FNP REVIEW QUESTIONS
A pregnant patient presents with symptoms of sinus congestion, facial pressure, headache, and fever that have been present for 11 days. The patient also reports she felt better for a few days before feeling worse again. What is the recommended treatment for this patient?
Amoxicillin-clavulanate Amoxicillin-clavulanate (Augmentin) is the first-line treatment for ABRS and is generally safe during pregnancy. Rhinosinusitis is a common infection that can be caused by both viruses and bacteria. The vast majority of cases are caused by viruses and typically resolve spontaneously over several weeks. In cases caused by bacteria, the majority of patients will be acutely sick for 10 or more days and will have a fever and toxic appearance. Another characteristic of acute bacterial rhinosinusitis (ABRS) is referred to as "double sickening", where patients have initial symptom improvement followed by worsening of symptoms. ABRS should be treated with antibiotics. In the general population, the first-line treatment is Amoxicillin-clavulanate (Augmentin). Augmentin is the preferred treatment in pregnancy as studies have found no evidence of fetal risk. For patients with a penicillin allergy, Doxycycline Hyclate (Vibramycin) is preferred unless they are pregnant. It is important to remember that Doxycycline should be avoided during pregnancy as there is evidence suggesting fetal harm. A third-generation cephalosporin is recommended for pregnant patients with a penicillin allergy with ABRS. Pregnant patients can also manage symptoms with acetaminophen (Tylenol).
A nurse practitioner teaches nurse practitioner students in the clinic about screening for sexually transmitted infections (STIs) during pregnancy. When should STI testing be done during pregnancy?
At the initial prenatal visit The best time to perform routine screening for STIs is at the first prenatal visit. Untreated STIs can cause fetal harm, so early identification is key. It is important to screen for and treat sexually transmitted infections during pregnancy. Recommended tests including chlamydia, gonorrhea, syphilis, HIV, and hepatitis B & C. Untreated, many of these infections can cause fetal harm. Chlamydia and gonorrhea, for example, can cause newborn eye infections with the potential for permanent damage. Syphilis is also a concern as there has been a significant increase in the number of infants
The nurse practitioner provides education to a patient that is 10 weeks pregnant regarding cardiovascular changes during pregnancy. At which gestational age of pregnancy does blood volume begin to increase?
Blood volume typically increases between 10-12 weeks. Blood volume increases start at 10-12 weeks. Blood volume increases 40-50% from pre-pregnancy levels Blood volume increases significantly during pregnancy. This increase occurs to help with maternal and fetal circulatory demands and to help prepare the body for the blood loss that occurs with birth. The average increase in blood volume is approximately 40-50% of pre-pregnancy levels. Increases include both plasma and red blood cells. The increase in plasma is typically double that of RBCs, which explains the decrease in hemoglobin and hematocrit that occurs during pregnancy. This adaptation is described as physiologic anemia.
The nurse practitioner teaches nursing students about Edward syndrome. Which chromosome is affected in Edward syndrome?
Chromosome 18 Chromosome 18 is impacted in Edward syndrome. Trisomy 18, commonly called Edward syndrome, is a genetic disorder that occurs when there are three copies of chromosome 18. The condition causes a variety of abnormalities. Most fetuses with Trisomy 18 will die before birth or soon after birth as a result of life-threatening complications (National Organization for Rare Disorders, n.d.). For children that survive with Trisomy 18, the condition can cause malformations of the head and face, heart defects, and a variety of other structural abnormalities. The condition can be identified through maternal screening and diagnosis in the prenatal period.
The nurse practitioner answers a patient's questions about the Quad Screen. Which disease is screened for through the Quad Screen?
Down Syndrome The Quad Screen routinely screens for Trisomy 18 and Trisomy 21 (Down Syndrome). The second-trimester screening is called the "Quad Screen" and consists of measuring levels of Alpha fetal protein (AFP), HCG, Estriol, and Inhibin A in the maternal blood. These measurements help screen for fetal genetic abnormalities. Specific conditions screened for with the Quad Screen include Trisomy 21 (Down Syndrome), Trisomy 18, and Spina bifida. Abnormal screening tests do not confirm the presence of a genetic condition but indicate the level of risk. A patient with an abnormal screening test should be counseled on diagnostic tests available including amniocentesis or chorionic villus sampling. Screening tests are generally performed first, as diagnostic tests can be invasive and carry increased risks.
A nurse practitioner provides education to nursing students. Which is the most common causative organism of UTIs during pregnancy?
Escherichia coli E. coli is the number one cause of UTIs in pregnancy. Urinary tract infections and asymptomatic bacteriuria commonly occur during pregnancy. Escherichia coli is the number one cause of UTIs in pregnant and non-pregnant women. Increased smooth muscle relaxation that occurs as a result of pregnancy, can increase the risk that bacteria can ascend the urinary tract and cause infection. Additional causative organisms include Enterobacteriaceae, Pseudomonas, Enterococci, and Staphylococcus aureus (Hooton & Gupta, 2021).
A pregnant patient in her third trimester of pregnancy complains of dark patches of skin on her face. The patient wonders how these spots appeared. Which is a known cause of melasma?
Hormonal changes Hormonal changes, including increases in the hormone melanotropin, are responsible for hyperpigmentation on the face during pregnancy. The areas will likely resolve on their own after pregnancy but can be triggered by additional pregnancies or the use of oral contraceptives. Many physiological changes occur during pregnancy that impact each body system. The integumentary system, in particular, is often visibly affected. Examples of conditions impacting the body during pregnancy include striae gravidarum ("stretch marks"), melasma, angiomas and linea nigra. Differentiating these normal skin variations during pregnancy is an important role of the nurse practitioner, as is providing education to patients about each condition.
A pregnant patient is 32 weeks gestation and presents with RUQ pain after eating. Which is the best explanation for the patient's symptoms?
Hypercholesterolemia and decreased emptying of the gallbladder These physiological changes are consistent with gallstones. There is an increased risk of gallstones during pregnancy because of these physiological changes. Symptoms of gallstones typically include RUQ pain (especially after eating). If the cystic or common bile duct is occluded by gallstones, dark urine and yellowing of the skin may be present. Physiologic changes to the GI system during pregnancy can contribute to a variety of conditions that cause discomfort to patients. Many of these changes result from increased production of estrogen and progesterone. These hormonal changes cause the relaxation of smooth muscles that line the esophagus and intestines. Additionally, abdominal bloating and pressure can cause abdominal pain. It is important to identify and accurately diagnose the causes of abdominal pain during pregnancy.
A nurse practitioner provides education to a patient with anxiety on the use of benzodiazepines during pregnancy. Which statement indicates patient understanding?
If benzodiazepines are needed during pregnancy, those with a short half-life are preferred Benzodiazepines with a short half-life are preferred as they limit the time of fetal exposure. Benzodiazepines are commonly prescribed to patients to help manage acute and severe anxiety. These medications should always be prescribed with caution because of the risk of dependence. During pregnancy, it is important to consider maternal and fetal risks. Generally, benzodiazepines should be prescribed at the lowest effective dose. Benzodiazepines with a short half-life are preferred during pregnancy to limit fetal exposure. The medications should be used sparingly to prevent maternal and fetal dependence. Prolonged administration close to delivery should be avoided to prevent neonatal toxicity and withdrawal. Symptoms of neonatal toxicity and withdrawal include low APGAR scores, apnea, lethargy, irritability, restlessness, and poor feeding (Hendrick, 2021). Some studies show an increased risk of preterm birth and cleft lip or palate with the use of benzodiazepines during pregnancy. Counseling should be provided to patients and the risk-benefit ratio should be evaluated prior to prescription and shared decision making is recommended.
The nurse practitioner should counsel a pregnant patient that which medication, taken during pregnancy, may affect the newborn after delivery?
Lorazepam Benzodiazepines increase the risk of neonatal toxicity and withdrawal symptoms. Chronic health problems such as asthma, diabetes, hypertension, allergies, autoimmune conditions, and mental health conditions require management during pregnancy to protect both mom and baby. Oftentimes management requires the use of one or more medications. It is important to consider the fetal risks in utero of using medication. It is also important to remember that some medications can impact an infant after birth. For example, the use of benzodiazepines and opioids during pregnancy increases the risk of neonatal toxicity and withdrawal symptoms (Hendrick, 2021). Symptoms of neonatal toxicity and withdrawal include low APGAR scores, apnea, lethargy, irritability, restlessness, and poor feeding (Hendrick, 2021). Another example is pregnant patients with diabetes who may use insulin. Because of changes in maternal and fetal blood sugar with delivery, newborns should be closely monitored for signs of neonatal hypoglycemia (Abrawmowksi, Ward, & Hamdan, 2021). Symptoms of neonatal hypoglycemia include bluish/pale skin, lethargy, irritability, and apnea.
The nurse practitioner provides education to a patient on the stages of development during pregnancy. At which gestational age does the embryo become a fetus?
Nine weeks From nine weeks gestation until birth, the pregnancy is referred to as a fetus. There are several stages of growth and development that occur during pregnancy. Immediately after fertilization, the fertilized cell is referred to as a zygote. The zygote undergoes growth and division as it travels down the fallopian tube. By the time the zygote enters the uterus, it has become a group of cells referred to as a morula. The cells in the morula begin to differentiate into an inner cell mass and outer cell mass; when this occurs the cells become a blastocyst. The blastocyst then implants in the uterus, becoming an embryo that will grow and develop into a fetus.
Which three conditions are caused by trisomy?
Patau syndrome Patau syndrome, also called Trisomy 13, occurs when there are three copies of chromosome 13. Edward syndrome Edward syndrome, also called Trisomy 18, occurs when there are three copies of chromosome 18. Down syndrome Down syndrome, also called Trisomy 21, occurs when there are three Trisomy is a genetic abnormality that occurs when there is an extra chromosome present. Examples of trisomy include Trisomy 21 (Down syndrome), Trisomy 18 (Edwards syndrome), and Trisomy 13 (Patau syndrome). The trisomy number refers to the chromosome that is affected. For example, Trisomy 21 (Down syndrome) affects chromosome 21. Trisomy typically results in significant physical and intellectual abnormalities, which can be fatal. These conditions can be identified in the prenatal period through maternal screening and diagnostic tests.
A nurse practitioner teaches a nursing student about managing early pregnancy loss in the primary care setting. Which statement by the student indicates further teaching is needed?
Prophylactic antibiotics should be given to prevent endometritis Antibiotics are only indicated if patients have signs of infection including fever and significant abdominal/pelvic pain Early pregnancy loss, commonly referred to as miscarriage, occurs in approximately 10 to 20 percent of pregnancies (Mayo Clinic, 2019). The vast majority of miscarriage occurs in the first trimester before 13 weeks gestation. The most common cause of miscarriage is fetal chromosomal abnormalities. Symptoms of miscarriage can include vaginal bleeding, abdominal cramping, and passage of fetal tissue. All pregnant patients with these symptoms should be evaluated with pelvic ultrasound and a serum beta HCG (Prine & Macnaughton, 2011). Ultrasound will indicate the viability of the fetus. Beta HCG can also be monitored as these numbers will trend downward with a nonviable pregnancy. There are three types of management for miscarriage as long as the patient is stable and there are no signs of infection. The first type of treatment is expectant management. Expectant management is when a woman waits for the tissue to pass on its own, which can sometimes take several weeks. Medical management is treatment with intravaginal misoprostol which causes expulsion of the tissue within 24 to 48 hours. Surgical management is when a healthcare provider dilates the cervix and manually removes the tissue from the uterus (commonly called a D & C). D & C is indicated when there is extremely heavy bleeding or signs of infection. Patients should be referred to a specially trained provider for this procedure. Emotional and mental health support is also important for these patients.
A nurse practitioner provides prenatal care for a patient in her second trimester. Which screening test is indicated?
Quad Screen The Quad Screen is recommended in the second trimester between 15-20 weeks gestation. It measures Alpha fetal protein (AFP), HCG, Estriol, and Inhibin A. The results help identify fetal risks of developing chromosomal abnormalities that can result in birth defects. Several screening tests are available and recommended during pregnancy to identify the risk for fetal genetic abnormalities. The first-trimester screen consists of a maternal blood test for PAPP-A (pregnancy-associated placental protein) and an ultrasound of the fetus to measure nuchal translucency. Second-trimester screening is called the "Quad Screen'' and consists of measuring levels of Alpha fetal protein (AFP), HCG, Estriol, and Inhibin A in the maternal blood. Abnormal screening tests do not confirm the presence of a genetic condition but indicate the level of risk. Patients with abnormal screening tests should be counseled on diagnostic tests available including amniocentesis and chorionic villus sampling. Screening tests are generally performed first, as diagnostic tests can be invasive and carry increased maternal and fetal risks.
The nurse practitioner discusses first trimester screenings with a pregnant patient at 9 weeks gestation. Which statement indicates the patient understands first trimester screenings?
Screening tests are recommended for everyone, not just patients considered to be high risk ACOG (n.d.) guidance states that all pregnant patients should be offered prenatal screening tests, regardless of age or risk factors. Patients should be counseled on the screening process at their first prenatal visit. Discuss with patients that ACOG (n.d.) recommends screening all pregnant patients regardless of age or risk factors. Review the patient's history together to screen for and identify risk factors. Provide written materials for patients to take home and discuss with family members. Be prepared to dispel myths and answer patient questions regarding the screening process. Several screening tests are available and recommended for all patients during pregnancy to identify the risk of fetal genetic abnormalities. The first-trimester screening consists of measurement of maternal biochemical markers including pregnancy-associated placental protein (PAPP-A) and human chorionic gonadotropin (HCG). In addition, an ultrasound is performed to measure nuchal translucency. Abnormal findings on these tests increase the risk of Down syndrome and Trisomy 18. A patient with an abnormal screening test should be counseled on diagnostic tests available including amniocentesis or chorionic villus sampling. Screening tests are generally performed first, as diagnostic tests can be invasive and carry increased risks.
Which lab result indicates a pregnant patient should be treated with supplemental iron?
Serum ferritin of 15 mcg/L Ferritin less than 30 mcg/L (ng/mL) confirms the diagnosis of iron deficiency anemia in pregnancy (Auerbach & Landy, 2021). Blood volume increases significantly during pregnancy, which can result in physiologic anemia because of a decrease in hemoglobin and hematocrit. It is important to interpret laboratory studies accurately, as some decreases in hemoglobin and hematocrit can also be caused by pathologic anemia such as iron deficiency anemia. Iron deficiency anemia is the most common type of pathologic anemia in pregnancy. It occurs when a lack of iron causes red blood cells to be small (microcytic) and pale (hypochromic). Lab studies typically show low hemoglobin, hematocrit, mean corpuscular volume, and ferritin. Ferritin less than 30 mcg/L (ng/mL) confirms the diagnosis of iron deficiency anemia and warrants iron supplementation (Auerbach & Landy, 2021). Supplementation can be provided through oral iron as long as it is tolerated by the patient. Doses range from 40 to 200 mg of elemental iron per day. Oral iron should be taken on an empty stomach to promote absorption.
A nurse practitioner reviews the vitals of a pregnant patient in her second trimester and notices an increase in resting heart rate of 15 bpm over baseline. Which is the best explanation for this increase in heart rate?
The heart rate typically increases in the second trimester to meet increased cardiac output demands Around 15 weeks gestation, there is a noticeable increase in the heart rate of 10-15 bpm over baseline that continues through the pregnancy to help meet increased cardiac output demands. Many physiological changes occur during pregnancy that impacts each body system. The cardiovascular system in particular undergoes changes to help meet the cardiac demand of the mom and fetus. It is not abnormal to see a transient enlargement of the heart. The heart often shifts up and towards the left as the uterus grows into the abdomen. Significant changes also occur in blood volume and cardiac output. Understanding the cardiovascular changes in pregnancy will help nurse practitioners identify normal and abnormal findings on exams.
A newly pregnant patient expresses concerns about continuing her selective serotonin reuptake inhibitor (SSRI) during pregnancy. The nurse practitioner provides counseling and education to the patient. Which statement from the patient indicates an understanding of SSRI use in pregnancy?
There are risks that exist if I continue or stop taking my SSRI Maternal and fetal risks exist with SSRI use during pregnancy and with uncontrolled depression and anxiety during pregnancy. SSRIs are one of the most widely used classes of medications to help manage anxiety and depression. These medications cross the placenta and fetal blood-brain barrier and therefore present risks to the fetus (Stewart & Vigod, 2020). It is important to counsel patients on these medications and their impact during pregnancy. The use of these medications present risks such as fatal cardiac defects, low birth weight, and decreased APGAR score at birth. The incidence of these risks varies on the specific SSRI being used. One example is paroxetine, which should be avoided in the first trimester because of the risks of fetal cardiac defects. It is important to note that while medications present fetal risk, uncontrolled depression and anxiety during pregnancy also present maternal and fetal risk. Uncontrolled depression and anxiety during pregnancy are associated with decreased prenatal care, increased substance use during pregnancy, low birth weight, premature birth, and low APGAR scores at birth. A thorough risk-benefit analysis should be performed to determine the necessity of these medications during pregnancy. Shared decision-making is encouraged.
A nurse practitioner provides education to a patient on potential complications associated with amniocentesis. Which statement should be included in patient teaching?
There is a risk of leakage of amniotic fluid after the procedure Leakage of amniotic fluid is a known risk of amniocentesis. It is typically minimal and should resolve on its own. Amniocentesis is a prenatal diagnostic test that can detect a variety of fetal genetic abnormalities such as Down syndrome, trisomy 13, trisomy 18, and neural tube defects (ACOG, n.d.). Indications for amniocentesis generally include abnormal maternal screening tests. The procedure is performed by using ultrasound to help introduce a needle through the maternal abdomen into the fetal amniotic sac to obtain a sample of amniotic fluid. The amniotic fluid contains fetal cells that help confirm the diagnosis of genetic abnormalities. The procedure is performed at 15 weeks gestation or later. There are risks with the procedure that patients should be counseled on including leakage of amniotic fluid, hemorrhage, and infection for both mom and fetus. The risk of fetal loss is less than 1%. It is standard practice to administer Rhogam after the procedure to women who are Rh-negative.
The nurse practitioner provides counseling to a newly pregnant patient on recommendations for weight gain over the course of her pregnancy. Which is the recommended weight gain for a woman with a BMI of 35?
Weight gain of 11-20 pounds Pregnant patients who are obese (BMI greater than 30) should gain no more than 11-20 pounds throughout pregnancy. Weight gain during pregnancy is determined by pre-pregnancy weight and BMI. BMI falls into four different categories: underweight, healthy weight, overweight and obese. It is important for the nurse practitioner to identify the patient's BMI to provide appropriate counseling on healthy weight gain during pregnancy. Excess weight gain during pregnancy can increase risks for both the mom and baby. Risks to the mother include gestational diabetes and delivery complications. Risks to the baby include birth defects, shoulder dystocia, and macrosomia.
A nurse practitioner cares for a pregnant patient at 22 weeks gestation age. Which is an indication for fetal ultrasound?
Measure the diameter of developing baby's skull Biparietal diameter is one of four measurements performed during the anatomy ultrasound that help determine fetal size and age. It is measured, in centimeters, as the length of a transverse section of the fetal skull. Ultrasound is an extremely useful tool during pregnancy. Most healthy women will have two ultrasounds during their pregnancy: an initial dating ultrasound in the first trimester and an anatomy scan during the second trimester. The second-trimester ultrasound is an in-depth ultrasound that determines the fetal size and helps identify any abnormalities. Several measurements help determine fetal size including biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). Abnormal results of the anatomy scan are monitored closely and often result in additional evaluation.
A newly pregnant patient expresses concerns about continuing venlafaxine during pregnancy. The nurse practitioner provides counseling and education to the patient. Which statement from the patient indicates additional teaching is needed?
"If I continue my medication during pregnancy, there is a risk my baby could have heart problems." There are no associated teratogenic effects associated with venlafaxine (Effexor). The medication has not been found to cause any specific congenital malformations. SNRIs are a class of medications that can be used to help manage anxiety and depression. These medications do cross the placenta and fetal blood-brain barrier and therefore present risks to the fetus. It is important to counsel patients on these medications and their impact during pregnancy. The most widely studied SNRIs for pregnancy include duloxetine (Cymbalta) and venlafaxine (Effexor). Each medication carries individual risks. Duloxetine is associated with an increased risk of postpartum hemorrhage. Venlafaxine is associated with an increased risk of preeclampsia, and may also increase the risk of spontaneous abortion and postpartum hemorrhage. There are no major congenital malformations associated with these medications. If either of these medications are used during pregnancy, the baby should be monitored for poor neonatal adaptation syndrome after delivery. Signs of poor adaptation include agitation, irritability, hypoglycemia, hypothermia, and respiratory distress (Steward & Vigod, 2021). While these medications carry risks, untreated anxiety and depression during pregnancy also increase maternal and fetal risks. A thorough risk-benefit analysis should be performed to determine the necessity of these medications during pregnancy. Shared decision-making is encouraged.
A nurse practitioner teaches nurse practitioner students on the management of pregnant patients with depression. Which statement by the student indicates additional teaching is needed?
"Measurement of medication serum levels is indicated for patients on SSRIs." Only certain medications need to be monitored for serum levels such as desipramine, imipramine, and nortriptyline (Grigoriadis, 2020). Uncontrolled depression during pregnancy carries several maternal and fetal risks. Managing depression can help reduce these risks. Psychotherapy is the preferred first-line treatment for depression in pregnancy. Pharmacotherapy is recommended for pregnant patients when the benefits outweigh the risks. Medication selection is generally initiated with an SSRI. To help reduce fetal risks, one medication is always preferred over several medications (Grigoriadis, 2020). Medications should be used at the lowest, effective dose. It is important to note that over the course of the pregnancy, medication doses may need to be increased to counteract the decrease in serum medication levels that can occur as a normal physiologic response to pregnancy (Grigoriadis, 2020). Monitoring serum levels of medications is typically reserved for specific medications including desipramine, imipramine, and nortriptyline (Grigoriadis, 2020). Medically and psychologically complex patients and patients who are not responsive to treatment should be referred to a specialist.
A patient asks the nurse practitioner "Why should NSAIDs be avoided during pregnancy?". Which is the correct response of the nurse practitioner?
"NSAIDs may cause low amniotic fluid." NSAIDs can cause oligohydramnios (low amniotic fluid) as a result of decreased renal blood flow. NSAIDs are cyclooxygenase (COX) inhibitors. This means they function by blocking COX enzymes in the body to reduce the production of prostaglandins. Prostaglandins are compounds in the body that are released at the site of injury or infection to begin the inflammatory process. By reducing the number of prostaglandins, NSAIDs help reduce symptoms like pain and fever. NSAIDs also reduce renal prostaglandins which can decrease renal blood flow. This decreased renal blood flow can impact amniotic fluid production resulting in oligohydramnios, which is low amniotic fluid. Because of the risk of low amniotic fluid, NSAIDS should generally be avoided during pregnancy unless the benefits outweigh the risk. Tylenol is generally recommended during pregnancy to reduce fever, inflammation, and pain.
The nurse practitioner conducts a prenatal visit with expectant parents. In response to a question regarding the risk of an infant being born with a congenital heart defect, which four statements are correct responses?
"Taking angiotensin-converting enzyme (ACE) inhibitors for high blood pressure during the first trimester may have a role in congenital heart disease." Taking ACE inhibitors during the first trimester of pregnancy increases the risk of an infant being born with congenital heart disease. "Smoking or being exposed to secondhand smoke during pregnancy may have a role in the development of congenital heart disease." Smoking or being exposed to secondhand smoke during pregnancy does increase the risk of an infant being born with congenital heart disease. "Genetics and family history may have a role in the development of congenital heart disease." Genetics and family history may have a role in the development of congenital heart disease, particularly if the infant's parent or sibling has a history of congenital heart disease. "Using retinoic acids for acne treatment during the first trimester may have a role in the development of congenital heart disease." Using retinoic acids during the first trimester of pregnancy has been associated with the development of congenital heart disease. Congenital heart disease occurs in about 1% of live births in the United States and is the most common type of birth defect. Defects can involve the walls of the heart, the valves of the heart, and the large vessels that carry blood to and from the heart. Doctors often do not know why congenital birth defects occur, but research has identified some risk factors. Environmental risk factors include smoking or exposure to secondhand smoke and taking certain medications, particularly in the first trimester. Family history and genetics is a risk, particularly if the infant's parent or sibling has a congenital heart defect. Certain medical conditions increase the risk of an infant being born with congenital heart disease. These conditions include diabetes diagnosed before pregnancy or diabetes diagnosed in the first trimester. A diagnosis of gestational diabetes later in pregnancy is not a major risk factor. The inherited disorder of phenylketonuria is a risk factor, and infection with rubella during pregnancy also poses a major risk for the development of congenital heart disease. Pregnant patients may lower their infant's risk of a congenital heart defect by taking only medications that are deemed safe for pregnancy, controlling existing health conditions such as phenylketonuria and diabetes, meeting with a genetics counselor if advisable, and stopping smoking and avoiding secondhand smoke.
The nurse practitioner provides counseling to a newly pregnant patient with a healthy body mass index (BMI). Which is the recommended additional calorie intake per day throughout pregnancy?
A range of 0 to 450 calories The amount of additional calories needed varies by trimester. No additional calories are needed in the first trimester. Starting in the second trimester, up to an additional 450 calories a day is recommended. Nutrition is an important part of preconception and pregnancy. Pregnancy places several demands on the body. Meeting energy and nutritional needs helps promote the health of both mom and baby. Important nutritional considerations include both the quantity and quality of food. Diets should be rich in vitamins and minerals. Certain types of food should also be avoided such as unpasteurized milk, soft cheeses, and cold deli meats, as these can increase the risk of foodborne illness.
The nurse practitioner determines which patient is the highest risk and should be counseled on amniocentesis?
A 27-year-old female at 18 weeks gestation with a positive maternal screening test. A positive maternal screening test indicates an abnormality was detected. This patient should be counseled on amniocentesis to help confirm the diagnosis.
A nurse practitioner provides education to a pregnant patient with a history of asthma on management during pregnancy. Which patient statement indicates understanding?
"Keeping my asthma under control during pregnancy will reduce risks to me and my baby." Well-controlled asthma improves maternal and fetal oxygenation, which supports adequate fetal growth and development. Asthma is one of the most common chronic conditions encountered during pregnancy. According to the Asthma and Allergy Foundation of America (2016), one-third of women will have a worsening of asthma severity during pregnancy, while one-third of women will have improvement and one-third of women will have no change in asthma severity. It is important to control asthma symptoms during pregnancy, as there is a direct impact on the fetus. If the woman does not have adequate oxygenation, the fetus will not have adequate oxygenation. All pregnant women with asthma should be prescribed a short-acting beta-agonist, rescue inhaler (Albuterol) for quick relief of symptoms. For patients with moderate asthma, an inhaled corticosteroid should also be prescribed. Budesonide is preferred during pregnancy, as it has been the most widely studied (Schatz & Weinberger, 2020). Patients should be educated on potential complications of asthma during pregnancy including increased risk of preterm labor, hypertensive disorders, and low birth weight (AAFA, 2016). 0 CommentsSort by
Which patient has the most risk factors of mental health challenges during the postpartum period?
A 22-year-old multiparous woman with a history of depression during her pregnancy. This patient has 3 risk factors: young age, multiple children at home, and depression during pregnancy.
A nurse practitioner assesses four pregnant patients. Which patient needs a late pregnancy ultrasound?
A 27-year-old female patient at 38 weeks gestation has vaginal bleeding and back pain. Vaginal bleeding and back pain increase suspicion for placental abruption, which is most likely to occur in the third trimester and can cause significant maternal and fetal complications. Ultrasound is an extremely useful tool during pregnancy. Most healthy women will have two ultrasounds during their pregnancy: an initial dating ultrasound in the first trimester and an anatomy scan during the second trimester. However, there are several indications for third-trimester ultrasounds including discrepancies between size and dates, concerns about transverse or breech fetal positioning, previous placenta abnormalities, and maternal conditions such as hypertension or diabetes that can impact fetal growth. Ultrasound should also be performed with any new vaginal bleeding to confirm pregnancy viability and rule out life-threatening conditions like placental abruption.
The nurse practitioner reviews the chart of four newly pregnant patients. In addition to offering routine prenatal screening, which patient is recommended to have additional genetic testing?
A 27-year-old female patient with low hemoglobin and hematocrit and is of Mediterranean descent. Patients of African, Middle Eastern, and Mediterranean descent should be offered additional screening because of the increased risk of hemoglobinopathies. The American College of Obstetricians and Gynecologists (2017) recommends that all pregnant women should have access to genetic carrier screening. Specifically, screening for Spinal Muscle Atrophy and Cystic Fibrosis is recommended for all pregnant women. Additional screening is recommended based on condition and risk factors. Patients of African, Middle Eastern, and Mediterranean descent should be screened for hemoglobinopathies with a complete blood count and hemoglobin electrophoresis (if indicated). Screening for Fragile X Syndrome is recommended for patients with a family history of Fragile X. Individuals of Ashkenazi Jewish or French Canadian descent should be offered to screen for Tay-Sachs disease.
A nurse practitioner provides preconception counseling regarding chromosomal abnormalities that can occur with pregnancy. Which is a risk factor for aneuploidy?
Advanced maternal age Advanced maternal age is the leading cause of aneuploidy. Many types of chromosomal abnormalities can occur when genetic material is exchanged or during cell division. Aneuploidy occurs when there is an extra or missing chromosome. Most commonly, this is seen as an extra chromosome, referred to as trisomy. Down syndrome is the most common type of trisomy. It occurs when there is extra genetic material that affects chromosome 21. Down syndrome can cause a spectrum of intellectual disabilities and physical abnormalities. The biggest risk factor for Down syndrome is advanced maternal age. At 25 years old the risk of having a child with Down syndrome is 1 in 1200; at 35 years old the risk increases to 1 in 350. When a woman reaches 45 years old, the risk increases substantially to 1 in 30. Additional examples of trisomy include Trisomy 16 and Trisomy 18 (Edwards syndrome). Trisomy 16 typically results in fetal death in the first trimester of pregnancy. Trisomy 18 (Edwards syndrome) causes significant birth defects that are often fatal in the first year of life.
The nurse practitioner provides counseling to a newly pregnant patient regarding risk factors for Down syndrome. Which two factors increase the risk of Down syndrome?
Advanced maternal age The biggest risk factor for Down syndrome is advancing maternal age. Previous child with Down syndrome There is a hereditary component to Down syndrome that can cause parents to pass the genetic translocation to their offspring. Down syndrome is a genetic abnormality that impacts chromosome 21. Down syndrome can cause a spectrum of intellectual disabilities and physical abnormalities. The biggest risk factor for Down syndrome is advancing maternal age. At 25 years old the risk of having a child with Down syndrome is 1 in 1200; at 35 years old the risk increases to 1 in 350. When a woman reaches 45 years old, the risk increases substantially to 1 in 35 (Perry, 2013). Additional risk factors include having a previous child with Down syndrome or being a known carrier of the genetic translocation associated with Down syndrome (Mayo Clinic, n.d.).
A nurse practitioner discusses dietary needs with a newly pregnant 25-year-old patient. Which is the recommended calcium intake during pregnancy?
Approximately 1000 mg ACOG (2021) recommends pregnant women who are 19 or older get 1000 mg of calcium a day. Calcium is one of the 13 essential minerals the body needs to function. Calcium helps to build strong bones. During pregnancy, calcium helps to build strong bones and teeth for the baby. ACOG (2021) recommends pregnant women who are 19 years or older get 1000 mg of calcium a day. For pregnant women who are 18 or younger, 1300 mg of calcium a day is recommended (ACOG, 2021). Foods that are high in calcium include dairy products (milk, cheese), broccoli, and dark leafy vegetables.
On exam of a newly pregnant patient, the family nurse practitioner notices a bluish coloration of the vagina and cervix. This exam finding is consistent with which sign?
Chadwick sign Chadwick sign is a normal finding in early pregnancy. It is associated with the bluish color of the vagina and cervix that can be seen during a pelvic exam. The blue color occurs as a result of increased vascularity from changes in hormones during early pregnancy. In early pregnancy, there are many physiological changes that occur to help the body prepare for and sustain a pregnancy. Many of these changes are related to increases in hormones including progesterone and estrogen. These hormones help to enlarge the uterus and increase blood flow to the uterus. Identifying these normal physical changes during pregnancy is an important part of the nurse practitioner's role. On exam, these changes are identified in several ways. For example, because of increased vascularity, the nurse practitioner may see increased friability and blue coloration of cervical and vaginal tissue. Additionally, the nurse practitioner may palpate softening of the cervix and lower uterine segment as the uterus expands and changes position.
A nurse practitioner cares for a pregnant patient at approximately 10 weeks gestational age. Which is an indication for fetal ultrasound?
Determine gestational age A first trimester ultrasound is one of the best methods for determining gestational age. Ultrasound is an extremely useful tool during pregnancy. Most healthy women will have two ultrasounds during their pregnancy: an initial dating ultrasound in the first trimester and an anatomy scan during the second trimester. A first-trimester ultrasound is one of the best methods for determining gestational age. First-trimester ultrasound is also used in confirming the presence of the fetus in the uterus, assessing for multiple pregnancies, measuring nuchal translucency, and detecting fetal heartbeats. Indications for additional first-trimester ultrasounds include vaginal bleeding or abnormal findings on previous ultrasounds
Which statement is true regarding the evaluation and management of postpartum depression?
Diagnosis of postpartum depression requires that symptoms have been present for at least two weeks The diagnosis of postpartum depression follows the same DSM-5 criteria as major depression, which requires that five or more symptoms have been present for at least two weeks (Viguera, 2020) Postpartum depression is depression that can occur up to a year after giving birth. The same diagnostic criteria are applied for postpartum depression and major depression according to the DSM-5, which requires that at least five depressive symptoms are present for at least two weeks. At least one of the following two symptoms must be present: depressed mood or loss of pleasure/interest (Viguera, 2020). Postpartum depression is managed similarly to major depression. First-line treatment for mild to moderate postpartum depression generally includes psychotherapy with or without pharmacotherapy. With consideration to pharmacotherapy, SSRIs are generally considered first-line as they are the most widely studied. In breastfeeding moms, it is important to consider the amount of medication that is secreted in breast milk. Each medication excretes a different percentage of medication in the breast milk. The preferred medications for breastfeeding moms are paroxetine (Paxil) and sertraline (Zoloft), with 2% and 7% of the medication excreted respectively (Kimmel & Meltzer-Brody, 2020). For patients with severe postpartum depression, a referral to a psychiatrist is recommended. For patients with active thoughts of hurting themselves or someone else, hospitalization is necessary.
The nurse practitioner reviews the medical history and prenatal course of a pregnant patient at 11 weeks gestation. The patient had an abnormal maternal screening test. Which is a reason why chorionic villus sampling (CVS) is indicated instead of amniocentesis for this patient?
Earlier diagnosis of genetic abnormalities The benefit to CVS is that it can be done earlier in the pregnancy (between 10-13 weeks) and can help guide future decision-making. Chorionic villus sampling (CVS) is a prenatal diagnostic test that can detect a variety of fetal genetic abnormalities such as Down syndrome, trisomy 13, and trisomy 18 (ACOG, n.d.). Unlike amniocentesis, CVS cannot detect neural tube defects. Indications for CVS generally include abnormal maternal screening tests. The procedure is performed by obtaining a small tissue sample from the fetal placenta using a needle through the maternal abdomen or a catheter through the cervix. This tissue contains fetal genetic material that can be used to confirm the diagnosis of genetic abnormalities. The procedure is performed earlier than amniocentesis, usually between 10 and 13 weeks gestation. There are risks with the procedure that patients should be counseled on including leakage of amniotic fluid, hemorrhage, and infection for both mom and fetus. With CVS there are also risks of preterm labor and fetal limb defects. It is standard practice to administer Rhogam to women who are Rh-negative
Which is the best tool to help a nurse practitioner screen for postpartum depression?
Edinburgh Postnatal Depression Scale The Edinburgh Postnatal Depression Scale (EPDS) is the best screening tool for postpartum depression as it is sensitive, and specific to the postpartum period. Postpartum depression is depression that can occur up to a year after giving birth. Screening for postpartum depression is an essential part of postpartum care. should be done at all follow-up visits. The best tool for screening during the postpartum period is the Edinburgh Postnatal Depression Scale (EPDS), which is a self-reported questionnaire that consists of 10 items and can be completed in less than five minutes (Viguera, 2021). The PHQ-9 (Patient Health Questionnaire) can be completed as an alternative if the EPDS is not available. The same diagnostic criteria are applied for postpartum depression and major depression according to the DSM-5, which requires that at least five depressive symptoms are present for at least two weeks. At least one of the following two symptoms must be present: depressed mood or loss of pleasure/interest (Viguera, 2020). It is important to note, that when screening for postpartum depression, there should be a plan and resources in place to help support patients with a positive screen.
A pregnant woman in her first trimester presents with dysuria and urinary frequency. Her urinalysis is positive for leukocytes and nitrites. The patient has no allergies. Which is the best medication to prescribe?
Fosfomycin Fosfomycin (Monurol) can be used in any trimester of pregnancy and is generally considered safe in pregnancy. Urinary tract infections and asymptomatic bacteriuria commonly occur during pregnancy. Clinicians should be mindful of patient allergies, history of resistance, and dating of the pregnancy when selecting an antibiotic for treatment. Available antibiotics for treatment during pregnancy include Amoxicillin-clavulanate (Augmentin), Nitrofurantoin (Macrobid), Trimethoprim-sulfamethoxazole (Bactrim), Cephalexin (Keflex), and Fosfomycin (Monurol). Fetal effects must be considered when selecting an antibiotic. For example, Macrobid should be avoided during the first trimester as some studies show associated birth defects. Bactrim should also be avoided during the first trimester as it is a folic acid antagonist (Hooton & Gupta, 2021). Fosfomycin (Monurol) is a safe and effective single-dose treatment when there is no concern for pyelonephritis.
A pregnant patient at 12 weeks gestation had a routine urine culture that identified > 100,000 CFU/mL of Escherichia coli. The patient is asymptomatic. What is the appropriate treatment for this patient?
Fosfomycin 3 g orally as a single dose Fosfomycin (Monurol) is an appropriate treatment for asymptomatic bacteriuria and is generally considered safe during pregnancy. Urinary tract infections and asymptomatic bacteriuria commonly occur during pregnancy. A positive urine culture should be treated with antibiotics, even if the patient is asymptomatic. Untreated UTIs can cause adverse pregnancy outcomes including preterm birth and low birth weight (Hooton & Gupta, 2021). Clinicians should be mindful of patient allergies, history of resistance, and safety during pregnancy when selecting an antibiotic for treatment. Fosfomycin (Monurol) is a safe and effective single-dose treatment when there is no concern for pyelonephritis. Additional options for treatment include Amoxicillin-clavulanate (Augmentin), Nitrofurantoin (Macrobid), Trimethoprim-sulfamethoxazole (Bactrim), and Cephalexin (Keflex). Both Macrobid and Bactrim should be avoided during the first trimester because of fetal risks. A test of cure should be performed during pregnancy to make sure the infection has been adequately treated.
A 50-year-old man presents to the clinician with a history of loss of libido and milky white discharge from both the nipples. He also states he has headaches and blurring of the peripheral vision for the last two months. MRI of the brain reveals a mass found in the anterior pituitary. Which symptom is most likely to occur in this man?
Headache The patient most likely has pituitary adenoma, which is prolactinoma. Unlike women, men tend to present with either a headache or visual changes in the presence of a prolactinoma. They also present with decreased libido, impotence, erectile dysfunction, oligozoospermia (due to secondary hypogonadism). Prolactin-secreting tumors of the pituitary gland are called prolactinomas. It is the most common secretory tumor of the pituitary gland accounting for up to 40% of total pituitary adenomas. Prolactinomas cause a wide variety of symptoms either due to the mass effect of the tumor or due to hypersecretion of prolactin. Prolactin prevents the secretion of GnRH secretion. Prolactinomas clinically present because of the mass effect of the tumor or because of hyperprolactinemia. Microprolactinomas (less than 1 cm) can present with symptoms of hyperprolactinemia or are detected incidentally on neuroimaging done for other reasons. Macroprolactinomas, on the other hand, present with mass effects on the surrounding structures. Prolactin levels should be checked in all men with confirmed hypogonadism and as part of the routine evaluation of male infertility. Prolactinoma causes oligozoospermia, not azoospermia. Gynecomastia and priapism are also not noted.
A nurse practitioner provides education to a pregnant patient with a history of migraines on management during pregnancy. Which patient statement indicates additional teaching is needed?
I can use ergotamine if acetaminophen doesn't work" Ergotamine (Ergomar) is contraindicated in pregnancy because of fetal risk. Migraines impact many women of reproductive age. During pregnancy, migraines generally improve for about 60 to 70 percent of women and worsen for about 5 percent of women (Lee, Guinn & Hickenbottom, 2020). The safest medication during pregnancy for acute migraine therapy is acetaminophen (Tylenol). If there is no improvement with Tylenol alone, it can be combined with caffeine to help with symptom management. Pregnant women should limit daily caffeine intake to less than 200 mg a day to prevent adverse fetal effects. Second-line treatment includes aspirin and other NSAIDs, although they should be avoided in very early pregnancy and in the third trimester. Third-line treatment includes triptans and opioids, which should be used sparingly to prevent risks to the fetus. Ergotamine (Ergomar) is contraindicated during pregnancy as it is known to cause fetal harm.
A pregnant female patient presents for a routine examination. She has multiple comorbidities and is concerned about her child's disease risk. Which is a perinatal risk factor for congenital heart disease?
Maternal viral infection Maternal exposures and illnesses such as rubella and cytomegalovirus (CMV) may increase the child's risk of congenital heart disease. Congenital heart disease in the pediatric population refers to structural abnormalities in the cardiac system. It is the most common congenital disease in children. A comprehensive review of potential risk factors is necessary during obstetric care. Multiple perinatal risk factors are correlated with congenital heart disease (CHD). These include infections, especially viral illnesses. The maternal use of tobacco, illegal drugs, and multiple medications may increase the child's risk. If the mother has a chronic disease such as diabetes, CHD, or lupus, the fetus may be at a higher risk. Advanced maternal age (over 40 years old) increases the likelihood of chromosomal abnormalities, which could result in cardiac structural defects. Additionally, if the mother has a history of diseases such as diabetes or obesity during pregnancy, the risk is higher.
A nurse practitioner provides prenatal care for a patient in her first trimester. Which two tests are part of the first-trimester screening?
Pregnancy-associated placental protein (PAPP-A) Serum PAPP-A is measured via a maternal blood test as part of the first-trimester screen. Nuchal translucency ultrasound Nuchal translucency is measured by ultrasound and is performed as part of the first-trimester screen. Several screening tests are available and recommended during pregnancy to identify the risk of fetal genetic abnormalities. The first-trimester screening consists of measurement of maternal biochemical markers including pregnancy-associated placental protein (PAPP-A) and human chorionic gonadotropin (HCG). In addition, an ultrasound is performed to measure nuchal translucency. Abnormal findings on these tests indicate an increased the risk of Down syndrome and Trisomy 18. Patients with abnormal screening tests should be counseled on diagnostic tests available including amniocentesis and chorionic villus sampling. Screening tests are generally performed first, as diagnostic tests can be invasive and carry increased fetal and maternal risks.
The nurse practitioner evaluates a pregnant patient at 34 weeks gestation and reviews the results of the urinalysis revealing protein in the urine but otherwise unremarkable. Which best explains the proteinuria?
Proteinuria may occur during pregnancy, as the kidneys can't always meet increased filtration demands. Some spillage of protein in the urine can occur during pregnancy when the kidneys can't meet increased filtration demands. Blood pressure should be evaluated to rule out preeclampsia. If blood pressure is within normal limits, continue with routine monitoring.
The family nurse practitioner reviews the results of a patient's Quad Screen. The results have come back abnormal. Which is the best next step for further evaluation and management?
Refer to a OBGYN or Maternal-Fetal Medicine specialist A specialist is needed to assist with additional diagnostic testing which can be invasive. Refer the patient as soon as possible... Several screening tests are available and recommended during pregnancy to identify risk for genetic abnormalities. The second-trimester screening is called the "Quad Screen" and consists of measuring levels of Alpha fetal protein (AFP), HCG, Estriol, and Inhibin A in the maternal blood. Abnormal screening tests do not confirm the presence of a genetic condition but indicate the level of risk. Patients with abnormal screening tests should be counseled on diagnostic tests available including amniocentesis or chorionic villus sampling. Screening tests are generally performed first, as diagnostic tests can be invasive and carry increased risks. Diagnostic tests should be performed by a specialist in the field.
The nurse practitioner teaches nurse practitioner students about Trisomy 13. Which characteristics are consistent with Trisomy 13?
Small head and jaw, low set and/or malformed ears, cleft lip, and clenched hands These characteristics are consistent with Trisomy 13 (Patau syndrome). The clenched hands are extremely characteristic of this condition. Explanation Trisomy 13, commonly referred to as Patau syndrome, is a genetic disorder that occurs when there are three copies of chromosome 13. The condition causes a variety of abnormalities including physical and intellectual disabilities. Many of these abnormalities can be life threatening and result in infant death within the first month of life (Genetic and Rare Diseases Information Center, n.d.). For children that survive with Trisomy 13, common characteristics of the condition include small head and jaw, low set and/or malformed ears, cleft lip, and clenched hands. The condition can be identified in the prenatal period through maternal screening and diagnostic tests.
A pregnant female patient presents to the clinic requesting the results of her fetal ultrasound, as she is concerned about the genetic risk for cardiac abnormalities. Which is correct regarding normal fetal circulation?
The fetal heart has higher pressure on the right side and lower pressure on the systemic side. This is the correct pressure gradient in fetal circulation, as it allows adequate systemic and pulmonary perfusion. Fetal circulation is a complex yet efficient system that allows the uterine arteries to supply blood to the fetus. Oxygenated blood is provided by the mother and flows through the foramen ovale and into the left atria. After it enters the left ventricle it is pushed into the aorta, ensuring adequate cerebral perfusion. Venous blood enters the right atria and passes into the right ventricle. This blood enters the pulmonary artery, into the ductus arteriosus and aorta. Lower extremity, chest, and abdomen perfusion is supplied by this circuit. After birth, these 2 circuits include the lungs after postnatal vascular resistance changes. The ductus arteriosus should become smaller and the foramen ovale should close. Vascular resistance reduction is gradual over the first 2 months of life. 0 Comments
The nurse practitioner measures the fundal height of a pregnant patient. The fetus has been measuring appropriately for size and dates. The nurse practitioner identifies the top of the fundus at the umbilicus. Which is the approximate gestational age?
Twenty weeks At 20 weeks the fundus should be identified at or near the umbilicus. Measuring fundal height is an important part of routine prenatal care. Fundal height is measured as the distance, in centimeters, from the pubic bone to the top of the fundus. This measurement helps assess for adequate fetal growth. It is most reliable in the second and third trimesters. There is some variability in the measurements, typically plus or minus 2 weeks gestational age. Abnormal measurements should be evaluated with ultrasound.
A nurse practitioner provides education to nursing students on the mechanisms in which medications cross the placenta during pregnancy. Which mechanism is most commonly used to facilitate this process?
simple diffusion Most medications cross the placenta through simple diffusion. Simple diffusion occurs when molecules passively cross a semipermeable membrane such as the placenta. The placenta is an organ that develops within the uterus to support a growing fetus. The placenta has several functions including supplying oxygen and nutrients, and removing waste products from the fetus. The placenta is a semipermeable membrane that helps block certain harmful substances from reaching the fetus and allows certain other substances to pass through the placenta such as medications. There are several mechanisms by which these substances are absorbed through the placenta. The vast majority of medications cross the placenta through simple diffusion that occurs at the chorionic villi. Simple diffusion is a type of passive transport in which molecules can go through a semipermeable membrane without using energy and without the assistance of additional proteins. It is because of simple diffusion that providers must be mindful of the medications prescribed to pregnant women, as these medications can cross the placenta and directly impact the fetus.