Chapter 6: Maternal Adaptation during Pregnancy - ML5
D. positive pregnancy test
A client makes an appointment at the prenatal clinic because the client thinks the client might be pregnant. Which assessment would the nurse identify as a presumptive sign of pregnancy? A. cervical softening B. vagina violet in color C. amenorrhea D. positive pregnancy test
C. Have you been sexually active in the past 2 months? The client is presenting with presumptive or subjective symptoms of pregnancy. Given her symptoms and age, asking about sexual activity is the most appropriate question. Whether she is taking an oral contraceptive will not assist in identifying the cause of her symptoms. If she has vaginal itching, the underlying cause of her symptoms needs to be identified before treatment can be prescribed. Asking about family history is part of a comprehensive health history, but is not the priority based on the client's presentation.
A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client? A. Do you have vaginal itching? B. Are you taking oral contraceptives? C. Have you been sexually active in the past 2 months? D. Do you have a family history of breast cancer?
A. human chorionic gonadotropin The commonly used laboratory tests for pregnancy are based on the use of a venipuncture or a urine specimen to detect the presence of human chorionic gonadotropin (hCG), a hormone created by the chorionic villi of the placenta, in the urine or blood serum of the pregnant client. Because these tests are only accurate 95% to 98% of the time, positive results from these tests are considered probable rather than positive signs. The test does not evaluate the level of estrogen, progesterone, or follicle-stimulating hormone.
A client comes to the clinic and tells the nurse, "I think I might be pregnant." After completing the history and physical examination, the nurse obtains a blood specimen for pregnancy testing. When explaining this test to the client, which hormone will the nurse identify as being measured by this test? A. human chorionic gonadotropin B. progesterone C. follicle-stimulating hormone D. estrogen
B. "What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy." Braxton Hicks contractions are the painless, intermittent, "practice" contractions of pregnancy.
A client is about 16 weeks' pregnant and is concerned because she feels her "abdomen" contracting. She calls the primary care provider's office and speaks to the nurse. What is the nurse's most appropriate response to this client's concern? A. "You need to go to the emergency room right away." B. "What you are feeling are called Braxton Hicks contractions. They are considered practice contractions during pregnancy." C. "You need to come to the office to be examined." D. "You have nothing to be concerned about. I am sure you are not feeling contractions at this point in your pregnancy."
C. visualization of the fetus by ultrasound There are only three documented or positive signs of pregnancy: 1) demonstration of a fetal heart separate from the mother's, 2) fetal movements felt by an examiner, and 3) visualization of the fetus by ultrasound. The absence of a period is an example of a presumptive symptom, which is a symptom that, when taken as a single entity, could easily indicate other conditions. Laboratory tests of either urine or blood serum for human chorionic gonadotropin (hCG) are examples of probable signs of pregnancy, which are objective and so can be verified by an examiner.
A client who has just given a blood sample for pregnancy testing in the health care provider's office asks the nurse what method of confirming pregnancy is the most accurate. The nurse explains the difference between presumptive symptoms, probable signs, and positive signs. What should the nurse mention as an example of a positive sign, which may be used to diagnose pregnancy? A. laboratory test of a urine specimen for hCG B. laboratory test of a blood serum specimen for hCG C. visualization of the fetus by ultrasound D. absence of a period
B. presumptive The most common presumptive sign of pregnancy is a missed menstrual period, or amenorrhea. Other presumptive signs include nausea, fatigue, swollen, tender breasts, and frequent urination.
A client's menstrual period is two weeks late. She has been feeling tired and has had episodes of nausea in the morning. What classification of pregnancy symptoms is this client experiencing? A. probable B. presumptive C. positive D. no classification
A. The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. Slight bleeding after a pelvic exam in a pregnant woman is common due to the vascularity of her cervix during pregnancy. Suggesting a bleeding disorder is frightening and not substantiated by the data. Bleeding is not a normal finding during pregnancy and losing the mucus plug occurs at the end of pregnancy, just prior to labor.
A pregnant client at 24 weeks' gestation calls the clinic crying after a prenatal visit, where she had a pelvic exam. She states that she noticed blood on the tissue when she wiped after voiding. What initial statement by the nurse would explain this finding? A. The cervix is very vascular during pregnancy, so spotting after a pelvic exam is not unusual. B. She may have a bleeding disorder so she needs to come back to the clinic for blood work. C. It is possible she is losing her mucus plug, which can cause bloody show. D. Some bleeding during pregnancy is not uncommon and this finding is expected.
B. Congenital hypothyroidism Iodized sodium is needed by the body for normal thyroid function. Women with severe iodine deficiencies deliver infants with congenital hypothyroidism. Low birth weight is related to smoking and alcohol. Neural tube defects are caused by low folic acid levels. When vitamin A levels are too low, night blindness may occur.
A pregnant client is concerned she may develop preeclampsia, so she has stopped adding any salt to her food and is now questioning the nurse about avoiding prepared foods. The nurse should point out some salt is very beneficial and can help prevent which negative outcome for her baby? A. Neural tube defects B. Congenital hypothyroidism C. Night blindness D. Low birth weight
A. Hemorrhoids The displacement of the intestines and possible slowed motility of the intestines can lead to constipation in the pregnant woman. This, along with elevated venous pressure, can lead to development of hemorrhoids.
A pregnant mother may experience constipation and the increased pressure in the veins below the uterus can lead to development of what problem? A. Hemorrhoids B. Umbilical hernia C. Varicose veins D. Gastrointestinal reflux
C) When quickening occurs Quickening or feeling the baby move inside the body is a dramatic event and causes the pregnant woman's feelings about the pregnancy to change. Quickening occurs during the second trimester of the pregnancy, which is after the third but before the seventh month. Lightening occurs near the end of the pregnancy.
A pregnant patient tells the nurse that she is not happy to learn about the pregnancy. At which point in the pregnancy does the nurse realize that the patient will change her mind about the pregnancy? A) Around the third month B) After the seventh month C) When quickening occurs D) After lightening happens
C. He walks around furniture as if his abdomen is enlarged.
A pregnant woman's husband does not voice concerns at prenatal visits. Which observation would lead the nurse to suspect that the husband is emotionally involved in the pregnancy? A. He states he is concerned about the loss of his free time. B. He has refused to paint the baby's room blue. C. He walks around furniture as if his abdomen is enlarged. D. He states he definitely wants a girl.
B) Urinary frequency The client is in her first trimester and would most likely experience urinary frequency as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids would be more common during the later stages of pregnancy.
A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which of the following would the nurse include? A) Ankle edema B) Urinary frequency C) Backache D) Hemorrhoids
D. 2+ Protein in urine Explanation: During pregnancy, there may be a slight amount of glucose found in the urine due to the fact that the kidney tubules are not able to absorb as much glucose as there were before pregnancy. However, there should be minimal protein in the urine. A specific gravity of 1.010 and a straw- like color are both normal findings.
A urinalysis is done on a client in her third trimester. Which result would be considered abnormal? A. Trace of glucose B. Specific gravity of 1.010 C. Straw-like color D. 2+ Protein in urine
A. encourage her to identify someone that she can talk to and share the pregnancy experience. A pregnant woman without social support needs to identify someone with whom she can share the experience of pregnancy because social support is a crucial part of adapting to parenthood. Telling her to move home and telling her that she will feel better as the pregnancy progresses do not address the issue of isolation. Also, moving home may not be a possibility for this woman. The nurse should maintain a professional relationship and not commit to a long-term relationship with a client.
A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to: A. encourage her to identify someone that she can talk to and share the pregnancy experience. B. offer to meet with the client on a regular basis to provide her someone to talk to about her concerns. C. tell her to move home so her family will be nearby to help her. D. remind her that she is still early in the pregnancy and she will feel better about it as the pregnancy progresses.
B. at the level of the umbilicus The uterus, which starts as a pear-shaped organ, becomes ovoid as length increases over width. By 20 weeks' gestation, the fundus, or top of the uterus, is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy.
A woman is at 20 weeks' gestation. The nurse would expect to find the fundus at which area? A. midway between the umbilicus and xiphoid process B. at the level of the umbilicus C. midway between the pubis and umbilicus D. just above the symphysis pubis
C. Arrange for prenatal care if the test is positive. Explanation: Home pregnancy testing can be accurate as soon as a period is missed; it should not take the place of prenatal care.
A woman tells the nurse that she is going to use a home pregnancy test to determine whether she is pregnant. Which precautions should the nurse give her? A. Use a diluted urine specimen. B. Refrain from eating for 4 hours before testing. C. Arrange for prenatal care if the test is positive. D. Wait until after two missed menstrual periods.
B. 1 lb (0.45 kg) Explanation: The recommended weight gain pattern for a woman whose prepregnant weight is within the normal range would be 1 lb (0.45 kg) per week during the second and third trimesters. Underweight women should gain slightly more than 1 lb (0.45 kg) per week. Overweight women should gain about 2/3 lb (0.30 kg) per week.
A woman's prepregnant weight is within the normal range. During her second trimester, the nurse would determine that the woman is gaining the appropriate amount of weight when her weight increases by which amount per week? A. 2/3 lb (0.30 kg) B. 1 lb (0.45 kg) C. 1.5 lb (0.68 kg) D. 2 lb (0.90 kg)
D. 85 beats per minute. During pregnancy, heart rate increases by 10 to 15 beats per minute between 14 and 20 weeks of gestation, and this elevation persists to term. Therefore, a prepregnancy heart rate of 72 would increase by 10 to 15 beats per minute to a rate of 82 to 87 beats per minute.
Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks' pregnant. The nurse would expect this woman's heart rate to be approximately: A. 95 beats per minute. B. 100 beats per minute. C. 90 beats per minute. D. 85 beats per minute.
D. Hegar sign. Hegar sign refers to the softening of the lower uterine segment or isthmus. Bluish coloration of the cervix is termed Chadwick sign. Goodell sign refers to the softening of the cervix. Ortolani sign is a maneuver done to identify developmental dysplasia of the hip in infants.
During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as: A. Chadwick sign. B. Ortolani sign. C. Goodell sign. D. Hegar sign.
C. disturbed body image Explanation: The diagnosis of disturbed body image is the most appropriate because the client is equating the weight gain of pregnancy as being fat. The client may or may not have a knowledge deficit. There is no evidence to support the diagnosis of imbalanced nutrition. There is also no evidence to support that the client is experiencing powerlessness.
During an assessment, a client who is 5 months pregnant tells the nurse that she has to change her diet because she is just becoming too fat. Which nursing diagnosis should the nurse use to guide interventions for the client at this time? A. imbalanced nutrition B. powerlessness C. disturbed body image D. deficient knowledge
C. Both findings are normal at this point of the pregnancy. Explanation: A pregnant woman will normally experience a decrease in her blood pressure during the second trimester. An increase in the heart rate of 10 to 15 beats per minute on average is also normal, due to the increased blood volume and increased workload of other organ systems. Hormonal changes cause the blood vessels to dilate, leading to a lowering of blood pressure.
During an exam, the nurse notes that the blood pressure of a client at 22 weeks' gestation is lower, and her heart rate is 12 beats per minute higher than at her last visit. How should the nurse interpret these findings? A. The heart rate increase may indicate that the client is experiencing cardiac overload. B. The blood pressure should be higher since the cardiac volume is increased. C. Both findings are normal at this point of the pregnancy. D. Combined, both of these findings are very concerning and warrant further investigation.
A. Supine hypotension syndrome The left side-lying position prevents the heavy uterus from resting on and compressing her vena cava, a condition known as supine hypotensive syndrome. Compression of the vena cava can cause maternal hypotension and poor gas exchange between the placenta and fetus. Preeclampsia is a condition characterized by elevated blood pressure and proteinuria. Once diagnosed, the treatment includes resting in a left-lateral position, but a side-lying position does not prevent preeclampsia. Urinary frequency in the third trimester is due to the enlarged uterus pressing on the bladder and is not influenced by position. Remaining in an upright position for 1 to 2 hours after meals helps to decrease heartburn.
During late pregnancy, the nurse teaches a pregnant woman to lay on her left side to avoid what condition? A. Supine hypotension syndrome B. Frequent urination C. Preeclampsia D. Heartburn
B. Smoked salmon and bagels salmon and bagels Pregnant women should not eat refrigerated meats or smoked seafood unless it is part of a cooked dish. 6 ounces of white tuna, a well-cooked hot dog and a steak that is cooked thoroughly are all safe foods. A 17-year-old wo
In assessing the dietary intake over the last 24 hours of a pregnant client, which food would be most concerning to the nurse? A. Medium-well steak and a fresh salad B. Smoked salmon and bagels C. 6 oz of white tuna with crackers D. Cooked hot dog on a bun with mustard
A. melasma (chloasma) Melasma (chloasma), or "mask of pregnancy," is a blotchy brown discoloration on the face. In some women, a darkened line up the abdomen appears, which is called linea nigra. Striae gravidarum are "stretch marks. Melanotropin is the hormone responsible for melasma (chloasma).
Increased pigmentation on the face of some pregnant women is called: A. melasma (chloasma) B. striae gravidarum (stretch marks) C. melanotropin D. nigra
B, A, D, E, C Explanation: The correct sequence is amenorrhea, uterine enlargement, quickening, Braxton Hicks contractions, and labor.
Place the following events in the sequence the pregnant woman would experience them, from first to last. All options must be used. A. uterine enlargement B. amenorrhea c. labor d. quickening e. Braxton Hicks contractions
B. "I will add spinach to my salad every evening." Explanation: The client should be instructed to eat foods that are high in folic acid such as spinach, asparagus, and legumes. Adding spinach every day to the evening salad indicates that teaching about folic acid nutrition has been effective. Oranges, milk, cabbage, and cauliflower are not food items that will specifically influence the folic acid level.
The nurse instructs a pregnant client on the need to increase foods containing folic acid. Which client statement indicates that teaching has been effective? A. "I need to drink two glasses of milk each day." B. "I will add spinach to my salad every evening." C. "Cabbage and cauliflower are important for me to eat." D. "Eating an extra orange a day is important."
D. ultrasound picture of her fetus A positive sign of pregnancy is visualization of the fetus by ultrasound at 6+ weeks. Amenorrhea is a presumptive sign and can be caused by a variety of factors. Positive hCG in the blood and uterine growth are both probable signs but can be caused by hydatidiform or tumors.
The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant? A. continued amenorrhea B. positive hCG blood result C. uterine growth D. ultrasound picture of her fetus
B. "Many women feel this way during the first trimester." Explanation: The best response is to let the client know this is a common feeling among all pregnant women. Most women experience ambivalence during the first trimester whether the pregnancy was planned or not. Acceptance of the pregnancy commonly occurs during the second trimester when quickening, or feeling the baby move, occurs. However, it is not appropriate for the nurse to assume the client will become excited as each pregnancy is unique and a time of dramatic alterations. Stating not to worry and everything will be fine is nontherapeutic communication and does not focus on the client's concern. The nurse would discuss the client's feelings and concerns before making a referral.
The nurse is caring for a client at 8 weeks' gestation who states, "I did not plan for this right now and I am not happy or excited about this pregnancy. I am not sure what to do." Which response by the nurse is best? A. "You will become excited and happy when you feel the baby move." B. "Many women feel this way during the first trimester." C. "Do not worry. Once you hold this baby, everything will be fine." D. "We can refer you to a clinic for potential termination if you desire."
B. 300
The nurse is counseling a client with a BMI of 23 about weight gain during pregnancy. The nurse teaches the client that during the second and third trimester of pregnancy, dietary intake should be increase by how many calories per day above what she was eating prior to the pregnancy? A. 100 B. 300 C. 500 D. 1000
A. morning sickness C. breast changes D. amenorrhea Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). Probable signs are signs that appear in the first and early second trimesters, seen via objective criteria, but can also be indicators of other conditions (e.g., hydatidiform mole). Positive signs affirm that proof exists that there is a developing fetus in any trimester and are objective criteria seen by a trained observer or diagnostic study, (e.g., ultrasound.)
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply. A. morning sickness B. fetal heartbeat C. breast changes D. amenorrhea E.. ultrasound pictures F. hydatidiform mole
A. physical symptoms similar to the mother Explanation: Couvade syndrome is the occurrence of physical symptoms by the partner, similar to the physical symptoms of the mother. Other emotional symptoms may occur, but they are typically on a person-to-person basis.
The nurse is preparing to teach a community class to a group of first-time parents. Which information should the nurse include concerning what the pregnant woman's partner may experience as a normal response? A. physical symptoms similar to the mother B. no changes, only the mother has changes during pregnancy C. desire to be the woman and give birth D. feeling distanced from the mother
A. "I will need to take iron supplementation throughout my pregnancy even if I am not anemic." Explanation: Slight bleeding after a pelvic exam in a pregnant woman is common due to the vascularity of her cervix during pregnancy. Suggesting a bleeding disorder is frightening and not substantiated by the data. Bleeding is not a normal finding during pregnancy and losing the mucus plug occurs at the end of pregnancy, just prior to labor.
The nurse is teaching the pregnant woman about nutrition for herself and her baby. Which statement by the woman indicates that the teaching was effective? A. "I will need to take iron supplementation throughout my pregnancy even if I am not anemic." B. "I can eat any seafood that I like because it contains phosphorus, which is a nutrient that pregnant women need." C. "Milk production requires higher levels of calcium; therefore, if I am going to breastfeed, I must take a calcium supplement during pregnancy." D. "Because I am pregnant, I can eat anything I want and not worry about weight gain."
A. urinary frequency Explanation: Lightening refers to the descent of the fetal head into the pelvis and engagement. With this descent, pressure on the diaphragm decreases, easing breathing, but pressure on the bladder increases, leading to urinary frequency. Dysuria might indicate a urinary tract infection. Constipation may occur throughout pregnancy due to decreased peristalsis, but it is unrelated to lightening.
The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time? A. urinary frequency B. dysuria C. constipation D. dyspnea
D. Pregnant women often experience mood swings and self-centeredness but this is normal. During the first trimester of pregnancy, the woman often has mood swings, bouts of irritability and is hypersensitive. The partner needs to know that these are all normal behaviors for a pregnant woman.
The partner of a pregnant client in her first trimester asks the nurse about the client's behavior recently, stating that she is very moody, seems happy one moment and is crying the next and all she wants to talk about is herself. What response would correctly address these concerns? A. Her body is changing and she may be angry about it. B. What you are describing may be normal but we need to talk to her more in depth. C. Moodiness and irritability are not usual responses to pregnancy. D. Pregnant women often experience mood swings and self-centeredness but this is normal.
B. fetal movement felt by examiner The positive signs of pregnancy are fetal image on sonogram, hearing a fetal heart rate, and the examiner feeling fetal movement.
What is a positive sign of pregnancy? A. Hegar sign B. fetal movement felt by examiner C. positive pregnancy test D. uterine contractions
B) calcium deficiency Explanation: Calcium deficiency is a major concern for the pregnant woman who is lactose intolerant. There are several ways to address this concern. Some lactose-intolerant individuals are able to tolerate cooked forms of milk, such as pudding or custard. Cultured or fermented dairy products, such as buttermilk, yogurt, and some cheeses may also be tolerated. A chewable lactase tablet may be taken with milk. Lactase-treated milk is available in most supermarkets and may be helpful. Other options are to drink calcium-enriched orange juice or soy milk or to take a calcium supplement. If the woman is infrequently exposed to sunlight, she will need a vitamin D supplement (Marchiano & Ural, 2005).
What is the major concern for a lactose intolerant woman who is pregnant? A. vitamin D deficiency B. calcium deficiency C. nausea and vomiting D. dangerous symptom of abdominal cramping
A. The areolae become more prominent. C. Nasal congestion increases due to edema. D. Heart rate increases 10 to 15 beats per minute. Explanation: The pregnant uterus is globular shaped, not pear-shaped. The heart rate usually increases 10 to 15 beats per minute over the prepregnancy rate of 60 to 100 beats per minute. The respiratory rate is essentially unchanged. The areolae of the breasts become more prominent with a deepened pigmentation. Mothers report that they experience more nasal congestion during pregnancy that occurs secondary to edema found in the nasal passages.
What physical changes take place when a woman becomes pregnant? Select all that apply. A. The areolae become more prominent. B. The uterus becomes pear-shaped. C. Nasal congestion increases due to edema. D. Heart rate increases 10 to 15 beats per minute. E. Respiratory rate increases 20%.
C. pica craving Explanation: Pica is the persistent ingestion of nonfood substances, such as clay, laundry starch, freezer frost, or dirt. Pica is associated with iron-deficiency anemia, but it is unknown whether iron-deficiency is the cause or the result. Some women find that the cravings cease when they begin taking iron supplements (Mills, 2007). If you suspect or discover that a pregnant woman is practicing pica, tell the registered nurse (RN) or the practitioner immediately.
When a woman is pregnant she often craves specific things, like pickles or ice cream. There is one craving that is associated with iron deficiency anemia and should be reported to the registered nurse if it occurs. What is this craving called? A. chocolate mania B. lactose mania C. pica craving D. carnivorous craving
C. detect fetal heart sounds with a Doppler. Explanation: Fetal heart sounds are audible with a Doppler at 10 to 12 weeks' gestation but cannot be heard through a stethoscope until 18 to 20 weeks' gestation. Fetal movements can be felt by a woman as early as 16 weeks of pregnancy and felt by the examiner around 20 weeks' gestation. The fetal outline is also palpable around 20 weeks' gestation.
Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to: A. hear the fetal heartbeat with a stethoscope. B. feel fetal movements. C. detect fetal heart sounds with a Doppler. D. palpate the fetal outline.
D. increased lordosis With pregnancy, the woman's center of gravity shifts forward, requiring a realignment of the spinal curvatures. There is an increase in the normal lumbosacral curve (lordosis). Ligaments of the sacroiliac joints and pubis symphysis soften and stretch. Increased swayback and an upper spine extension to compensate for the enlarging abdomen occur. Joint relaxation and increased mobility occur due to the influence of the hormones relaxing and progesterone.
Which change in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy? A. ligament tightening B. decreased swayback C. joint contraction D. increased lordosis
D. Breast tenderness Presumptive signs of pregnancy are things reported by the woman to the health care provider and occur early in pregnancy. Breast tenderness is a common sign reported by women in early pregnancy but is not a definitive sign. Reports of increased hunger and weight gain could be caused by any disorder or could be normal responses to eating cycles. Ballottement occurs late in the pregnancy and is a probable sign.
Which information provided by a client would be considered a presumptive sign of pregnancy? A. Weight gain B. Reports of increased hunger C. Ballottement D. Breast tenderness