Maternal Chapters Questions.
A pregnant patient comes into the clinic complaining of constipation. Which statement by the patient indicates the need for further teaching? "I need to drink 8 to 10 glasses of water a day." "I can stop taking my vitamins if I have hemorrhoids." "I need to increase the amount of fiber in my diet." "I am walking around the block every day.
"I can stop taking my vitamins if I have hemorrhoids." · Hemorrhoids are a result of constipation that can occur during pregnancy as a result of the increased amount of iron in the prenatal vitamins. Fluid, fiber, and exercise are beneficial in preventing constipation.
A pregnant patient asks the nurse about a darkened line that is seen on her abdomen. What would be the best response? "That is chloasma, the mask of pregnancy." "That is striae gravidarum, or more commonly known as stretch marks." "That is linea nigra, a darkened line from the pubis to the umbilicus, as a result of increased hormones." "That is spider nevi, a branched growth of dilated capillaries on the skin."
"That is linea nigra, a darkened line from the pubis to the umbilicus, as a result of increased hormones." · Linea nigra is a line that is midline of the abdomen from the pubis to the umbilicus that darkens during pregnancy as a result of an increased amount of hormones. Chloasma is the mask of pregnancy characterized by irregular darkening of the pigment of the cheeks, forehead, and nose. Striae gravidarum, or stretch marks, are reddish, wavy streaks that can appear on the thighs, abdomen, and breasts. Spider nevi are branched growth of dilated capillaries on the skin caused by increased blood flow resulting from high estrogen levels.
A pregnant patient comes to the clinic for a prenatal visit. At how many weeks' gestation would the patient need to be to hear fetal heart tones using a Doppler scan? 18 weeks 16 weeks 10 weeks 4 weeks
10 weeks · After 10 weeks, equipment, such as a Doppler scan, can be used to assess fetal heart tones. A fetoscope would be used later than 16 weeks.
While in the clinic, a first-time pregnant patient asks the nurse when she should be able to feel the fetus move. What is the nurse's best response? 14 to 16 weeks' gestation 6 to 8 weeks' gestation 8 to 10 weeks' gestation 10 to 12 weeks' gestation
14 to 16 weeks' gestation · Fetal movement, also called quickening, can be felt as early as 14 to 16 weeks' gestation. The movements are subtle at first, and gradually increase.
A nurse is collecting data on a patient who is 28 weeks pregnant. What would the nurse expect the fundal height to measure in centimeters? 20 cm 28 cm 32 cm 36 cm
28 cm · In the second and third trimesters, the measurement of fundal height in centimeters should equal the same as the fetus age in weeks ± 28 cm.
A patient has been admitted with preeclampsia. Following an assessment, the nurse notes the patient has edema of the face, hand, and abdomen. How would the nurse document this finding? 1+ 4+ 2+ 3+
3+ · Edema of the face, hands, sacrum, and abdomen is documented as 3+. Minimal edema on pedal and pretibial areas is documented as 1+. Obvious edema of the lower extremities is documented as 2+. Massive, generalized edema is documented as 4+.
What are the most appropriate patient problems for a breast-feeding mother? (Select all that apply.) Select all that apply. Anxiety related to lactation expectations Imbalanced nutrition: less than body requirements related to the demands during lactation Potential for infection related to dry, cracked nipples Ineffective health maintenance related to poor hygiene
A. Anxiety related to lactation expectations B. Imbalanced nutrition: less than body requirements related to the demands during lactation C. Potential for infection related to dry, cracked nipples
Which of the following maternal changes are presumptive signs of pregnancy? (Select all that apply.) Select all that apply. Breast changes Hegar sign Amenorrhea Fetal heart tones Chadwick sign
A. Breast changes C. Amenorrhea E. Chadwick sign
Which characteristics are indications of true labor? (Select all that apply.) Select all that apply. Contractions get stronger with ambulation. Contractions follow a regular pattern. Contractions may be felt in the back but are most often noticed in the fundus. Each contraction gets longer and longer. The cervix softens, effaces, and dilates.
A. Contractions get stronger with ambulation. B. Contractions follow a regular pattern.
The nurse teaches care of the umbilical cord to a new mother. What instruction will the nurse provide? Apply Vaseline to the cord stump several times a day to keep it moist until it comes off. Place the infant in warm bathwater to help the cord stump to soak off over the next 7 to 10 days. Apply alcohol on the cord stump daily to keep it dry until it falls off. Gently manipulate the cord stump side to side, until it loosens and can be easily removed.
Apply alcohol on the cord stump daily to keep it dry until it falls off. The cord stump needs to be kept dry, and applying alcohol daily will help keep the stump dry until it falls off. The cord stump needs to be kept dry; applying Vaseline will not accomplish this. The cord stump needs to be kept dry, so soaking is not appropriate. The cord stump should be allowed to fall off naturally by being kept dry.
A woman comes to the clinic for her first prenatal visit. The nurse asks when her first day of her last menstrual cycle was. The woman reports July 10, 2004. What would the nurse calculate her estimated date of delivery to be using the Naegele rule? April 3, 2005 April 17, 2005 March 3, 2005 March 17, 2005
April 17, 2005 · Using the Naegele rule, the nurse counts back 3 months from the first day of the last menstrual cycle and then adds 7 days. This results in April 17, 2005.
Which actions by the nursing mother will support milk production and promote infant comfort? (Select all that apply.) Select all that apply. Drink 2 to 3 alcoholic beverages per day. Consume more protein and approximately 1500 extra calories daily. Drink 8 to 10 glasses of fluids daily. Avoid spicy foods, chocolate, and onions. Continue her prenatal vitamins and minerals until they are gone.
B. Drink 8 to 10 glasses of fluids daily. C. Avoid spicy foods, chocolate, and onions. D. Continue her prenatal vitamins and minerals until they are gone.
What are the signs and symptoms of maternal hyperglycemia? (Select all that apply) Shakiness Frequent urination Disorientation Flushed hot skin Hunger Fatigue
B. Frequent urination D. Flushed hot skin F.Fatigue
Which physical signs and symptoms might the postpartum patient experience following delivery? (Select all that apply.) Select all that apply. A low-grade fever the first 48 hours after delivery Increased urination beginning 4 to 6 hours after delivery Bright red vaginal drainage that will saturate one pad every 15 minutes A normal bowel movement within 2 to 3 days Increased diaphoresis, most commonly at night
B. Increased urination beginning 4 to 6 hours after delivery D. A normal bowel movement within 2 to 3 days E. Increased diaphoresis, most commonly at night
In order for the fetus to move through the pelvis, it must go through the mechanisms of labor. Place the following mechanisms in order by number if the fetus is in the vertex position. a. Expulsion b. Extension c. Engagement d. Internal rotation e. Descent f. External rotation and restitution g. Flexion C, E, D, G, B, F, A C, E, G, D, B, F, A C, F, G, D, B, E, A C, E, G, D, B, A, F C, D, G, E, B, F, A E, C, G, D, B, F, A A, E, G, D, B, F, C
C, E, G, D, B, F, A
A pregnant patient comes to the hospital saying she thinks her water has broken. The nurse checks the fluid with Nitrazine test paper to determine if the fluid is amniotic fluid or vaginal secretions. What color will the nurse expect the paper to turn if the fluid is amniotic? Deep blue Yellow Olive-yellow Olive-green
Deep blue · The Nitrazine paper will turn blue-green (pH 6.5), blue-gray (pH 7.0), or deep blue (7.5) if the fluid is amniotic because it is slightly alkaline. Olive-green, olive-yellow, or yellow indicates that the fluid is acidic. Amniotic fluid is slightly alkaline.
A pregnant patient comes to the clinic for a prenatal visit. She complains of being frequently awakened at night by leg cramps. What instructions should the nurse give this patient? Have her spouse rub her leg until the cramp goes away. Walk around the room till the cramp goes away. Dorsiflex her foot when the cramp occurs. Plantar flex her foot when the cramp occurs.
Dorsiflex her foot when the cramp occurs. · Leg cramps often occur in pregnancy, possibly due to pressure on the pelvic blood vessels and nerves or altered calcium and phosphorus. Dorsiflexion of the foot may help reduce these cramps. Plantar flexing the foot will not relieve pressure on the pelvic blood vessels or nerves. Rubbing her leg will not relieve pressure on the pelvic blood vessels or nerves. Walking around the room will not relieve pressure on the pelvic blood vessels or nerves.
What is the term for shortening and thinning of the cervix during the first stage of labor? Contractions Scarring Dilation Effacement
Effacement · Effacement is the process of shortening and thinning of the cervix. Effacement is complete when only a thin edge can be palpated. Dilation is the process of the cervix and cervical canal enlarging and widening of the cervical opening. Contractions are tightening of the pregnant uterus that can be regular or irregular and cause the progression of dilation and effacement. Scarring is the result of a prior infection or surgery of the cervix and may slow cervical dilation.
The nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse? Ignore this as it is common after childbirth. Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming." Assess the new mother for pain and offer analgesics as ordered. Inform the chaplain for spiritual counseling as the patient is rejecting her infant.
Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming." Often new mothers feel overwhelmed; allowing them time to discuss their feelings and fears will help promote bonding with their children. Further assessment needs to be done to determine if there is a spiritual problem and a need for the chaplain to be contacted. The signs of rejection are not the same as the signs of pain; thus, further assessment would need to be done. This is not a normal experience after childbirth, so ignoring it would be inappropriate
The father's behavior when introduced to his new baby is typically an intense fascination. What is this behavior considered? Taking-in Enforcement Bonding Engrossment
Engrossment A new father's behavior of typical intense fascination is called engrossment. Bonding is also known as parent-child attachment, but is not limited to the father. Enforcement or taking-in does not refer to the father's fascination with his new baby.
When assessing cultural preferences of a laboring patient, the nurse remembers to ask about traditional birth practices. Which birth practice is most common in non-American cultures? Father is not present Bury the placenta Stoic about pain Father and female relatives present
Father is not present · In southeast Asia, Laos, India, and Iran, the most common practice is that the father is not present during the birth of a child. Stoicism about the pain of childbirth is unique to the culture of Mexico. Burying the placenta for good luck is unique to cultures of American Indians. Having both the father and female relatives present at birth is unique to the culture of Mexico.
During a postpartum check, the nurse assesses the new mother's uterus and notes it to be boggy. What is the nurse's first intervention? Gently massage the fundus to increase contractility. Direct the patient to assume a lateral position with her upper leg drawn toward the chest. Contact the health care provider for an oxytocic medication. Instruct the patient to void.
Gently massage the fundus to increase contractility. Gently massaging the fundus will increase the contractility of the uterus, decreasing the risk for uterine hemorrhage. Contacting the health care provider for medication would occur if the nurse could not get the fundus to firm backup. The nurse should have instructed the patient to void before assessing the fundus. This is how the nurse would assess the perineum and rectum, not the fundus.
Based on the definitions of gravida and para, what documentation best describes a woman in the clinic who is currently pregnant and has had two prior children? Gravida III, para II Gravida I, para I Gravida II, para II Gravida II, para I
Gravida III, para II · Gravida is a term used for number of times a woman has been pregnant. Para is a term that denotes the number of births. This patient would be gravida III and para II.
A nurse is writing a care plan for a diagnosis of imbalanced nutrition: less than body requirements. What is the most common nutrition-related discomfort of pregnancy? Spontaneous abortion Hyperemesis gravidarum Ectopic pregnancy Multifetal pregnancy
Hyperemesis gravidarum · Hyperemesis gravidarum is one of the most common nutrition-related discomforts of pregnancy, because of the lack of fluid and food intake leading to metabolic problems. Lack of fluid and food intake during pregnancy can lead to metabolic problems but is not related to spontaneous abortion. An ectopic pregnancy is when the fertilized ovum implants outside the uterus. This is not related to a lack of fluid or food intake during pregnancy. A multifetal pregnancy involves more than one fetus in the uterus. It is not related to a lack of fluid or food intake during pregnancy.
A new mother reports feeling weak, light-headed, and being sick to her stomach. The LPN/LVN also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy. The pulse is 110 beats/min and the blood pressure is 80/60. What complication do these symptoms indicate? Puerperal infection Pregnancy-induced hypertension Preeclampsia Hypovolemic shock
Hypovolemic shock The identified signs and symptoms show the patient to be going into hypovolemic shock. A patient with a puerperal infection would have a temperature of 100.4° F or higher on 2 successive days during the first 10 days after delivery. This patient's skin is cool. Pregnancy-induced hypertension occurs during pregnancy. This patient has already given birth. Preeclampsia is an abnormal condition of pregnancy characterized by the onset of acute hypertension after the 24th week of gestation. This patient has already given birth.
A patient who is 9 weeks pregnant comes to the hospital complaining of vaginal bleeding. An ultrasound reveals no heartbeat or uterine growth. The patient is to be scheduled for a D & C. What type of abortion is this? Threatened spontaneous abortion Complete spontaneous abortion Inevitable spontaneous abortion Incomplete spontaneous abortion
Incomplete spontaneous abortion · Incomplete spontaneous abortion is the termination of pregnancy before 20 weeks and some, but not all, of the products of conception are expelled. Threatened spontaneous abortion is unexplained bleeding and cramping. The fetus may or may not be alive. Membranes remain intact and the cervical os remains closed. Inevitable spontaneous abortion is when bleeding increases and the cervical os begins to dilate. Membranes may rupture. Complete spontaneous abortion is when all the product of conception is expelled from the uterus.
The health care provider is performing the Leopold maneuver on a laboring patient to check for fetal position. What is the most common position for delivery? ROA ROP LOA LOP
LOA · LOA stands for left occipitoanterior, the most common position for delivery. ROP stands for right occipitoposterior. It is not the most common position for delivery. ROA stands for right occipitoanterior. It is the second most common position for delivery. LOP stands for left occipitoposterior. It is not the most common position for delivery.
While assessing a laboring patient, which fetal heart tone (FHT) would the nurse consider cause for further or constant monitoring? FHT at 136 beats/min Late deceleration Early deceleration Accelerations
Late deceleration · Late decelerations are an indication that there may be uteroplacental insufficiency. The fetus may not be getting enough oxygen. Constant monitoring will be needed to make sure the fetal heart tones do not decrease to the point of demise. Early decelerations are an indication of head compression. Accelerations are not a characteristic of FHTs. This is a normal count for FHTs.
The nurse is caring for a patient in labor. While assessing the patient's vital signs, the nurse notes a drop in the patient's blood pressure. To prevent supine hypotension, the nurse should encourage the patient to be in what position? Trendelenburg Supine Left lateral side lying Right lateral side lying
Left lateral side lying · A left lateral side-lying position helps reduce pressure on the maternal vessels and prevents their compression. The Trendelenburg's position or supine position will not relieve the pressure the uterus puts on the aorta and vena cava. The right lateral side-lying position will not relieve the pressure the uterus puts on the aorta and vena cava.
When a pregnant patient is being monitored for preeclampsia, fetal condition is also monitored. If the health care provider requests a kick count, how many counts per hour would be considered to be a concern? 6 to 8 counts per hour 4 to 6 counts per hour Less than 3 counts per hour 10 counts per hour
Less than 3 counts per hour · Fetal activity decreases if hypoxia develops; therefore, fetal activity less than 3 counts per hour is considered serious and needs to be reported.
After delivery, a newborn is classified according to weight at any given gestational age. What would a newborn weighing 2500 g or less be classified as? Low birth weight (LBW) Appropriate for gestational age (AGA) Small for gestational age (SGA) Large for gestational age (LGA)
Low birth weight (LBW) · At birth, an infant who weighs 2500 g or less is classified as LBW. LGA is weight above the 90th percentile. SGA is weight below the 10th percentile. AGA is weight between the 10th and 90th percentiles.
When does Rh incompatibility occur? Only when the mother is Rh positive and the fetus is Rh positive. Only when the mother is Rh negative and the fetus is Rh positive. Only when the mother is Rh negative and the fetus is Rh negative. Only when the mother is Rh positive and the fetus is Rh negative.
Only When the mother is Rh negative and the fetus is Rh positive Rh incompatibility occurs only when the mother is Rh negative and the fetus is Rh positive; this happens when the father of the fetus is Rh positive.
The laboring patient has just had membranes ruptured by the health care provider. The amniotic fluid is greenish-brown in color. What does this abnormal finding indicate? Fetal hemolytic disease Intrauterine infection Passage of meconium stool by the fetus Premature separation of the placenta
Passage of meconium stool by the fetus · The greenish-brown color of amniotic fluid is an indication of the passage of meconium stool by the fetus that can lead to hypoxic episodes in the fetus. Premature separation of the placenta would have port wine-colored amniotic fluid. Intrauterine infection is characterized by thick, cloudy, foul-smelling amniotic fluid. Yellow-stained amniotic fluid is an indication of fetal hemolytic disease or an intrauterine infection.
A pregnant patient complains of having to go to the bathroom frequently and sometimes even has stress incontinence. What can the nurse teach the patient to do to increase the tone of the perineum muscles? Perform pelvic tilt exercises. Wear an abdominal support. Perform Kegel exercises. Avoid waiting so long to go to the bathroom.
Perform Kegel exercises. · Kegel exercises can be taught to help tone the muscles of the perineum and help prevent stress incontinence. To be effective, the exercises need to be performed several times a day. Pelvic tilt exercises do not affect the tone of the perineal muscles. Wearing an abdominal support or frequent elimination will not increase perineal muscle tone.
The vital signs of a newborn baby girl are: T—97.9, P—140, R—34 with brief periods of apnea, and B/P—80/40 with an increase in systolic pressure when crying. What is the nurse's next intervention? Notify the health care provider, because the baby's heart rate reveals tachycardia. Realize these vital signs are normal for a newborn and document the data on the flow sheet. Assess lung sounds due to a high respiratory rate with apnea. Check the baby's blood glucose level as her temperature is low for a newborn
Realize these vital signs are normal for a newborn and document the data on the flow sheet. The baby's vital signs fall within the normal ranges for a newborn; therefore, the nurse would document the data. The heart rate would need to be greater than 140 beats/min to be considered tachycardia. The respiratory rate would need to be greater than 60 breaths/min to be considered abnormal. A newborn with a temperature less than 97.4 would be assessed for hypoglycemia.
A patient delivered her infant 36 hours ago. She is sitting in bed when she feels a gush of warm fluid between her legs. She calls the nurse, who finds her bleeding. This is an example of late postpartum hemorrhage. What is the most common cause of late postpartum hemorrhage? Retained placenta Laceration of the perineum Uterine atony Retained fragments of the placent
Retained fragments of the placenta · The most common cause of late postpartum hemorrhage is retained fragments of the placenta. Uterine atony, a retained placenta, and laceration of the perineum are common causes of early postpartum hemorrhage.
A patient with a family history of pregnancy-induced hypertension (PIH) asks the nurse if there is a cure. What information will the nurse give to this patient? Termination of the pregnancy Medication Increased fluids Bed rest
Termination of the pregnancy · The only known cure for PIH is the termination of the pregnancy.
When the delivery of the placenta is complete, which stage of labor is complete? Fourth stage Third stage First stage Second stage
Third stage · The delivery of the placenta completes the third stage of delivery, lasting approximately 5 to 20 minutes. The first stage of labor ends with the complete dilation of the cervix. The second stage of labor ends with the birth of the baby. The fourth stage of labor ends when the mother's vital signs are observed to be within normal ranges 2 to 4 hours after the birth.
The nurse is instructing a new mother about treatment for mastitis. Which statement by the patient indicates the need for further teaching? "I can take analgesics and apply ice packs for the pain." "I need to notify my health care provider I have a fever of 101.1 or higher." "I need to finish all the antibiotics as prescribed." "I will need to stop breast-feeding until the infection is gone."
"I will need to stop breast-feeding until the infection is gone." · The patient will need to continue breast-feeding or use a breast pump to empty the breast and prevent milk stasis. The other statements indicate an understanding of mastitis by the patient.