Chapter 7: Antepartum Assessment, Care, and Education

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

ANS: A In general, immunizations with live virus vaccines (e.g., measles, mumps, rubella, varicella, smallpox) are contraindicated during pregnancy because they may have teratogenic effects on the fetus. Inactivated vaccines are safe and can be used in women who have a risk of developing diseases such as tetanus, hepatitis B, and influenza. PTS: 1 DIF: Cognitive Level: Understanding REF: 119 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

55. The capacity of the uterus in a term pregnancy is how many times its prepregnant capacity? Record your answer as a whole number. ______ times

ANS: 500 The prepregnant capacity of the uterus is about 10 mL, and it reaches 5000 ml (5 L) by the end of the pregnancy, which reflects a 500-fold increase. PTS: 1 DIF: Cognitive Level: Understanding REF: 93 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

56. Calculate the estimated date of birth (EDD) in October using Nägele's rule for a client whose last normal menstrual period (LNMP) began on January 1. Record your answer as a whole number. _______

ANS: 8 Nägele's rule is often used to establish the EDD. This method involves subtracting 3 months from the date that the LNMP began, adding 7 days, and then correcting the year, if appropriate. Subtracting 3 months from January 1 gives you the month of October and adding 7 days = October 8. PTS: 1 DIF: Cognitive Level: Analysis REF: 107 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

21. Which laboratory result would be a cause for concern if exhibited by a client at her first prenatal visit during the second month of her pregnancy? a. Rubella titer, 1:6 b. Platelets, 300,000/mm3 c. White blood cell count, 6000/mm3 d. Hematocrit 38%, hemoglobin 13 g/dL

ANS: A A rubella titer of less than 1:8 indicates a lack of immunity to rubella, a viral infection that has the potential to cause teratogenic effects on fetal development. Arrangements should be made to administer the rubella vaccine after birth during the postpartum period because administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women receiving the vaccine during the postpartum period should be cautioned to avoid pregnancy for 3 months. The lab values for WBCs, platelets, and hematocrit/hemoglobin are within the expected range for pregnant women. PTS: 1 DIF: Cognitive Level: Analysis REF: 110 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. Which complaint made by a client at 35 weeks of gestation requires additional assessment? a. Abdominal pain b. Ankle edema in the afternoon c. Backache with prolonged standing d. Shortness of breath when climbing stairs

ANS: A Abdominal pain may indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae. Ankle edema in the afternoon is a normal finding at this stage of the pregnancy. Backaches while standing is a normal finding in the later stage of pregnancy. Shortness of breath is an expected finding at 35 weeks. PTS: 1 DIF: Cognitive Level: Analysis REF: 121 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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

ANS: A Between 16 and 36 weeks, fundal height measurement corresponds with the weeks of gestation. The patient was last at the clinic at 23 weeks and would be rescheduled to return at 27 week, or in 4 weeks. The fundal height is 3 cm less than it should be, so the nurse is concerned about fetal well-being. Fetal movement is one of the first indicators of fetal well-being. If the patient's bladder is full, the fundal height measurement will surpass the expected finding. Weight gain can be an indicator of well-being, nutritional status, and excess fluid volume. It is not as reliable an indicator as fetal movement for well-being. DTRs are assessed routinely to assess for hyperreflexia associated with gestational or pregnancy-induced hypertension. PTS: 1 DIF: Cognitive Level: Synthesizing REF: 111 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE

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

ANS: A Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle contraction. Warm packs can be used to relax the muscle, but more immediate relief is necessary, such as dorsiflexion of the foot. Pointing the toes will contract the muscle and not relieve the pain. Because she is prone to blood clots, massaging the affected leg muscle is contraindicated. PTS: 1 DIF: Cognitive Level: Application REF: 115 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

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

ANS: A Gravida (the first number) is 4 because this woman is now pregnant and was pregnant three times before. Para (the next four numbers) represents the outcomes of the pregnancies and would be described as follows: • T: 1 = term birth at 41 weeks of gestation (son) • P: 2 = preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter) • A: 0 = abortion; none • L: 2 = living children, her son and her daughter She is currently pregnant so she is a gravida 4. She had one term infant, two preterm infants, no abortion, and three living children. PTS: 1 DIF: Cognitive Level: Application REF: 107 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

24. When a pregnant woman develops ptyalism, what should the nurse advise? a. Chew gum or suck on lozenges between meals. b. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals. c. Take short walks to stimulate circulation in the legs and elevate the legs periodically. d. Use pillows to support the abdomen and back during sleep.

ANS: A Some women experience ptyalism, or excessive salivation. The cause of ptyalism may be decreased swallowing associated with nausea or stimulation of the salivary glands by the ingestion of starch. Small frequent meals and use of chewing gum and oral lozenges offer limited relief for some women. All other options include recommendations for pregnant women; however, they do not address ptyalism. PTS: 1 DIF: Cognitive Level: Application REF: 97 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

51. The nurse is teaching a pregnant client about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? (Select all that apply.) a. Report watery vaginal discharge. b. Report puffiness of the face or around the eyes. c. Report any bloody show when you go into labor. d. Report visual disturbances, such as spots before the eyes. e. Report any dependent edema that occurs at the end of the day.

ANS: A, B, D Watery vaginal discharge could mean that the membranes have ruptured. Puffiness of the face or around the eyes and visual disturbances may indicate preeclampsia or eclampsia. These three signs should be reported. Bloody show as labor starts may mean the mucous plug has been expelled. One of the earliest signs of labor may be bloody show, which consists of the mucous plug and a small amount of blood. This is a normal occurrence. Up to 70% of women have dependent edema during pregnancy. This is not a sign of a pregnancy complication. PTS: 1 DIF: Cognitive Level: Application REF: 121 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

53. Which are presumptive signs of pregnancy? (Select all that apply.) a. Quickening b. Amenorrhea c. Ballottement d. Goodell's sign e. Chadwick's sign

ANS: A, B, E Quickening, amenorrhea, and Chadwick's sign are presumptive signs of pregnancy. Ballottement and Goodell's sign are probable signs of pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 102 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

50. A pregnant client reports that she works in a long-term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine. As the nurse, you are aware that some immunizations are safe to administer during pregnancy, whereas others are not. Which vaccines could this client receive? (Select all that apply.) a. Tetanus b. Varicella c. Influenza d. Hepatitis A and B e. Measles, mumps, rubella (MMR)

ANS: A, C, D Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe to administer to women who have a risk for contracting or developing the disease. Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus. PTS: 1 DIF: Cognitive Level: Application REF: 119 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

52. The nurse is planning care for a client in her first trimester of pregnancy who is experiencing nausea and vomiting. Which interventions should the nurse plan to teach this client? (Select all that apply.) a. Suck on hard candy. b. Take prenatal vitamins in the morning. c. Try some herbal tea to relieve the nausea. d. Drink fluids frequently but separate from meals. e. Eat crackers or dry cereal before arising in the morning.

ANS: A, D, E A client experiencing nausea and vomiting should be taught to suck on hard candy, drink fluids frequently but separately from meals, and eat crackers, dry toast, or dry cereal before arising in the morning. Prenatal vitamins should be taken at bedtime because they may increase nausea if taken in the morning. Before taking herbal tea, the client should check with her health care provider. PTS: 1 DIF: Cognitive Level: Application REF: 114 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

54. Which factors contribute to the presence of edema in the pregnant client? (Select all that apply.) a. Diet consisting of processed foods b. Hemoconcentration c. Increase in colloid osmotic pressure d. Last trimester of pregnancy e. Decreased venous return

ANS: A, D, E Processed foods, which are high in sodium content, can contribute to edema formation. As the pregnancy progresses, because of the weight of the uterus, compression takes place, leading to decreased venous return and an increase in edema formation. A decrease in colloid osmotic pressure would contribute to edema formation and fluid shifting. Hemodilution would also lead to edema formation. PTS: 1 DIF: Cognitive Level: Analysis REF: 101 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation SHORT ANSWER

40. A client who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition? a. Congenital anomalies b. Death before or after birth c. Neonatal hypoglycemia d. Neonatal withdrawal syndrome

ANS: B Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight, abruptio placentae, placenta previa, preterm birth, perinatal mortality, and SIDS. Smoking does not appear to cause congenital anomalies, hypoglycemia, or withdrawal syndrome. PTS: 1 DIF: Cognitive Level: Understanding REF: 120 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

28. You are performing assessments for an obstetric client who is 5 months pregnant with her third child. Which finding would cause you to suspect that the client was at risk? a. Client states that she doesn't feel any Braxton Hicks contractions like she had in her prior pregnancies. b. Fundal height is below the umbilicus. c. Cervical changes, such as Goodell's sign and Chadwick's sign, are present. d. She has increased vaginal secretions.

ANS: B Based on gestational age (20 weeks), the fundal height should be at the umbilicus. This finding is abnormal and warrants further investigation about potential risk. With subsequent pregnancies, multiparas may not perceive Braxton Hicks contractions as being evident compared with their initial pregnancy. Cervical changes such as Goodell's and Chadwick's signs should be present and are considered a normal finding. Increased vaginal secretions are normal during pregnancy as a result of increased vascularity. PTS: 1 DIF: Cognitive Level: Application REF: 111 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

30. Which physiologic finding is consistent with normal pregnancy? a. Systemic vascular resistance increases as blood pressure decreases. b. Cardiac output increases during pregnancy. c. Blood pressure remains consistent independent of position changes. d. Maternal vasoconstriction occurs in response to increased metabolism.

ANS: B Cardiac output increases during pregnancy as a result of increased stroke volume and heart rate. Systemic vascular resistance decreases while blood pressure remains the same. Maternal blood pressure changes in response to client positioning. In response to increased metabolism, maternal vasodilation is seen during pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 96 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

13. Which advice to the client is one of the most effective methods for preventing venous stasis? a. Sit with the legs crossed. b. Rest often with the feet elevated. c. Sleep with the foot of the bed elevated. d. Wear elastic stockings in the afternoon.

ANS: B Elevating the feet and legs improves venous return and prevents venous stasis. Sitting with the legs crossed will decrease circulation in the legs and increase venous stasis. Elevating the legs at night may cause pressure on the diaphragm and increase breathing problems. Elastic stockings should be applied before lowering the legs in the morning. PTS: 1 DIF: Cognitive Level: Application REF: 119 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

48. The nurse is scheduling the next appointment for a healthy primigravida currently at 28 weeks gestation. When will the nurse schedule the next prenatal visit? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks

ANS: B From 29 to 36 weeks, routine prenatal assessment is every 2 weeks. If the pregnancy is high risk, the patient will see the health care provider more frequently. PTS: 1 DIF: Cognitive Level: Understanding REF: 106 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

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

ANS: B Increasing estrogen levels during pregnancy can affect the respiratory tract passages, leading to increased vascular responses that manifest as coldlike symptoms. Progesterone, as the hormone of pregnancy, maintains the pregnancy and does not have any direct effects on the maternal respiratory passages. Although it is possible for a client to develop allergies based on exposure to antigen triggers, it is not typically associated with pregnancy states. An increase in fluid may lead to potential edema, but it is not associated with coldlike symptoms. PTS: 1 DIF: Cognitive Level: Analysis REF: 97 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

12. A client in her first trimester complains of nausea and vomiting. She asks, "Why does this happen?" What is the nurse's best response? a. "It is due to an increase in gastric motility." b. "It may be due to changes in hormones." c. "It is related to an increase in glucose levels." d. "It is caused by a decrease in gastric secretions."

ANS: B Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause of nausea and vomiting. PTS: 1 DIF: Cognitive Level: Application REF: 113 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

38. Use Nägele's rule to determine the EDD (estimated day of birth) for a client whose last menstrual period started on April 12. a. February 19 b. January 19 c. January 21 d. February 7

ANS: B Nägele's rule subtracts 3 months from the month of the last menstrual period (month 4 month - 3 = January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days = April 19), so the correct answer is January 19. PTS: 1 DIF: Cognitive Level: Application REF: 107 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

26. When the pregnant woman develops changes caused by pregnancy, the nurse recognizes that the darkly pigmented vertical midabdominal line is the: a. epulis. b. linea nigra. c. melasma. d. striae gravidarum.

ANS: B The linea nigra is a dark pigmented line from the fundus to the symphysis pubis. Epulis refers to gingival hypertrophy. Melasma is a different kind of dark pigmentation that occurs on the face. Striae gravidarum (stretch marks) are a different kind of line caused by lineal tears that occur in connective tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: 99 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

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

ANS: B The patient is experiencing classic signs of physiologic anemia, or an increase in the amount of plasma resulting in a dilution of circulating red blood cells (RBCs). Red blood cell production will continue to increase throughout pregnancy, with a resulting resolution in physiologic anemia. The health care provider will likely order a complete blood count to verify this. The anemia is physiologic and not chronic because there is no decrease in circulating RBCs. The absence of proteinuria and glucosuria is reassuring, but these findings are not correlated with fatigue. Adequate fluid volume intake is essential in pregnancy but is not responsible for the development of physiologic anemia or the corresponding fatigue. PTS: 1 DIF: Cognitive Level: Analysis REF: 95, 96 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

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

ANS: B To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 3 months (March 10), and adds 7 days (March 17). April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of adding 7 days. March is the correct month, but instead of adding 7 days, 17 days were added. April 17 is subtracting 2 months instead of 3. PTS: 1 DIF: Cognitive Level: Understanding REF: 107 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

35. Which of these findings would indicate a potential complication related to renal function during pregnancy? a. Increase in glomerular filtration rate (GFR) b. Increase in serum creatinine level c. Decrease in blood urea nitrogen (BUN) d. Mild proteinuria

ANS: B With pregnancy, one would expect the serum creatinine and BUN levels to decrease. An elevation in the serum creatinine level should be investigated. With pregnancy, the GFR increases because of increased renal blood flow and is thus a normal expected finding. A decrease in the blood urea nitrogen level and mild proteinuria are expected findings in pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 98 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

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

ANS: C At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks' gestation is located at the level of the umbilicus. Lightening has not yet occurred. At 20 weeks, the uterus should be at the umbilical level. The descent of the fetal head (lightening) occurs in late pregnancy. Waiting until the next appointment avoids the direct question and might increase the anxiety of the mother and grandmother. PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

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

ANS: C Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension. PTS: 1 DIF: Cognitive Level: Analysis REF: 96 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

17. A client, gravida 2, para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is palpated 3 cm below the umbilicus. This finding is: a. appropriate for gestational age. b. a sign of impending complications. c. lower than normal for gestational age. d. higher than normal for gestational age.

ANS: C By 20 weeks, the fundus should reach the umbilicus. The fundus should be at the umbilicus at 20 weeks, so 3 cm below the umbilicus is an inappropriate height and needs further assessment. This is lower than expected at this date. It may be a complication, but it may also be because of incorrect dating of the pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. A gravida client at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include? a. Palpation of the lumbar spine b. Exercise pattern and duration c. Observation of posture and body mechanics d. Ability to sleep for at least 6 hours uninterrupted

ANS: C Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis. Pregnancy should not cause alterations in the spine. Any assessment for malformation should be done early in pregnancy. Certain exercises can help relieve back pain. Rest is important for well-being, but the main concern with back pain is to assess posture and body mechanics. PTS: 1 DIF: Cognitive Level: Application REF: 113 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

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

ANS: C Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the cervix, vagina, and labia, called Chadwick's sign. Softening of the cervix is Goodell's sign. Chadwick's sign is a probable sign of pregnancy. The softening of the lower segment of the uterus is Hegar's sign, which can allow the uterus to be flexed against the cervix. PTS: 1 DIF: Cognitive Level: Application REF: 102 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

42. The client with an IUD has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action? a. A therapeutic abortion will need to be scheduled because fetal damage is inevitable. b. Hormonal analyses will be done to determine the underlying cause of the false-positive test result. c. The IUD will need to be removed to avoid complications such as miscarriage or infection. d. The IUD will need to remain in place to avoid injuring the fetus.

ANS: C Pregnancy with an intrauterine device (IUD) in place is unusual but it can occur and cause complications such as spontaneous abortion and infection. A therapeutic abortion is not indicated unless infection occurs. PTS: 1 DIF: Cognitive Level: Understanding REF: 107 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

29. What is the best explanation that you can provide to a pregnant client who is concerned that she has "pseudoanemia" of pregnancy? a. Have her write down her concerns and tell her that you will ask the physician to respond once the lab results have been evaluated. b. Tell her that this is a benign self-limiting condition that can be easily corrected by switching to a high-iron diet. c. Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition. d. Contact the physician and get a prescription for iron pills to correct this condition.

ANS: C Providing factual information based on physiologic mechanisms is the best option. Although having the client write down her concerns is reasonable, the nurse should not refer this conversation to the physician but rather address the client's specific concerns. Switching to a high-iron diet will not correct this condition. This physiologic pattern occurs during pregnancy as a result of hemodilution from excess blood volume. Iron medication is not indicated for correction of this condition. There is no need to contact the physician for a prescription. PTS: 1 DIF: Cognitive Level: Application REF: 95 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

43. The health care provider reports that the primigravida's fundus can be palpated at the umbilicus. Which priority question will the nurse include in the client's assessment? a. "Have you noticed that it is easier for you to breathe now?" b. "Would you like to hear the baby's heartbeat for the first time?" c. "Have you felt a fluttering sensation in your lower pelvic area yet?" d. "Have you recently developed any unusual cravings, such as for chalk or dirt?"

ANS: C Quickening is the first maternal sensation of fetal movement and is often described as a fluttering sensation. Quickening is detected at approximately 20 weeks in the primigravida and as early as 16 weeks in the multigravida. The fundus is at the umbilicus at 20 weeks' gestation. Lightening is associated with descent of the fetal head into the maternal pelvis and is associated with improved lung expansion. Lightening occurs approximately 2 weeks before birth in the primipara. Fetal heart tones can be detected by Doppler as early as 9 to 12 weeks of gestation. Pica is the craving for non-nutritive substances such as chalk, dirt, clay, or sand. It can develop at any time during pregnancy. It can be associated with malnutrition and the health care provider should monitor the client's hematocrit/hemoglobin, zinc, and iron levels. PTS: 1 DIF: Cognitive Level: Synthesizing REF: 112 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

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

ANS: C She has had four pregnancies, including the current one (gravida 4). She had two pregnancies that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she is classified as a gravida 4. Gravida 4 is correct, but she is para 2; the pregnancy that was terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she would be classified as a gravida 4, not 3. PTS: 1 DIF: Cognitive Level: Analysis REF: 106 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

15. Which is the gravida and para for a client who delivered triplets 2 years ago and is now pregnant again? a. 2, 3 b. 1, 2 c. 2, 1 d. 1, 3

ANS: C She has had two pregnancies (gravida 2); para refers to the outcome of the pregnancy rather than the number of infants from that pregnancy. She is pregnant now, so that would make her a gravida 2. She is para 1 because she had one pregnancy that progressed to the age of viability. PTS: 1 DIF: Cognitive Level: Analysis REF: 106 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

32. A pregnant client complains of frequent heartburn. The client states that she has never had these symptoms before and wonders why this is occurring now. The best response that the nurse can provide is: a. examine her dietary intake pattern and tell her to avoid certain foods. b. tell her that this is a normal finding during early pregnancy and will resolve as she gets closer to term. c. explain to the client that physiologic changes caused by the pregnancy make her more likely to experience these types of symptoms. d. refer her to her health care provider for additional testing because this is an abnormal finding.

ANS: C The presentation of heartburn is a normal abnormal finding that can occur in pregnant woman because of relaxation of the lower esophageal sphincter as a result of the physiologic effects of pregnancy. Although foods may contribute to the heartburn, the client is asking why this presentation is occurring, so the nurse should address the cause first. It is independent of gestation. There is no need to refer to the physician at this time because this is a normal abnormal finding. There is no evidence of complications ensuing from this presentation. PTS: 1 DIF: Cognitive Level: Analysis REF: 113 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

6. What is the reason for vascular volume increasing by 40% to 60% during pregnancy? a. Prevents maternal and fetal dehydration b. Eliminates metabolic wastes of the mother c. Provides adequate perfusion of the placenta d. Compensates for decreased renal plasma flow

ANS: C The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

7. Physiologic anemia often occurs during pregnancy because of: a. inadequate intake of iron. b. the fetus establishing iron stores. c. dilution of hemoglobin concentration. d. decreased production of erythrocytes.

ANS: C When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 95 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

27. When documenting a client encounter, what term will the nurse use to describe the woman who is in the 28th week of her first pregnancy? a. Multigravida b. Multipara c. Nullipara d. Primigravida

ANS: D A primigravida is a woman pregnant for the first time. A multigravida has been pregnant more than once. A nullipara is a woman who has never been pregnant or has not completed a pregnancy of 20 weeks or more. A primipara has delivered one pregnancy of at least 20 weeks. A multipara has delivered two or more pregnancies of at least 20 weeks. PTS: 1 DIF: Cognitive Level: Knowledge REF: 106 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

4. Which suggestion is appropriate for the pregnant client who is experiencing heartburn? a. Drink plenty of fluids at bedtime. b. Eat only three meals a day so the stomach is empty between meals. c. Drink coffee or orange juice immediately on arising in the morning. d. Use Tums or Alkamints to obtain relief, as directed by the health care provider.

ANS: D Antacids high in calcium (e.g., Tums, Alkamints) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the woman to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach. PTS: 1 DIF: Cognitive Level: Understanding REF: 114 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

3. A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider? a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. b. These conditions are abnormal. Refer the client to an ear, nose, and throat specialist. c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.

ANS: D As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy. Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone levels increase during pregnancy. The client should be reassured that these symptoms are within normal limits. No referral is needed at this time. Relaxation of the smooth muscles in the respiratory tract is affected by progesterone. PTS: 1 DIF: Cognitive Level: Analysis REF: 97 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

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

ANS: D Because this is a prenatal history, the client is pregnant. Gravida is the number of times the uterus has been pregnant, which in this case is three. The patient reported one Term birth, noPreterm births, one Abortion or miscarriage, and presumably one Live child. PTS: 1 DIF: Cognitive Level: Application REF: 106 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

22. A client in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse give about safe travel during pregnancy? a. "Only travel by car during pregnancy." b. "Avoid use of the seat belt during the third trimester." c. "You can travel by plane until your 38th week of gestation." d. "If you are traveling by car stop to walk every 1 to 2 hours."

ANS: D Car travel is safe during normal pregnancies. Suggest that the woman stop to walk every 1 to 2 hours so she can empty her bladder. Walking also helps decrease the risk of thrombosis that is elevated during pregnancy. Seat belts should be worn throughout the pregnancy. Instruct the woman to fasten the seat belt snugly, with the lap belt under her abdomen and across her thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her uterus. Travel by plane is generally safe up to 36 weeks if there are no complications of the pregnancy, so only travelling by car is an inaccurate statement. PTS: 1 DIF: Cognitive Level: Application REF: 119 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

33. Which physiologic event may lead to increased constipation during pregnancy? a. Increased emptying time in the intestines b. Abdominal distention and bloating c. Decreased absorption of water d. Decreased motility in the intestines

ANS: D Decreased motility in the intestines leading to increased water absorption would cause constipation. Increased emptying time in the intestines leads to increased nutrient absorption. Abdominal distention and bloating are a result of increased emptying time in the intestines. Decreased absorption of water would not cause constipation. PTS: 1 DIF: Cognitive Level: Application REF: 98 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

36. A pregnant client notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products as a cleansing solution or makeup. What would the priority nursing intervention be in response to this situation? a. Refer the client to a dermatologist for further examination. b. Ask the client if she has been eating different types of foods. c. Take a culture swab and send to the lab for culture and sensitivity (C&S). d. Let the client know that this is a common finding that occurs during pregnancy.

ANS: D This condition is known as chloasma or melasma (mask of pregnancy) and is a result of pigmentation changes relative to hormones. It can be exacerbated by exposure to the sun. There is no need to refer to a dermatologist. Intake of foods is not associated with exacerbation of this process. There is no need for a C&S to be taken. The client should be assured that this is a normal finding of pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 98 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

23. The client has just learned she is pregnant and overhears the gynecologist saying that she has a positive Chadwick's sign. When the client asks the nurse what this means, how should the nurse respond? a. "Chadwick's sign signifies an increased risk of blood clots in pregnant women because of a congestion of blood." b. "That sign means the cervix has softened as the result of tissue changes that naturally occur with pregnancy." c. "This means that a mucous plug has formed in the cervical canal to help protect you from uterine infection." d. "This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix."

ANS: D Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Although Chadwick's sign occurs with hyperemia (congestion with blood), the sign does not signify an increased risk of blood clots. The softening of the cervix is called Goodell's sign, not Chadwick's sign. Although the formation of a mucous plug protects from infection, it is not called Chadwick's sign. PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

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

ANS: D Nägele's rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and adding 7 days. The incorrect responses add months instead of subtracting months and subtract days instead of adding days. PTS: 1 DIF: Cognitive Level: Analysis REF: 107 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

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

ANS: D Nägele's rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and then adding 7 days. PTS: 1 DIF: Cognitive Level: Understanding REF: 107 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

39. Which of the client health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy? a. Sexual intercourse two or three times weekly b. Moderate exercise for 30 minutes daily c. Working 40 hours a week as a secretary in a travel agency d. Relaxing in a hot tub for 30 minutes a day, several days a week

ANS: D Pregnant women should avoid activities that might cause hyperthermia. Maternal hyperthermia, particularly during the first trimester, may be associated with fetal anomalies. She should not be in a hot tub for more than 10 minutes at less than 100° F. Sexual intercourse is generally safe for the healthy pregnant woman; moderate exercise during pregnancy can strengthen muscles, reduce backache and stress, and provide a feeling of well-being; working during pregnancy is acceptable as long as the woman is not continually on her feet or exposed to environmental toxins and industrial hazards. PTS: 1 DIF: Cognitive Level: Analysis REF: 118 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

34. Which physiologic findings are seen with respect to gallbladder function that might lead to the development of gallstones during pregnancy? a. Decrease in alkaline phosphatase levels compared with nonpregnant women b. Increase in albumin and total protein as a result of hemodilution c. Hypertonicity of gallbladder tissue d. Prolonged emptying time

ANS: D Prolonged emptying time is seen during pregnancy and may lead to the development of gallstones. In pregnancy, there is a twofold to fourfold time increase in alkaline phosphatase levels as compared with those in nonpregnant woman. During pregnancy, a decrease in albumin level and total protein are seen as a result of hemodilution. Gallbladder tissue becomes hypotonic during pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 98 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

8. Which is a positive sign of pregnancy? a. Amenorrhea b. Breast changes c. Fetal movement felt by the woman d. Visualization of fetus by ultrasound

ANS: D The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 105 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

45. A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all of the time. The patient's urine test is positive for hCG. What is the best nursing action related to this information? a. Ask the patient if she has had any nausea or vomiting in the morning. b. Schedule the patient to be seen by a health care provider within the next 4 weeks. c. Send the patient to the maternity screening area of the clinic for a routine ultrasound. d. Determine if there are any factors that might prohibit her from seeking medical care.

ANS: D The patient has presumptive and probable indications of pregnancy. However, she has not sought out health care until late in the first or early in the second trimester. The nurse must assess for barriers to seeking health care, physical or emotional, because regular prenatal care is key to a positive pregnancy outcome. Asking if the patient has nausea or vomiting will only add to the list of presumptive signs of pregnancy, and this information will not add to the assessment data to determine whether the client is pregnant. The patient needs to see a health care provider before the next 4 weeks because she is late in seeking early prenatal care. Ultrasounds must be prescribed by a health care provider and ordering one is not in the nurse's scope of practice. PTS: 1 DIF: Cognitive Level: Analysis REF: 102 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

37. Determine the obstetric history of a client in her fifth pregnancy who had two spontaneous abortions in the first trimester, one infant at 32 weeks' gestation, and one infant at 38 weeks' gestation. a. G5 T1 P2 A2 L 2 b. G5 T1 P1 A1 L2 c. G5 T0 P2 A2 L2 d. G5 T1 P1 A2 L2

ANS: D This client is in her fifth pregnancy, which is G5, she had one viable term infant (between 38 and 42 weeks' gestation), which is T1, she had one viable preterm infant (between 20 and 37 weeks' gestation), which is P1, two spontaneous abortions (before 20 weeks' gestation), which is A2, and she has two living children, which is L2. PTS: 1 DIF: Cognitive Level: Application REF: 107 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

11. Why should a woman in her first trimester of pregnancy expect to visit her health care provider every 4 weeks? a. Problems can be eliminated. b. She develops trust in the health care team. c. Her questions about labor can be answered. d. The conditions of the expectant mother and fetus can be monitored.

ANS: D This routine allows for monitoring maternal health and fetal growth and ensures that problems will be identified early. All problems cannot be eliminated because of prenatal visits, but they can be identified. Developing a trusting relationship should be established during these visits, but that is not the primary reason. Most women do not have questions concerning labor until the last trimester of the pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 112 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions? a. These contractions may indicate preterm labor. b. These are contractions that never cause any discomfort. c. Braxton Hicks contractions only start during the third trimester. d. These occur throughout pregnancy, but you may not feel them until the third trimester.

ANS: D Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance