEq/dL.

 

ANS: a

Feedback
a. The nurse would expect to see a drop in the hematocrit: The H in HELLP stands for hemolysis.
b. The nurse would expect to see low platelets.
c. The nurse would expect to see hemolysis.
d. The sodium is usually unaffected in HELLP syndrome.

 

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Intrapartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Moderate

 

 

 

  1. A labor nurse is caring for a patient, 39 weeks’ gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question?
  2. Type and cross-match her blood.
  3. Insert an internal fetal monitor electrode.
  4. Administer an oral stool softener.
  5. Assess her complete blood count.

 

ANS: b

Feedback
a. It would be appropriate to type and cross-match the patient for a blood transfusion.
b. This action is inappropriate. When a patient has a placenta previa, nothing should be inserted into the vagina.
c. To prevent constipation, it is appropriate for a patient to take a stool softener.
d. It is appropriate to monitor the patient for signs of anemia.

 

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Patient Advocacy; Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential; Safe and Effective Care Environment: Management of Care | Difficulty Level: Moderate

 

 

 

  1. A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see?
  2. Postpartum hemorrhage
  3. Neonatal hyperglycemia
  4. Postpartum oliguria
  5. Neonatal macrosomia

 

ANS: d

Feedback
a. The patient is not especially high risk for a postpartum hemorrhage.
b. The nurse would expect to see neonatal hypoglycemia, not hyperglycemia.
c. The nurse would expect to see postpartum polyuria.
d. The nurse would expect to see neonatal macrosomia.

 

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Difficult

 

 

 

  1. According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia:
  2. Take the patient’s blood pressure every 6 hours
  3. Encourage the patient to rest on her back
  4. Notify the physician of a urine output greater than 30 mL/hr
  5. Administer magnesium sulfate according to agency policy

 

ANS: d

Feedback
a. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The blood pressure is taken every 1 hour or more frequently according to physician orders or institutional protocol.
b. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a side-lying position to enhance uterine perfusion.
c. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria and the physician must be notified.
d. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 weeks’ gestation. The nurse is preparing to administer the second dose of beta-methasone prescribed by the physician. Marilyn asks: “What is this injection for again?” The nurse’s best response is:
  2. “This is to help your baby’s lungs to mature.”
  3. “This is to prepare your body to begin the labor process.”
  4. “This is to help stabilize your blood pressure.”
  5. “This is to help your baby grow and develop in preparation for birth.”

 

ANS: a

Feedback
a. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours.
b. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours.
c. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours.
d. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. A woman who is 36 weeks pregnant presents to the labor and delivery unit with a history of congestive heart disease. Which of the following findings should the nurse report to the primary health-care practitioner?
  2. Presence of chloasma
  3. Presence of severe heartburn
  4. 10-pound weight gain in a month
  5. Patellar reflexes +1

 

ANS: c

Feedback
a. Chloasma is a normal pregnancy finding.
b. Heartburn is an expected finding during the third trimester.
c. The weight gain may be due to fluid retention. Fluid retention may occur in patients with pregnancy-induced hypertension and in patients with congestive heart failure. The physician should be notified.
d. Although slightly hyporeflexic, patellar reflexes of +1 are within normal limits.

 

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. The single most important risk factor for preterm birth includes:
  2. Uterine and cervical anomalies
  3. Infection
  4. Increased BMI
  5. Prior preterm birth

 

ANS: d

The single most important factor is prior preterm birth with a reoccurrence rate of up to 40%.

 

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. Your antepartal patient is 38 weeks’ gestation, has a history of thrombosis, and has been on strict bed rest for the last 12 hours. She is now experiencing shortness of breath. What about the patient may be a contributing factor for her shortness of breath?
  2. Physiologic changes in pregnancy result in vasodilation, which increases the tendency to form blood clots.
  3. Physiologic changes in pregnancy result in vasoconstriction, which increases the tendency to form blood clots.
  4. Physiologic changes in pregnancy result in anemia, which increases the tendency to form blood clots.
  5. Physiologic changes in pregnancy result in decreased perfusion to the lungs, which increases the tendency to form blood clots.

 

ANS: a

The patient’s shortness of breath, bed rest, and history of thrombosis indicate possible pulmonary embolism. Her pregnant state also increases the potential for thrombosis resulting from increased levels of coagulation factors and decreased fibrinolysis, venous dilation, and obstruction of the venous system by the gravid uterus. Thromboembolitic diseases occurring most frequently in pregnancy include deep vein thrombosis and pulmonary embolism.

 

KEY: Integrated Process: Critical Thinking | Cognitive Level: Complication | Content Area: Physiologic Adaptation: Alteration in Body Systems | Client Need: Physiologic Adaptation | Difficulty Level: Hard

 

 

 

  1. Metabolic changes during pregnancy __________ glucose tolerance.
  2. lower
  3. increase
  4. maintain
  5. alter

 

ANS: a

Metabolic changes during pregnancy lower glucose tolerance.

 

KEY: Integrated Process: Knowledge | Cognitive Level: Synthesis | Content Area: Maternity

| Client Need: Physiologic Adaptation | Difficulty Level: Hard

 

 

 

True/False

 

 

 

  1. Immediately postpartum, the insulin needs in diabetic women increase dramatically.

 

ANS: FalseThere is a significant decrease in the need for insulin immediately after delivery related to the loss of antagonistic placental hormones and suppression of the anterior pituitary growth hormone.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Easy

 

 

 

  1. The perinatal nurse observes the placental inspection by the health-care provider after birth. This examination may help to determine whether an abruption has occurred prior to or during labor.

 

ANS: True

Fifty percent of abruptions occur before labor and after the 30th week, 15% occur during labor, and 30% are identified only upon inspection of the placenta after delivery.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

 

 

 

  1. It is critical for the perinatal nurse to learn, as part of the facility’s policies and procedures, to immediately perform a vaginal examination on a woman who presents with vaginal bleeding after 24 weeks’ gestation.

 

ANS: False

Placenta previa should be suspected in all patients who present with bleeding after 24 completed weeks of gestation. Because of the risk of placental perforation, vaginal examinations are not performed.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse knows that the survival rate for infants born at or greater than 28 to 29 gestational weeks is greater than 90%.

 

ANS: True

With appropriate medical care, neonatal survival dramatically improves as the gestational age increases, with over 50% of neonates surviving at 25 weeks’ gestation, and over 90% surviving at 28 to 29 weeks of gestation.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. A patient with hypertension who is receiving intravenous magnesium sulfate therapy has requested an epidural anesthetic. The perinatal nurse should first review the patient’s complete blood count results for evidence of a decreased platelet count.

 

ANS: True

Baseline information, including complete blood count (CBC), clotting studies, serum electrolytes, and renal function tests, is used to alert the care providers to changes in the patient’s condition as additional laboratory tests are obtained.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Difficult

 

 

 

  1. The perinatal nurse knows that the laboring diabetic patient’s blood glucose level should always be less than 120 mg/dL.

 

ANS: True

Blood glucose levels are assessed every hour, and fluid/insulin adjustments are made as needed to maintain maternal blood glucose levels between 80 and 120 mg/dL.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

Multiple Response

 

 

 

  1. The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta previa risk factors include (select all that apply):
  2. Cocaine use
  3. Tobacco use
  4. Previous caesarean birth
  5. Previous use of medroxyprogesterone (Depo-Provera)

 

ANS: a, b, c

Feedback
a. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years.
b. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years.
c. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age.
d. Previous use of medroxyprogesterone (Depo-Provera) is not a risk factor for placenta previa.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks’ gestation. An appropriate nursing action would be to (select all that apply):
  2. Assess the fetal heart rate
  3. Obtain urine for culture and sensitivity
  4. Assess Kerry’s blood pressure and pulse
  5. Palpate Kerry’s abdomen for contractions

 

ANS: a, b, d

Feedback
a. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient’s abdomen should be palpated to assess for contractions, and the fetus’s heart rate should be monitored.
b. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency). The patient’s abdomen should be palpated to assess for contractions, and the fetus’s heart rate should be monitored.
c. Assessment of blood pressure and pulse is not an important nursing action in this scenario.
d. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient’s abdomen should be palpated to assess for contractions and the fetus’s heart rate should be monitored.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse knows that tocolytic agents are most often used to (select all that apply):
  2. Prevent maternal infection
  3. Prolong pregnancy to 40 weeks’ gestation
  4. Prolong pregnancy to facilitate administration of antenatal corticosteroids
  5. Allow for transport of the woman to a tertiary care facility

 

ANS: c, d

Feedback
a. Tocolytics are not used to treat maternal infection.
b. Tocolytics are generally only effective in delaying delivery for several days.
c. Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of antenatal corticosteroids to accelerate fetal lung maturity.
d. Delaying the birth provides time for maternal transport to a facility equipped with a neonatal intensive care unit.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information provided about preterm labor and birth prevention includes (select all that apply):
  2. Encouraging regular, ongoing prenatal care
  3. Reporting symptoms of urinary frequency and burning to the health-care provider
  4. Coming to the labor triage unit if back pain or cramping persist or become regular
  5. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5 minutes

 

ANS: a, b, c

Feedback
a. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur.
b. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur.
c. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider if symptoms of preterm labor occur.
d. Lying on the right side; drinking fluids, not withholding fluids; and counting fetal movements if contractions occur every 5 minutes are recommended if a woman thinks she is contracting.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse describes for the new nurse the various risks associated with prolonged premature preterm rupture of membranes. These risks include (select all that apply):
  2. Chorioamnionitis
  3. Abruptio placentae
  4. Operative birth
  5. Cord prolapse

 

ANS: a, b, d

Even though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cord prolapse.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. Betamethasone is a steroid that is given to a pregnant woman with signs of preterm labor. The purpose of giving steroids is to (select all that apply):
  2. Stimulate the production of surfactant in the preterm infant
  3. Be given between 24 and 34 weeks’ gestation
  4. Increase the severity of respiratory distress
  5. Accelerate fetal lung maturity

 

ANS: a, b, d

Betamethasone is a steroid that is given to pregnant women with signs of preterm labor between 24 and 34 weeks’ gestation. It stimulates the production of surfactant in the preterm infant and accelerates fetal lung maturity.

 

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Pharmacological and Parenteral Therapies: Expected Effects/Outcomes | Client Need: Pharmacologic and Parenteral Therapies | Difficulty Level: Hard

 

 

 

  1. Marked hemodynamic changes in pregnancy can impact the pregnant woman with cardiac disease. Signs and symptoms of deteriorating cardiac status include (select all that apply):
  2. Orthopnea
  3. Nocturnal dyspnea
  4. Palpitations
  5. Irritation

 

ANS: a, b, c

Signs and symptoms of deteriorating cardiac status with cardiac disease include orthopnea, nocturnal dyspnea, and palpitations, but do not include irritation.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Synthesis | Content Area: Reduction of Risk Potential-Potential for Complications | Client Need: Physiologic Adaptation | Difficulty Level: Hard

 

 

 

Short Answer

 

 

 

  1. A condition where the placenta attaches to the lower uterine segment of the uterus

 

ANS: Placenta previa

KEY: Integrated Process: Teaching/Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. A pregnancy that ends before 20 weeks’ gestation

 

ANS: Miscarriage

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. Birth prior to 37 completed weeks of pregnancy

 

ANS: Preterm birth

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. Specks or spots in the vision where the patient cannot see; “blind spots”

 

ANS: Scotoma

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. A disease characterized by an abnormal placental development that results in the production of fluid-filled grapelike clusters and a vast proliferation of trophoblastic tissue

 

ANS: Hydatidiform mole/Gestational trophoblastic disease

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. No expulsion of the products of conception, but bleeding and dilation of the cervix such that a pregnancy is unlikely

 

ANS: Inevitable abortion

 

KEY: Integrated Processes: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. Placement of suture to mechanically close a weak cervix

 

ANS: Cervical cerclage

 

KEY:  Integrated Process: Teaching and Learning | | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

Fill-in-the-Blank

 

 

 

  1. The perinatal nurse knows that an early pregnancy loss occurs before __________ weeks, and a late pregnancy loss is one that occurs between 12 and __________ weeks.

 

ANS: 12; 20

Not all conceptions result in a live-born infant. Of all clinically recognized pregnancies, 10% to 20% are lost, and approximately 22% of pregnancies detected on the basis of hCG assays are lost before the appearance of any clinical signs or symptoms. By definition, an early pregnancy loss occurs before 12 weeks of gestation; a late pregnancy loss is one that occurs between

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. Mary, a G3 TPAL 0020 woman at 20 weeks’ gestation, has had a transvaginal ultrasound. Mary has been informed that she has cervical incompetence. The perinatal nurse explains that this diagnosis means that her cervix has __________ without __________ contractions.

 

ANS: dilated; regular

Patients with cervical incompetence usually present with painless dilation and effacement of the cervix, often during the second trimester of pregnancy. The patient frequently gives a history of repeated second trimester losses with no apparent etiology. Incompetent cervix is estimated to cause approximately 15% of all second trimester losses.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse knows that nausea and vomiting are common in pregnancy and usually resolve by __________ weeks’ gestation. The severe form of this condition is __________.

 

ANS: 16; hyperemesis gravidarum

Feedback 1: Nausea and vomiting are a common condition of pregnancy which affect 70% to 85% of pregnant women and usually resolve by the 16th week of gestation.

Feedback 2: Hyperemesis gravidarum represents the extreme end of the nausea/vomiting spectrum in terms of severity. Criteria for the diagnosis of hyperemesis gravidarum include persistent vomiting unrelated to other causes, a measure of acute starvation (usually large ketonuria), and some discrete weight loss, most often 5% of the prepregnancy weight.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

 

 

 

  1. The perinatal nurse explains to the student nurse who is assessing the abdomen of a 32-week pregnant woman with placenta previa that it would not be unusual to find the fetus in a __________ or __________ position.

 

ANS: breech; transverse

Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. This condition accounts for 20% of all antepartal hemorrhages. Leopold maneuvers often reveal the fetus to be in a breech or oblique position or transverse lie because of the abnormal location of the placenta.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse knows that a __________ hemorrhage is limited to the uterus, and a __________ hemorrhage moves blood toward and through the cervix.

 

ANS: concealed; revealed

Feedback 1: A concealed hemorrhage occurs in 20% of cases and describes an abruption in which the bleeding is confined within the uterine cavity. The most common abruption is associated with a revealed or external hemorrhage, where the blood dissects downward toward the cervix.

Feedback 2: The most common abruption is associated with a revealed or external hemorrhage, where the blood dissects downward toward the cervix.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. The perinatal nurse encourages Colleen, who has just been discharged from the hospital for intravenous therapy for severe nausea and vomiting, to ensure that she __________ often, eats frequent, __________ meals and avoids __________ odors.

 

ANS: rests; small; cooking

The nurse should counsel the woman with nausea and vomiting to avoid foods and sensory stimuli that provoke symptoms (i.e., some women become nauseous when they smell certain foods being prepared) and also to eat small, frequent meals of dry, bland foods and include high-protein snacks in their diet.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

Chapter 11: Intrapartum and Postpartum Care of Cesarean Birth Families

 

 

 

Multiple Response

 

 

 

  1. Which of the following is a medical indication for a cesarean birth? (Select all that apply.)
  2. Maternal blood pressure of 130/90b. Cervical dilation of 1.5 cm per hour during the active phase of laborc. Late deceleration of the fetal heart rate with minimal variabilityd. Complete placenta previae. Arrest of fetal descent

 

ANS: c, d, eA maternal blood pressure of 130/90 may be an indication of mild PHI which is not a medical indication for cesarean birth. Cervical dilation of 1.5 cm/minutes is within normal limits for cervical changes during the active phase. Late decelerations combined with minimal variability in the fetal heart rate reflect fetal intolerance of labor and are an indication for cesarean birth. A complete placenta previa covers the internal os necessitating a cesarean birth. Arrest of fetal descent indicates cephalopelvic disproportion.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

  1. A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor and operative records indicate that she had premature rupture of membranes followed by 36 hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is 1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that apply.)
  2. Fluid volume deficitb. Infectionc. Impaired mother–infant attachmentd. Falls

 

ANS: a, b, c, dThe woman is at risk for fluid volume deficit related to blood loss and risk for postpartum hemorrhage due to risk of uterine atony. She is at risk for infection related to premature and prolonged rupture of membranes. The woman is at risk for impaired mother–infant attachment related to maternal pain and exhaustion. She is at risk for falls related to anesthesia and orthostatic hypotension.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

 

 

 

  1. The perinatal nurse teaches the student nurse that deep breathing exercises following a cesarean birth are critical to the prevention of (select all that apply):
  2. Pneumonia
  3. Atelectasis
  4. Abdominal distension
  5. Increased tidal volume

 

ANS: a, b

Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis.

 

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

Multiple Choice

 

 

 

  1. A nurse is admitting a woman for a scheduled cesarean section. Which of the following assessment data should be immediately reported to the physician?a. White cell count of 11,000b. Hemoglobin of 11 g/dLc. Hematocrit of 33%d. Platelet count of 97,000

 

ANS: d

Feedback
a. This laboratory value is within normal limits for a pregnant woman.
b. This laboratory value is within normal limits for a pregnant woman.
c. This laboratory value is within normal limits for a pregnant woman.
d. Normal range of platelets is 150,000 to 400,000. A low platelet count places the woman at risk for increased bleeding.

 

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Reduction of Risk Potential

Difficulty Level: Moderate

 

 

  1. A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couple’s anxiety levels.a. Explain the reason for the need for a cesarean section.b. Inform parents that their baby is in distress.c. Ask the couple to share their concerns.d. Reassure the couple that both the woman and baby are in no danger.

 

ANS: c

Feedback
a. Explaining the reason she is having a cesarean birth is helpful but may not address their concerns.
b. It is important to acknowledge that the baby is stable, but this response does not allow the couple to share their concerns that may be causing an increase in anxiety.
c. By asking the couple to share their concerns, the nurse can address these concerns.
d. Reassuring the couple that the woman and baby are in no danger is correct, but it is not the best answer because it does not allow the couple to verbalize their concerns.

 

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

 

 

  1. A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention?a. Itching of the palms and feetb. Nauseac. Urinary output of 300 mL in the past 4 hoursd. Respiratory rate of 10 breaths/minute

 

ANS: d

Feedback
a. This is a side effect of intrathecal morphine which is not life threatening.
b. This is a side effect of intrathecal morphine which is not life threatening.
c. A urinary output of 300 mL in 4 hours is within normal limits.
d. Correct. An adverse effect of intrathecal morphine that requires immediate intervention is respiratory distress.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Reduction of Risk Potential |Difficulty Level: Moderate

 

 

 

  1. A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time?
  2. Maintain the client flat in bed.
  3. Assess the client’s patellar reflexes.
  4. Monitor hourly urinary outputs.
  5. Assess the client’s respiratory rate.

 

ANS: d

Feedback
a. The client should be assisted to a position of comfort.
b. There is no indication in the scenario that the client must have her reflexes assessed.
c. The client’s hydration should be monitored postsurgery, but hourly assessments are unnecessary.
d. The client has undergone major abdominal surgery. Her respiratory function should be assessed regularly.

 

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Postpartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate

 

 

 

  1. A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see?
  2. Abdominal distension
  3. Polyuria
  4. Diastasis recti
  5. Dependent edema

 

ANS: a

Feedback
a. The nurse would expect to see a distended abdomen in a client with a paralytic ileus.
b. Polyuria is unrelated to a paralytic ileus.
c. Diastasis recti is unrelated to a paralytic ileus.
d. Dependent edema is unrelated to a paralytic ileus.

 

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension | Content Area: Physiological Adaptation: Alterations in Body Systems; Postpartum Care | Client Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse:
  2. Assists the woman to lie down in a supine position.
  3. Administers a rapid intravenous infusion of 500 mL of normal saline.
  4. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion.
  5. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.

 

ANS: b

Complications that may occur with spinal anesthesia block include maternal hypotension, decreased placental perfusion, and an ineffective breathing pattern. Prior to administration, the patient’s fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities). Following administration of the anesthetic, the patient’s blood pressure, pulse, and respirations and fetal heart rate must be taken and documented every 5 to 10 minutes.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

 

 

 

  1. The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic agent in an epidural is primarily to:
  2. Increase the total anesthetic volume
  3. Preserve a greater amount of maternal motor function
  4. Increase the intensity of the motor and sensory block
  5. Decrease the number of side effects

 

ANS: b

Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required and helps to preserve a greater amount of maternal motor function.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

 

 

 

  1. Tanya, a 30-year-old woman, is being prepared for an elective cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanya’s blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurse’s best response is to:
  2. Place a wedge under Tanya’s left hip.
  3. Discontinue Tanya’s intravenous administration.
  4. Have naloxone (Narcan) ready for administration.
  5. Have epinephrine ready for administration.

 

ANS: a

In the event of severe maternal hypotension, the nurse should place the patient in a lateral position or use a wedge under the hip to displace the uterus, elevate the legs, maintain or increase the IV infusion rate, and administer oxygen by face mask at 10 to 12 L/min, or according to institution protocol.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Difficult

 

 

 

  1. The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist Chantal in:
  2. Her role development in the “letting go” stage
  3. Decreasing her ambivalence about her labor and birth
  4. Understanding her guilt involved in her labor and birth
  5. Developing more positive feelings about her labor and birth

 

ANS: d

After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth. Unplanned or emergent cesarean deliveries and the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing Chantal to talk about the experience can help her develop a more positive attitude about her own experience.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. The best time to give prophylactic antibiotics to the women undergoing cesarean section is:
  2. One hour before the surgery
  3. Two hours before the surgery
  4. Not indicated unless she has an active infection
  5. At the time the cord is clamped

ANS: a
Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes prior to the skin incision.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. During a cesarean section, which action by the nurse is done to prevent compression of the descending aorta and vena cava?
  2. Right lateral tilt
  3. Left lateral tilt
  4. Elevate head of gurney at 30 degrees
  5. Administration of IV fluid preload of 500 to 1000 mL

 

ANS: b

Positioning of the patient with a left tilt maintains a left uterine displacement to decrease the risk of aortocaval compression related to compression on the aorta and inferior vena cava due to weight of the gravid uterus.

 

KEY: Integrated Process: Nursing Process: Intervention | Cognitive Level: Application and Comprehension | Content Area: Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Safe and Effective Care Environment | Difficulty: Hard

 

 

 

Fill-in-the-Blank

 

 

 

  1. A post-cesarean section client has been ordered to receive 500 mL of 5% dextrose in water every 4 hours. The drop factor of the macrodrip tubing is 10 gtt/mL. To what drip rate should the nurse regulate the IV? __________­­ gtt/min

 

ANS: 21

Feedback: 21 gtt/min

The formula for calculating drip rates is:

volume multiplied by drop factor = drip rate
time in minutes

 

 500 mL = 10 gtt/cc = 21 gtt/min
4 hours = 60 min/hr

 

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation | Cognitive Level: Synthesis | Content Area: Pharmacological and Parenteral Therapies: Medication Administration | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate

 

 

 

  1. The perinatal nurse knows that the presence of abdominal distension and gas in the post-cesarean birth mother is due to __________.

 

ANS: delayed peristalsis

Delayed peristalsis and constipation commonly occur because of slowed peristalsis associated with pregnancy hormones and childbirth anesthesia. In addition, incisional pain may contribute to a decrease in ambulation which contributes to delayed peristalsis.

 

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

 

 

 

  1. The Joint Commission Standard states that the __________, __________, and __________ are accurately identified and clearly communicated during the final verification process before the start of any surgical or invasive procedure.

 

ANS: site; procedure; patient

To decrease the risk of surgery or invasive procedure being done on the wrong patient or in the wrong site, a “time-out” is called, and active communication to verify correct procedure, site, and patient is done just prior to the beginning of surgery or invasive procedure.

 

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

 

 

 

True/False

 

 

 

  1. During an emergency cesarean birth the “time-out” procedure may be omitted based on the obstetrical emergency.

 

ANS: False

Joint commission guidelines for patient safety necessitate there always be a time-out to prevent wrong patient, wrong site, wrong procedure, and medical errors.

 

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy