MATERNAL CH 9,10,11,12,13
9. The nurse is assessing a patient who is 3 months pregnant. Which breast changes would the nurse expect to assess in this patient? A) Enlarged lymph nodes B) Slack, soft breast tissue C) Deeply fissured nipples D) Darkened breast areolae
Ans: D Feedback: As the pregnancy progresses, the areola of the nipples darkens, and its diameter increases. Enlarged lymph nodes; slack, soft breast tissue; and deeply fissured nipples are not expected breast changes in a pregnant patient.
11. What advice should the nurse provide to a patient who is 4 months pregnant and owns a cat? A) Give it away until after delivery. B) Refrain from cleaning the cat's dish. C) Be careful that it doesn't scratch the skin. D) Ask someone else to change the cat litter.
Ans: D Feedback: Toxoplasmosis, a protozoan infection, may be contracted through handling cat stool in soil or cat litter. Removing a cat from the home during pregnancy as a means of prevention is not necessary as long as the cat is healthy. The pregnant woman should be instructed not to change a cat litter box or garden in soil in an area where cats may defecate to avoid exposure to the disease. Cleaning the cat's dish is acceptable. Scratches do not cause the disease.
5. Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit? A) "Do you have a peptic ulcer?" B) "Have you ever had a heart attack?" C) "Have you had any neurologic diseases?" D) "Have you had any urinary tract infections?"
Ans: D Feedback: Urinary tract infections are associated with preterm birth. If the patient has a history of this type of infection, then interventions can be directed to help the patient avoid a urinary tract infection while pregnant. Although a part of the review of systems, asking about peptic ulcers, heart attacks, and neurologic diseases may not have as significant an impact on the developing fetus as having urinary tract infections.
12. Which nutritional information should the nurse suggest to a pregnant patient who follows a vegetarian eating plan? A) Include at least one serving of meat daily. B) Be careful not to eat more than four servings of fruit daily. C) Discontinue a vegetarian diet for the remainder of pregnancy. D) Anticipate needing a vitamin B12 supplement during pregnancy.
Ans: D Feedback: Vitamin B12 is found almost exclusively in animal protein, so if animal protein is excluded from the diet, vitamin B12 deficiency can occur unless this is supplemented. The patient should anticipate needing a vitamin B12 supplement while pregnant. The patient is a vegetarian and will not add meat to the diet. The intake of fruit will not adversely affect the patient or the development fetus. The patient may or may not want to discontinue the vegetarian diet while pregnant.
13. A patient having an examination to check the placement of an intrauterine device (IUD) is diagnosed as being pregnant. For which action should the nurse prepare the patient at this time? A) Removal of the IUD B) Surgery to abort the fetus C) Potential for a spontaneous abortion D) Nothing since the IUD can remain in place
Ans: A Feedback: A patient may become pregnant with an intrauterine device (IUD) in place. If this occurs, it needs to be removed to prevent infection during pregnancy. The fetus does not need to be aborted, and the patient will not spontaneously abort because the IUD is in place. The IUD cannot remain in place because of the risk for infection.
2. A pregnant patient is experiencing a vaginal discharge and wants to douche. What should the nurse instruct the patient about this health practice? A) Avoid routine douching. B) Use an alkaline solution. C) Use only a commercial solution. D) Use a solution that has been chilled.
Ans: A Feedback: Douching while pregnant is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix and lead to uterine infection. In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth. The alkalinity, purchase type, or temperature of the solution does not matter. The pregnant patient should not douche.
4. The nurse is determining the effectiveness of nutritional teaching with a pregnant patient. Which food item that the patient selects indicates that additional teaching on good sources of iron is needed? A) Milk B) Beef C) Grains D) Legumes
Ans: A Feedback: The foods richest in iron include organ meats; eggs; green, leafy vegetables; whole grains; enriched breads; or dried fruits. Milk is not a good source of iron and indicates that additional teaching is needed.
3. A pregnant patient asks if an over the counter vitamin can be taken during pregnancy instead of the prescribed prenatal vitamin. What should the nurse explain as the chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition? A) Folic acid B) Vitamin C C) Potassium D) Vitamin B12
Ans: A Feedback: Folic acid is added to maternal prenatal vitamins because of the threat of developing anemia. The pregnant patient should take a prenatal vitamin that contains a folic acid supplement of 0.4 to 0.6 mg, which may or may not be a part of an over the counter vitamin supplement. Vitamin C, potassium, and vitamin B12 are important; however, do not have the same risk of developing a health problem if not present in a prenatal vitamin supplement.
2. The nurse determines that a pregnant patient is working through developmental tasks. Which statement did the patient make to the nurse? A) "My mother and I are closer than ever before." B) "I'm thinking about everything I eat these days." C) "There are a lot of allergies in my husband's family." D) "I don't care what sex baby I have as long as it's healthy."
Ans: A Feedback: For the first time in her life, a woman during pregnancy can begin to empathize with the way her mother used to worry. This can make her own mother become more important to her and a new, more equal relationship develops. Thinking about diet, allergies, and the baby's sex are not developmental tasks for the pregnant patient.
9. How should the nurse record the obstetric history for a pregnant patient who previously delivered two live infants at term and had one abortion at 12 weeks' gestation? A) Gravida 3, para 2 B) Gravida 3, para 3 C) Gravida 4, para 2 D) Gravida 4, para 3
Ans: A Feedback: Gravida is defined as a woman who has been pregnant. Para is defined as the number of pregnancies that have reached viability, regardless of whether the infants were born alive. The patient was pregnant three times. The patient delivered two live births. The aborted fetus is not included in the para count. The patient was not pregnant four times.
19. A pregnant patient has a history of genital herpes lesions and has experienced outbreaks periodically throughout the pregnancy. What should the nurse instruct the patient regarding this virus if lesions are present at the time of delivery? A) A cesarean section will be advised at the time of birth. B) There are no precautions needed at the time of birth. C) The patient will need medication immediately after birth. D) The baby will be given a vaccination against the virus at birth.
Ans: A Feedback: If genital lesions are present at the time of birth, a fetus may contract the virus from direct exposure. A woman who has existing genital lesions at the time of birth will be advised to have a cesarean birth to reduce the risk of infecting the baby. There are precautions that need to be undertaken if lesions are present at the time of birth. The use of medication will depend on the patient's and infant's exposure to the virus.
13. A pregnant patient who has frequent allergic responses to drugs is concerned about an allergic reaction to the fetus. What information will the nurse use when responding to this patient's concern? A) Immunologic activity is decreased during pregnancy. B) The level of aldosterone during pregnancy reduces production of IgG antibodies. C) The kidneys release a hormone during pregnancy to prevent this from happening. D) The decreased corticosteroid activity during pregnancy ensures this will not happen.
Ans: A Feedback: Immunologic competency during pregnancy decreases probably to prevent a woman's body from rejecting the fetus as if it were a transplanted organ. Aldosterone does not impact the production of IgG antibodies. The kidneys do not influence an allergic response. Adrenal gland activity increases during pregnancy.
10. A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient? A) Transverse narrow B) Ideal for childbearing C) Similar in shape to a male D) Has weaker bones than normal
Ans: A Feedback: In an anthropoid pelvis, the transverse diameter is narrow. A gynecoid pelvis has an inlet that is well rounded forward and backward and has a wide pubic arch. This pelvic type is ideal for childbirth. An android pelvis is similar in shape to that of a male. The shape of the pelvis does not determine the strength of the bones.
12. The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed? A) "Pain with urination is expected during pregnancy." B) "I should call the doctor if I have any vaginal bleeding." C) "A sudden rush of fluid means that my membranes ruptured. D) "I should not worry if I vomit once a day for the first 12 weeks."
Ans: A Feedback: Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional patient teaching is needed. The patient should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy.
15. During a prenatal appointment, a patient who is 3 months pregnant states she ingests starch because of a craving. What should the nurse respond to this patient? A) Suggest a hemoglobin assessment be done. B) Kindly encourage the patient to discontinue the habit. C) Emphasize the protein, vitamin, and iron needs of pregnancy nutrition. D) Plan another appointment to discuss the hazards of ingesting nonfood substances.
Ans: A Feedback: Pica is a symptom that often accompanies iron deficiency anemia, and the primary care provider might need to assess the patient's serum iron level because correcting this underlying problem with an iron supplement may correct the pica. Stopping eating the nonfood substance may be difficult because the habit may be deeply ingrained. Emphasizing the importance of other nutrients while pregnant will not correct the problem. The nurse does not need to make another appointment to discuss the hazards of ingesting nonfood substances. The teaching can be conducted during the current appointment.
6. The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which patient statement indicates that the nurse's efforts have been successful? A) "It was so nice to not have to wait long in the waiting room." B) "I really hate having my weight and blood pressure measured around other people." C) "Why does everyone push breastfeeding and natural childbirth? What about what I want?" D) "I thought you would have more reading material on labor and delivery in the waiting room."
Ans: A Feedback: Strategies to individualize prenatal care include trying to schedule appointments so there won't be a long wait time, providing privacy for weight and blood pressure assessments, educating on care options and encouraging participating in decisions about care, and providing materials on pregnancy in the waiting room.
2. The nurse is instructing a pregnant patient to consume a diet high in complete proteins. Which food item should the nurse recommend as an example of a complete protein? A) A boiled or fried egg B) Green, leafy vegetables C) A slice of whole grain toast D) Applesauce or a whole apple
Ans: A Feedback: The protein in meat, poultry, fish, yogurt, eggs, and milk contain all nine essential amino acids required and are considered complete proteins. The protein in nonanimal sources does not contain all essential amino acids and are considered incomplete proteins. Green, leafy vegetables; whole grain toast; and apples or applesauce are carbohydrate sources.
15. What advice should the nurse provide to a pregnant patient who admits to continuing to drink alcohol one to two times a week? A) Avoid all alcohol while pregnant. B) Avoid alcohol in the first trimester. C) The effects of alcohol on the fetus are not fully understood. D) An occasional drink is permitted only after the first trimester.
Ans: A Feedback: There is evidence to confirm that women who consume large quantities of alcohol during pregnancy can have babies with congenital craniofacial deformities. It is impossible to define a safe level of alcohol consumption. Women should be screened for alcohol use at a first prenatal visit and advised to abstain from alcohol completely for the remainder of their pregnancy. Refer pregnant women with alcohol addiction to an alcohol treatment program as early in pregnancy as possible to help them reduce their alcohol intake.
4. A pregnant patient is experiencing leg cramps. What should the nurse include in the patient's teaching plan as a relief measure? (Select all that apply.) A) Avoid full leg extension. B) Elevate lower extremities. C) Elevate the legs on two pillows. D) Stand on each leg and perform a squat. E) Bend the knee and perform dorsiflexion.
Ans: A, B Feedback: If a pregnant woman is experiencing frequent leg cramps, she may be advised to elevate lower extremities frequently during the day to improve circulation and avoiding full leg extension. Elevating the legs on two pillows may or may not help the patient. The patient should not be instructed to perform squats or dorsiflexion to help with the leg cramps.
1. The nurse is planning a seminar that focuses on the 2020 National Health Goals during pregnancy for patients who are in the first trimester of pregnancy. Which information should the nurse include in this seminar? (Select all that apply.) A) Refusing alcohol B) Importance to stop smoking C) Maintaining health appointments D) Seeking alternative care approaches E) Abstaining from drugs and substances
Ans: A, B, C, E Feedback: The 2020 National Health Goals for pregnancy include objectives to abstain from social and binge alcohol intake, avoid smoking, receive prenatal care, and abstain from illicit drugs. Seeking alternative care approaches is not a 2020 National Health Goal for pregnancy.
7. The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit. For what will the nurse test this patient's urine? (Select all that apply.) A) Protein B) Glucose C) Bacteria D) Drug levels E) White blood cells
Ans: A, B, C, E Feedback: Urine is tested for proteinuria, glycosuria, nitrites, and pyuria. All of these can be done by means of test strips. The nurse will not test the patient's urine for drug levels as part of a routine prenatal visit.
4. The nurse in a community clinic is identifying ways to achieve the 2020 National Health Goals to support prenatal care. Which nursing actions would support the achievement of these goals? (Select all that apply.) A) Urge female patients to ingest an adequate intake of folic acid. B) Recommend pregnant patients attend developmental childbirth classes. C) Discuss strategies to avoid intimate partner violence with every pregnant patient. D) Provide a play area in the waiting room for the children of patients waiting to be seen. E) Support pregnant patients to achieve the recommended weight gain during pregnancy.
Ans: A, B, D, E Feedback: A number of 2020 National Health Goals speak directly to the importance of prenatal care to include increasing the proportion of pregnant women who attend a series of prepared childbirth classes, increasing the proportion of women of childbearing potential who have an intake of at least 400 mcg of folic acid from fortified foods or dietary supplements before pregnancy, increasing the proportion of mothers who achieve a recommended weight gain during their pregnancies, and making sites for prenatal care "family friendly" or maximally receptive to women and families. Strategies to avoid intimate partner violence will not help the nurse achieve the 2020 National Health Goals for prenatal care.
16. A patient enjoys exercising and wants to know if it can continue to be done while pregnant. What should the nurse instruct the patient about exercising at this time? (Select all that apply.) A) Drink plenty of liquids to prevent dehydration. B) Limit strenuous exercise to no longer than 20 minutes. C) Eat a low protein, simple carbohydrate snack before exercising. D) Warm up for 5 minutes by walking or cycling on low resistance. E) Avoid exercises that require jumping or rapid changes in direction.
Ans: A, B, D, E Feedback: The nurse should instruct the patient to drink liquids to prevent dehydration, limit strenuous exercise to 20 minutes, warm up before beginning an exercise session, and avoid exercises that can jar the body. The patient should be instructed to eat a protein and complex carbohydrate snack before exercise to maintain the serum glucose level.
7. During a previous prenatal visit, the nurse focused on the importance of adequate nutritional intake with a pregnant patient. Which assessment findings indicate that this teaching has been effective? (Select all that apply.) A) Shiny hair B) Smooth tongue C) Conjunctiva pale D) Chipped finger nails E) Normal muscle reflexes
Ans: A, B, E Feedback: Evidence of an adequate nutritional intake while pregnant includes shiny hair, smooth tongue, and normal muscle reflexes. Pale conjunctiva could indicate iron deficiency. Chipped fingernails could indicate inadequate protein intake.
13. The nurse is planning nutritional instructions for a pregnant patient who is a Mexican immigrant. On which areas should the nurse focus when preparing teaching for this patient? (Select all that apply.) A) Add fruits rich in vitamin C. B) Consume potatoes at every meal. C) Increase the intake of dairy products. D) Reduce the cooking time of vegetables. E) Limit the amount of added animal fat in foods.
Ans: A, C, D, E Feedback: In the Mexican culture, most vegetables are cooked for a long time so they lose most of their nutritional value. Diet is high in fiber and starch. Animal fat is frequently added during food preparation. The diet may be inadequate in calcium, iron, vitamin A, and vitamin C. The nurse should instruct the patient to add fruits rich in vitamin C, increase dairy product intake, reduce cooking times of vegetables, and limit the amount of animal fat in the diet.
3. A newly wed young adult patient tells the nurse that she hopes to become pregnant soon. What should the nurse recommend to this patient to support the 2020 National Health Goals for pregnancy? (Select all that apply.) A) Stop smoking. B) Increase exercise. C) Eat a healthy diet. D) Reduce work hours. E) Limit alcohol intake.
Ans: A, C, E Feedback: Nurses can help the nation achieve the 2020 National Health Goals for pregnancy by being certain women receive counseling in nutrition and low uses of alcohol and tobacco before pregnancy so they can enter intended pregnancies in the best health possible. Increasing exercise and reducing work hours are not interventions that would support the 2020 National Health Goals for pregnancy.
8. At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk during the pregnancy. Which data from the patient's past illness history does the nurse use to make this decision? (Select all that apply.) A) Seizure disorder B) Previous cesarean birth C) Hypertension for 10 years D) History of abnormal Pap smear E) Previous treatment for gonorrhea
Ans: A, C, E Feedback: Past illness history criteria that place a patient at risk during pregnancy include a seizure disorder, a chronic disease such as hypertension, and sexually transmitted infections. A previous cesarean birth and a history of abnormal Pap smears are criteria for the obstetrical history, which can place the patient at risk during pregnancy.
13. A pregnant patient is directed to perform a daily fetal movement count. What should the nurse instruct the patient about this count? (Select all that apply.) A) Lie down to do the count after eating a meal. B) Count only movements that are strong enough to hurt. C) Report if no movement is felt for any half hour period. D) Choose a different time frame each day to count movements. E) Count fetal movements until a total of 10 are counted and record the time.
Ans: A, E Feedback: A healthy fetus moves at about 10 times per hour. The nurse should instruct the patient to lie in a left recumbent position after a meal, observe and record the number of fetal movements or kicks the fetus makes until 10 movements are counted, and record the time. If an hour passes without 10 movements, the patient should walk around a little and try a count again. If 10 movements cannot be felt in a second 1 hour period, the patient should telephone the primary health care provider.
8. The nurse is planning care for several pregnant patients. Which patient is at the greatest risk for nutritional deficiency while pregnant? A) Patient who rarely eats fruit B) Patient with a 1 year old son C) Patient with 10 year old twins D) Patient who never follows a weight reduction diet
Ans: B Feedback: A pregnant woman with high parity or a short interval between pregnancies such as having a 1 year old son may enter pregnancy with depleted nutritional reserves that she has little to draw on during the first part of pregnancy. The other pregnant patients may have nutritional deficiencies that can be corrected with vitamin supplementation or adjustments in the diet.
10. After a routine examination, a patient tells the nurse that she plans to use a home pregnancy test to determine if she is pregnant. What should the nurse respond to this patient's plan? A) Use a diluted urine specimen. B) Arrange for prenatal care if the test is positive. C) Wait until after two missed menstrual periods. D) Refrain from eating for 4 hours before testing.
Ans: B Feedback: After a positive pregnancy test, the first step should be to arrange for prenatal care. This is the response that the nurse should make to the patient. The urine is not usually diluted for a home pregnancy test. The patient should not wait for 2 months before determining if she is pregnant. Eating does not impact the results of the home pregnancy test.
11. A pregnant patient scheduled for an amniocentesis asks the nurse how the placenta is not punctured during the procedure. What should the nurse respond to the patient? A) "A uterus feels soft over the placenta site." B) "A sonogram to locate it will be done first." C) "It would not be harmful even if it were punctured." D) "Placentas always form on the posterior uterine wall."
Ans: B Feedback: After the patient is placed in the supine position, a sonogram is done to determine the position of the fetus, the location of a pocket of amniotic fluid, and the placenta. The uterus does not feel soft over the placenta site. It would be harmful if the placenta were punctured during the procedure. Placentas do not always form on the posterior uterine wall.
8. During a physical assessment, the nurse palpates a pregnant patient's fundus at the level of the umbilicus. What statement should the nurse make to the patient about this assessment finding? A) "You are at 12 weeks of your pregnancy." B) "You are at 20 weeks of your pregnancy." C) "You are at 36 weeks of your pregnancy." D) "You can go into labor at any time now."
Ans: B Feedback: As a fetus grows, the uterus expands to accommodate its size. Typical fundal measurements are over the symphysis pubis at 12 weeks, at the umbilicus at 20 weeks, and at the xiphoid process at 36 weeks. The patient is not going to go into labor at any time.
5. The nurse teaches the importance of avoiding nonessential substances to a young adult female who is 6 weeks pregnant. Which patient statement indicates that teaching has been effective? A) "I can drink on weekends only." B) "Smoking is bad for me and my baby." C) "Smoking is permitted as long as I do it outdoors." D) "Only one beer or one glass of wine is permitted while pregnant."
Ans: B Feedback: Because almost all drugs are able to cross into the fetal circulation, it is important that a woman take no nonessential drugs, including alcohol and nicotine, during pregnancy. Alcohol perfuses across the placenta and can cause fetal alcohol sequence disorders. Because it is difficult to tell what quantity is "safe," pregnant women are advised to drink no alcohol during pregnancy. The statement that "smoking is bad for me and my baby" indicates that teaching has been effective. The patient should be instructed to avoid all alcohol intakes while pregnant and to not smoke.
14. During a routine prenatal examination, a pregnant patient's urine is found to have a trace amount of glucose. What does this finding indicate to the nurse? A) The patient has gestational diabetes. B) Lactose may be spilling into the urine. C) The patient is eating excessive calories. D) It is because of a decrease in glomerular filtration rate.
Ans: B Feedback: Because reabsorption of glucose by the tubule cells occurs at a fixed rate, this causes some accidental spilling of glucose into the urine during pregnancy. Lactose, which is being produced by the mammary glands but is not used during pregnancy, will also be spilled into the urine. If more than a trace amount of glucose is found in the pregnant patient's urine, this could indicate gestational diabetes. The increase of glucose in the urine is not because of eating excessive calories. The glomerular filtration rate increases in pregnancy.
18. A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms? A) Exercise helps reduce the frequency of them. B) If rhythmical, they could indicate preterm labor. C) Lying down for a few hours will help them stop. D) They are false labor and do not need to be reported.
Ans: B Feedback: Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. These sensations are Braxton Hicks contractions and can be similar to a forceful menstrual cramp. These contractions are not usually a sign of beginning labor but should be reported for evaluation. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of preterm labor. Exercise or rest does not reduce the frequency of Braxton Hicks contractions.
10. A pregnant patient asks the nurse what can be done for constipation. What should the nurse recommend to the patient? A) Mineral oil B) Increased fiber intake C) Eating more meat products D) Stopping prenatal vitamins temporarily
Ans: B Feedback: Eating fiber rich foods is a natural way to prevent constipation because the bulk of the fiber left in the intestine aids evacuation. Eating fiber rich foods this way is a better choice for preventing constipation than taking a fiber laxative because it allows a pregnant patient to receive nutrients from the food as well as prevent constipation. The pregnant patient should not use mineral oil to relieve constipation because it can prevent absorption of fat soluble vitamins A, D, K, and E, vitamins necessary for both good fetal and maternal health. Eating more meat products can add to the constipation. The patient should not be advised to stop prescribed prenatal vitamins.
15. The nurse is visiting the family of a newly pregnant patient whose spouse was ambivalent about the pregnancy during the first prenatal visit. Which observation indicates that the spouse is accepting the pregnancy? A) Spouse leaves the house when the nurse arrives. B) Spouse sits with the pregnant patient during the nurse's visit. C) Spouse shouts down the stairs about the location of clean laundry. D) Spouse tells the patient what needs to be obtained from the grocery store.
Ans: B Feedback: If childbearing is to be a family affair, it is important to determine a partner's degree of acceptance of the pregnancy and how well prepared the spouse is of assuming a new parenting role. After confirmation of pregnancy, include the partner in health care information or suggestions. The spouse sitting with the pregnant patient during the nurse's visit indicates that the spouse is accepting the pregnancy. Leaving the house, shouting down the stairs about laundry, and giving a list of grocery items could indicate indifference or no interest in the pending pregnancy. These actions do not support acceptance of the pregnancy.
1. The nurse is explaining the process of fertilization to a patient who has just learned of being pregnant. On which day during pregnancy should the nurse explain that the embryo implants on the uterine surface? A) Four days after fertilization B) Eight to 10 days after fertilization C) The 14th day of a "typical" menstrual cycle D) Ten days after the start of the menstrual flow
Ans: B Feedback: Implantation, or contact between the growing structure and the uterine endometrium, occurs approximately 8 to 10 days after fertilization. Four days after fertilization the structure is a zygote. Implantation does not occur on the 14th day of a typical menstrual cycle or 10 days after the start of a menstrual flow.
6. A pregnant patient tells the nurse that saturated fats are avoided by using vegetable oil. What additional information about vegetable oil can the nurse use to reinforce this patient's decision? A) Aids in fluid balance B) Contains linoleic acid C) Stimulates kidney function D) Has a high potassium content
Ans: B Feedback: Linoleic acid is a fat that is essential for new cell growth but cannot be manufactured by the body. Vegetable oils such as safflower, corn, olive, peanut, and cottonseed; fatty fish; omega 3-infused eggs; and omega 3-infused spreads are all good sources of linoleic acid. Vegetable oil does not aid in fluid balance, stimulate kidney function, or have high potassium content.
14. A patient who is 4 months pregnant is experiencing pyrosis. Which suggestion should the nurse make to the patient to help with this health problem? A) Try to include complex carbohydrates in meals. B) Eat small meals and do not lie down after meals. C) Increase vitamin intake by adding more citrus fruit. D) Take 30 ml of milk of magnesia after every meal.
Ans: B Feedback: Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the stomach causes regurgitation into the esophagus. Eating small meals and remaining upright limits the possibility of regurgitation. The patient should be instructed to avoid fatty and fried foods, coffee, carbonated beverages, tomato products, and citrus juices. Complex carbohydrates will not help with the problem. Milk of magnesia is not recommended to be taken for pyrosis.
12. A woman who is 4 months pregnant asks what can be done to alleviate frequent heart palpitations and leg cramps. Which nursing diagnosis would be applicable to the patient at this time? A) Pain related to severe complications of pregnancy B) Health seeking behaviors related to ways to relieve discomforts of pregnancy C) Risk for ineffective breathing pattern related to pressure of the growing uterus D) Impaired urinary elimination related to inability to excrete creatine from the muscles
Ans: B Feedback: The patient is asking for information to reduce the symptoms of heart palpitations and leg cramps caused by pregnancy. This is health seeking behavior. Heart palpitations and leg cramps are not severe complications of pregnancy. There is no evidence to suggest that the patient is at risk for an ineffective breathing pattern. There is also no evidence to support that the patient is experiencing impaired urinary elimination.
2. While conducting the first prenatal health history visit, the nurse learns that a pregnant patient is taking various herbal remedies and over the counter medications for minor ailments. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time? A) Risk for injury to fetus related to lifestyle choices B) Deficient knowledge regarding exposure to teratogens during pregnancy C) Health seeking behaviors related to strong cultural desire to have a healthy child D) Health seeking behaviors related to guidelines for nutrition and activity during pregnancy
Ans: B Feedback: The patient is taking herbal remedies and over the counter medications, many of which can be teratogenic to the developing fetus. This is the most appropriate nursing diagnosis for the nurse to select for this assessment finding. There is no enough information to determine if the fetus is at risk because of the patient's lifestyle choices. The patient has not asked for specific information so health seeking behavior diagnoses would not be appropriate for the patient at this time.
16. The nurse is planning a prenatal educational program for a community health center. What information should the nurse include that supports the 2020 National Health Goals for nutrition in pregnancy? (Select all that apply.) A) Avoid foods high in fats and calories. B) Take prenatal vitamins as prescribed. C) Ensure a daily intake of foods with folic acid. D) Limit the intake of foods high in simple carbohydrates. E) Maintain adequate nutrition before becoming pregnant.
Ans: B, C, E Feedback: Information that the nurse should include that supports the 2020 National Health Goals for nutrition in pregnancy include taking prenatal vitamins as prescribed because these will contain iron and folic acid. The nurse should also teach the participants to have a daily intake of foods with folic acid and to maintain adequate nutrition before becoming pregnant so that those entering pregnancy will have adequate nutritional stores. There are no specific foods that a pregnant patient should avoid such as those high in fat and calories. All pregnant patients do not need to limit the intake of foods high in simple carbohydrates.
9. The nurse is planning to instruct a patient who is 12 weeks pregnant on interventions to stop smoking. What should the nurse include in these instructions? (Select all that apply.) A) Purchase nicotine chewing gum. B) Follow a smoking cessation plan. C) Ask a friend to help with smoking cessation actions. D) Apply a nicotine patch when the cravings become severe. E) Ask the physician if a smoking cessation medication can be used.
Ans: B, C, E Feedback: Interventions to help a pregnant patient with smoking cessation include following a smoking cessation plan, asking a friend to help with smoking cessation actions, and asking the physician if a smoking cessation medication can be used. The patient should not be instructed to purchase nicotine chewing gum or a patch because nicotine is a pregnancy category C drug, will cross into the placenta, and adversely affect the developing fetus.
14. The nurse determines that a fetal nonstress test is nonreactive for over 20 minutes. What does the nurse realize as being reasons for this finding? (Select all that apply.) A) The patient is sleeping. B) The patient is hypoglycemic. C) The patient is using an illicit drug. D) The patient is exercising too much. E) The patient is smoking while pregnant.
Ans: B, C, E Feedback: Reasons for lessened variability during a fetal nonstress test include maternal smoking, drug use, or hypoglycemia. Lessened variability does not occur because the patient is sleeping or because the patient is exercising too much.
4. A pregnant patient asks why an fetoprotein serum level has been ordered. What should the nurse explain to the patient about this test? A) It screens for placenta function. B) It measures the fetal liver function. C) It may reveal chromosomal abnormalities. D) It tests the ability of the patient's heart to accommodate the pregnancy.
Ans: C
11. A patient who is 2 months pregnant is concerned about frequent urination. What should the nurse instruct the patient about this occurrence? A) This means urine is more concentrated. B) The fetus is adding urine to the patient's bladder. C) It is caused by pressure on the bladder from the uterus. D) There is a decrease in the glomerular cells of the kidney.
Ans: C Feedback: A pregnant woman may notice an increase in urinary frequency during the first 3 months of pregnancy, until the uterus rises out of the pelvis and relieves pressure on the bladder. An increase in urination early in pregnancy is not caused by concentrated urine or a decrease in the glomerular cells of the kidney. The fetus is not adding urine to the patient's bladder.
11. A woman of normal weight learns that she is pregnant and asks the nurse how much weight she should gain until delivery. What should the nurse respond to this patient? A) Do not gain over 20 lb. B) Any gain over 30 lb is ideal. C) Twenty five to 35 lb is ideal. D) The amount of weight gain is not important.
Ans: C Feedback: A weight gain of 25 to 35 lb encourages fetal growth yet does not lead to a maternal weight gain postpregnancy. A patient who is overweight might be encouraged to limit weight gain to 20 lb while pregnant. A weight gain over 30 lb might be recommended for the patient that is underweight. The amount of weight gain is important to ensure adequate growth and health of the developing fetus and mother.
1. During a prenatal examination, the nurse learns that a pregnant patient has a supernumerary nipple. What should the nurse teach the patient about this finding? A) Such growths fade with menopause. B) Bleeding from such growths is not uncommon. C) Such growths deepen in color during pregnancy. D) The tendency for supernumerary nipples is genetic.
Ans: C Feedback: Breast changes may be one of the first things women notice in pregnancy. Any supernumerary nipples may become darker and enlarge in size. There is no information to support that supernumerary nipples fade with menopause or bleed. There is also no information to support that supernumerary nipples are genetic in origin.
5. A pregnant patient tells the nurse that drinking enough fluids has always been a problem for her. What should the nurse counsel the patient as being an adequate daily amount of fluid to drink while pregnant? A) Two glasses B) Four glasses C) Eight glasses D) Ten glasses
Ans: C Feedback: Extra amounts of water are needed during pregnancy to promote kidney function because a woman must excrete waste products for two. Eight glasses of fluid daily is a common recommendation. Two or four glasses of fluid would not be an adequate amount. Ten glasses of fluid might be too much for the patient to consume each day.
3. The nurse is teaching a patient in the first trimester of pregnancy about the importance of folic acid in the diet and how folic acid supplements might be beneficial. For which reason is the nurse teaching the patient about this vitamin? A) Maintains energy throughout the pregnancy B) Controls the risk of hypertension while pregnant C) Prevents neural tube disorders in the developing fetus D) Sustains a slow and steady weight gain while pregnant
Ans: C Feedback: Folic acid deficiency in pregnancy can lead to midline closure defects such neural tube disorders. One of the 2020 National Health Goals addresses an adequate folic acid intake while pregnant, and the nurse can help the nation achieve this goal by urging women to have an optimum folic acid level. Folic acid is not encouraged in the pregnant patient to maintain energy, control the risk of hypertension, or sustain a slow and steady weight gain while pregnant.
12. A patient who is 16 weeks pregnant has a lower blood pressure than that of prepregnancy levels. What should the nurse realize as being the cause for this lower blood pressure? A) Prepregnancy blood pressure measurements were inaccurate. B) Blood pressure progressively decreases throughout the entire pregnancy. C) A decrease in the second trimester may occur because of placental growth. D) Dehydration because blood pressure increases steadily throughout pregnancy.
Ans: C Feedback: In some women, blood pressure actually decreases slightly during the second trimester because the expanding placenta causes peripheral resistance to circulation to lower. The lower blood pressure is not because prepregnancy blood pressure measurements were inaccurate. Blood pressure does not normally decrease throughout the entire pregnancy. There is no enough information to determine if the patient is dehydrated; however, this is not the reason for the blood pressure to be lower in the second trimester of pregnancy.
8. The nurse is reviewing the signs of labor with a patient entering the last phase of the third trimester of pregnancy. What should the nurse include as an indication that the labor is beginning? A) Excessive fatigue and headache B) Sharp, right sided abdominal pain C) Sudden gush of clear fluid from the vagina D) An increased pulse rate and upper abdominal pain
Ans: C Feedback: Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. Excessive fatigue, headache, abdominal pain, or increased pulse rate are not indications that labor is beginning.
7. A pregnant patient is concerned that she is allergic to something because her hands have been red and itchy since becoming pregnant. What should the nurse explain as the cause of the patient's symptoms? A) Allergy to fetal protein B) Reduced serum protein C) Increased estrogen level D) Chorionic gonadotropin hormone secretion
Ans: C Feedback: Palmar erythema, or palmar pruritus, occurs in early pregnancy and is probably caused by increased estrogen levels. Constant redness or itching of the palms can make a woman believe she has developed an allergy. This type of itching in early pregnancy is normal and is not caused by an allergy to fetal protein, reduced serum protein, or chorionic gonadotropin hormone secretion.
1. 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
Ans: C Feedback: 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.
7. A patient who is 28 weeks pregnant is demonstrating signs of placental insufficiency. The health care provider prescribes betamethasone. What should the nurse inform the patient regarding the purpose of this medication? A) It stops premature labor. B) It improves functioning of the placenta. C) It potentiates the formation of surfactant. D) It improves immunologic function of the fetus.
Ans: C Feedback: Synthetically increasing steroid levels in the fetus through the use of betamethasone can hurry alveolar maturation and surfactant production without interfering with permanent lung function prior to a preterm birth. Surfactant is formed and excreted by the alveolar cells of the lungs at about the 24th week of pregnancy, decreases alveolar surface tension on expiration, prevents alveolar collapse, and improves the infant's ability to maintain respirations in the outside environment at birth. Betamethasone is not being given to this patient to stop premature labor, improve the function of the placenta, or improve immunologic function of the fetus.
14. A nurse is 5 weeks pregnant and works on a care area where chemotherapy is administered to patients. Which statement indicates that this nurse needs additional health teaching about avoiding teratogens during pregnancy? A) "I care for about five patients a day." B) "I find giving emotional support taxing." C) "Latex gloves irritate my hands, so I don't use them." D) "I never accompany patients to the X ray department."
Ans: C Feedback: The nurse is not using latex gloves and is exposed to chemotherapeutic agents, which are known teratogens during pregnancy. This nurse needs additional instruction to reduce exposure from the chemotherapy agents. Caring for five patients a day does not necessarily increase the nurse's exposure to teratogens. Emotional support does not increase the nurse's exposure to teratogens. Avoiding X rays is a positive action to avoid teratogens.
9. A woman who is 6 weeks pregnant is concerned because she is nauseated every morning. Which measure should the nurse suggest the patient use to help relieve nausea? A) Take two aspirin on arising. B) Delay toothbrushing until noon. C) Delay breakfast until midmorning. D) Take a teaspoon of baking soda before breakfast.
Ans: C Feedback: The traditional solution for preventing nausea is for the pregnant patient to keep dry crackers, such as saltines, by the bedside and eat a few before rising because increasing carbohydrate intake seems to relieve nausea better than any other nutrition remedy. The patient can then eat a light breakfast or delay breakfast until 10 or 11 AM, which is past the time nausea seems to persist. Aspirin is irritating to the stomach and should not be taken. Delaying toothbrushing does not affect nausea. A teaspoon of baking soda should not be suggested because this could adversely affect the patient's electrolyte status.
15. The nurse is evaluating the fetal heart rate rhythm strip and determines that the amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding indicate to the nurse about variability? A) Variability is absent. B) Variability is minimal. C) Variability is normal. D) Variability is marked.
Ans: C Feedback: Variability is absent when there is no peak to trough range detected. Variability is minimal when an amplitude range is detected but the rate is 5 beat/min or fewer. Variability is moderate or normal when an amplitude range is detected and the rate is 6 to 25 beat/min. Variability is marked when an amplitude range is detected and the rate is greater than 25 beat/min.
6. The nurse is completing a physical assessment with a patient who has just learned of being pregnant. The patient's last menstrual period was August 15. When should the nurse instruct the patient that the baby will be due? A) July 15 B) June 22 C) May 22 D) April 15
Ans: C Feedback: When using Naegele's rule, the nurse should count backward 3 calendar months from the first day of the patient's last menstrual period and then add 7 days. For August 15, the month would be May and the day would be 15 plus 7 or 22. May 22 is when the patient's baby is due. July 15, June 22, and April 15 are inappropriate applications of Naegele's rule.
6. A pregnant patient who works as a secretary at a large corporation wants to take a leave of absence from work but is afraid of losing seniority. What should the nurse advise the patient? A) The patient should not ask for special favors. B) The leave of absence should occur after the baby is born. C) The employer cannot penalize the patient for being pregnant. D) It is not wise for any woman to work past the seventh month of pregnancy.
Ans: C Feedback: Women who are unable to continue working while pregnant are protected from loss of employment benefits during pregnancy by federal law. According to federal law, an employer cannot deprive women of seniority rights because they take a maternity leave. The patient is not asking for special favors. The maternity leave can occur before the delivery because the Family Medical and Leave Act can be used once the baby is delivered. There is no time limit about how long a pregnant patient can work.
8. After an examination, an advanced practice nurse confirms that a patient is pregnant. What did the nurse assess in this patient? (Select all that apply.) A) Painful breast tissue B) Positive pregnancy test C) Fetal movements felt by the nurse D) Visualization of the fetus by ultrasound E) Fetal heart rate separate from the patient's
Ans: C, D, E Feedback: There are only three documented or positive signs of pregnancy—demonstration of a fetal heart separate from the mother's, fetal movements felt by an examiner, and visualization of the fetus by ultrasound. Painful breast tissue is a presumptive sign of pregnancy. A positive pregnancy test is a probably sign of pregnancy.
3. When explaining what will occur during the first prenatal visit physical examination, a pregnant patient asks why a Papanicolaou smear is being done at this time. What should the nurse respond to the patient? A) It helps to date the pregnancy. B) It detects if uterine cancer is present. C) It predicts whether cervical cancer will occur. D) It detects cancer cells of the cervix, vulva, or vagina.
Ans: D Feedback: A Pap smear is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not present. A Pap smear is not used to date a pregnancy, detect uterine cancer, or predict if cervical cancer will occur.
3. The nurse is emphasizing the importance of adequate rest and sleep with a pregnant patient. Which position should the nurse suggest the patient use? A) On the back with a pillow under the head B) On the stomach with a pillow under her breasts C) On the back with a pillow under the knees and hips D) On the side with the weight of the uterus on the bed
Ans: D Feedback: A good resting or sleeping position for a pregnant patient is a left sided Sims' position, with the top leg forward. This position puts the weight of the fetus on the bed, not on the woman, and allows good circulation in lower extremities. Lying on the back could cause the weight of the uterus to occlude the inferior vena cava impeding blood flow to the patient and fetus. Stomach lying is not a reasonable option with the size of the uterus.
7. A patient makes an appointment at the prenatal clinic because she thinks she might be pregnant. Which assessment is a probable sign of pregnancy? A) Amenorrhea B) Enlargement and darkening of areola C) Nausea and vomiting D) A positive pregnancy test
Ans: D Feedback: A probable sign of pregnancy is one that is objective and can be measured by an observer. A positive pregnancy test is a probable sign of pregnancy. Amenorrhea, enlargement and darkening of areola, and nausea and vomiting are presumptive signs because they could indicate another health condition.
17. A pregnant patient is planning travel to a foreign country as part of a work assignment and needs immunizations. What should the nurse instruct the patient about immunizations while pregnant? A) Immunizations should be restricted to live viruses only. B) There are no restrictions on immunizations while pregnant. C) The only immunization that should be avoided is for the flu. D) Live virus immunizations are contraindicated while pregnant.
Ans: D Feedback: All live virus vaccines are contraindicated during pregnancy and should not be administered unless the risk of the disease outweighs the risk to the pregnancy because live virus vaccines can cross the placenta and infect the fetus. The influenza vaccine is recommended if it is flu season when visiting crowded locations.
5. A pregnant patient is concerned that orgasm will be harmful to the developing fetus. What should the nurse include when responding to this patient's concern? A) Orgasm during pregnancy is potentially harmful. B) Venous congestion in the pelvis makes orgasm painful. C) Most women do not experience orgasm during pregnancy. D) Some women experience orgasm intensely during pregnancy.
Ans: D Feedback: Because of increased pelvic congestion from the additional uterine blood supply at midpregnancy, most women notice increased clitoral sensation and may experience orgasm for the first time during pregnancy because of this. Orgasm during pregnancy is not harmful. Pelvic congestion does not make orgasm painful.
12. A pregnant patient is concerned that the baby is going to drown in the uterus because of the fluid. What should the nurse respond about fetal respiration? A) "You are breathing for the baby." B) "The baby's breathing is very minor until delivery." C) "The baby's lungs can accommodate all of the fluid." D) "Oxygen is provided to the baby through the placenta."
Ans: D Feedback: Fetal circulation differs from extrauterine circulation because the fetus derives oxygen and excretes carbon dioxide not from gas exchange in the lung but from exchange in the placenta. The baby's lungs are not functioning in utero so the response that the baby's breathing is very minor until delivery and the baby's lungs being able to accommodate the fluid are incorrect. The patient is not "breathing for the baby."
13. During the previous prenatal visit, the nurse instructed a pregnant patient on ways to reduce the impact of varicosities. Which patient statement indicates that additional teaching is needed? A) "I drink fluid throughout the day." B) "I'll try not to stand for long periods." C) "I point my toes up and down frequently." D) "I wear knee highs rather than pantyhose."
Ans: D Feedback: For varicosities, the patient should be instructed to avoid constrictive knee high hose. Fluid intake, avoiding prolonged positions, and dorsiflexion of the feet are ways to reduce the impact of varicosities and would not require additional teaching.
14. How should the nurse document a pregnant patient's gestational status using the GTPAL system after collecting the following data? Currently 18 weeks pregnant Patient's fourth pregnancy Delivered one nonviable fetus at 26 weeks Experienced one miscarriage Delivered one viable fetus at 38 weeks' gestation A) 3, 2, 1, 2, 1 B) 4, 2, 2, 1, 1 C) 3, 2, 1, 1, 1 D) 4, 1, 1, 1, 1
Ans: D Feedback: GTPAL is a more comprehensive system for classifying pregnancy status. By this system, the gravida classification remains the same, but para is broken down into T: the number of full term infants born (infants born at 37 weeks or after), P: the number of preterm infants born (infants born before 37 weeks), A: the number of spontaneous miscarriages or therapeutic abortions, and L: the number of living children. The patient has been pregnant four times. The patient delivered one viable infant at 38 weeks. The patient delivered one nonviable fetus at 26 weeks. The patient had one miscarriage. The patient has one living child.
5. The spouse of a pregnant patient is quiet during prenatal visits but is demonstrating emotional involvement in the pregnancy. What action did the spouse perform? A) States he definitely wants a girl B) Refuses to paint the baby's room blue C) States he is concerned about the loss of his free time D) Walks around furniture as if his abdomen is enlarged
Ans: D Feedback: Many men experience physical symptoms and may begin to gain weight along with their partner. As a woman's abdomen begins to grow, the partner may perceive himself as growing larger too, as if he were the one who was experiencing changing boundaries the same as his partner. This indicates emotional involvement in the pregnancy. Stating a specific sex for the baby, losing free time, and refusing to paint the baby's room blue are not indications that the spouse is emotionally involved in the pregnancy.
17. The nurse has identified the diagnosis of imbalanced nutrition for a pregnant patient. Which assessment data did the nurse use to identify this diagnosis for the patient? A) Patient eats salads at least twice a day. B) Patient does not like potatoes or bread. C) Patient eats red meat several times a week. D) Patient does not want to gain any weight while pregnant.
Ans: D Feedback: Not wanting to gain weight while pregnant could lead to imbalanced nutrition for both the mother and developing fetus. Eating salads and red meat will not lead to imbalanced nutrition. Avoiding potatoes and bread will not lead to imbalanced nutrition.
9. A pregnant patient enjoys exercising at a local health spa once a week. Which patient comment indicates to the nurse that additional health teaching is needed? A) "I'm learning to play table tennis." B) "I limit exercising to low impact aerobics." C) "The gym gets hot and stuffy by midmorning." D) "Nothing feels nicer than a hot tub soak after exercise."
Ans: D Feedback: Pregnant women should not soak for long periods in extremely hot water or hot tubs because heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. Playing table tennis, performing low impact aerobics, and the environment of the gym are not comments that indicate the need for additional teaching.
6. A father is preparing a 4 year old son for the arrival of a new baby. Which statement should the nurse suggest the father use to explain this to the child? A) "Mother will need to spend a lot of time with the new baby." B) "It will be fun to have a sister or brother to give your old toys to." C) "The new baby will need your bed so we're buying you a new one." D) "A new baby will make our family bigger but not change our love for you."
Ans: D Feedback: Preschool age children may need to be assured periodically during pregnancy a new baby will be an addition to the family and will not replace them in their parents' affection. Explaining that the mother will have less time for the child, equating the new baby as "fun," and taking away a bed for the baby will not help the child accept the new baby into the family.
10. An adolescent asks which sport would be safe for her to learn during pregnancy. Which activity should the nurse suggest to the patient? A) Skiing B) Jogging C) Bicycling D) Swimming
Ans: D Feedback: Swimming is a good activity for pregnant women and is not contraindicated as long as membranes are intact. It increases muscle tone but may help relieve backache. Pregnancy is not the time to learn to ski or ride a bicycle because the lack of skill could result in many falls. Jogging is questionable because of the strain the extra weight of pregnancy places on the knees.
1. The nurse is preparing to assess the nutritional status of a patient who is 8 weeks pregnant. What is the most effective way for the nurse to assess the patient's food intake thus far in the pregnancy? A) Assess skin status for hydration and color. B) Ask the patient to describe total intake for a week. C) Assess a list that the patient describes as a good diet. D) Ask the patient to describe intake for the last 24 hours.
Ans: D Feedback: The best method for assessing a woman's nutritional intake during pregnancy is to ask the patient to list all the food eaten within the past 24 hours, starting with waking up until going to sleep. This method of history taking yields much more accurate information than asking a patient how often a specific food is eaten. Assessing skin status may provide more information about hydration that nutritional status. Assessing a total intake for a week would be too extreme for the patient to recall. Assessing the patient from a list of foods does not identify what the patient has most recently eaten.
15. During an assessment, a patient 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 patient at this time? A) Powerlessness B) Imbalanced nutrition C) Deficient knowledge D) Disturbed body image
Ans: D Feedback: The diagnosis of disturbed body image is the most appropriate because the patient is equating the weight gain of pregnancy as being fat. The patient 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 patient is experiencing powerlessness.
11. The nurse is preparing to measure the diagonal conjugate of a pregnant patient's pelvis. Which anatomic landmarks will the nurse use to make this measurement? A) Medial surface of the ischial tuberosities B) Posterior surface of sacrum and the axis of the ischial tuberosities C) Interior surface of the sacral prominence and the posterior surface of the symphysis pubis D) Anterior surface of the sacral prominence and the posterior surface of the symphysis pubis
Ans: D Feedback: The diagonal conjugate is the measurement between the anterior surface of the sacral prominence and the posterior surface of the symphysis pubis. The ischial tuberosity diameter measurement is the distance between the ischial tuberosities or the transverse diameter of the outlet and is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus. Measurements are not made from the posterior surface of the sacrum and the axis of the ischial tuberosities or the interior surface of the sacral prominence and the posterior surface of the symphysis pubis.
2. A patient who learns of being 9 weeks pregnant asks the nurse to explain the changes that are occurring with her body. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time? A) Anxiety B) Impaired coping C) Deficient knowledge D) Readiness for enhanced knowledge
Ans: D Feedback: The patient asks the nurse to explain the changes that are occurring, which indicates that the patient is ready for more information or enhanced knowledge. Deficient knowledge would be appropriate if the patient where participating in some action or activity that would be harmful and would need information to correct that action. The patient's request for more information is not consistent with the diagnoses of anxiety or impaired coping.
18. The nurse provides instructions to a patient with hyperemesis gravidarum. Which outcome indicates that teaching has been effective? A) Patient has vomiting episodes only in the morning. B) Patient is able to tolerate soft foods after episodes of vomiting. C) Patient is able to ingest clear liquids between episodes of vomiting. D) Patient is able to ingest a regular diet after progressing through clear liquids and soft foods.
Ans: D Feedback: The pregnant patient with hyperemesis gravidarum may be hospitalized and treated with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started, and the woman discharged home. If able to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed to ensure she receives adequate nutrition. Vomiting episodes in the morning or tolerating clear liquids or soft foods between vomiting episodes indicates that teaching has not been effective.
10. A pregnant patient is scheduled for an abdominal ultrasound. What should the nurse instruct the patient about this procedure? A) Avoid drinking fluid 1 hour prior to the procedure. B) Expect to have a catheter inserted prior to the procedure. C) Empty the bladder 1 hour and just prior to the start of the procedure. D) Drink a glass of water every 15 minutes starting 90 minutes before the procedure.
Ans: D Feedback: The sound waves reflect best if the uterus can be held stable so it is helpful if the woman has a full bladder at the time of the procedure. To ensure this, ask her to drink a full glass of water every 15 minutes beginning 90 minutes before the procedure and not void until after the procedure. The patient will not have a catheter inserted for this procedure. The patient should not avoid fluids 1 hour prior to the procedure. The bladder should not be emptied until the procedure concludes.
4. The nurse is planning to instruct a patient who is 6 weeks pregnant about increasing the intake of milk each day. Which statement should the nurse make as the most effective health teaching measure? A) "The fetus needs milk to build strong bones and teeth." B) "Your future baby will benefit from a high milk intake." C) "Milk is a rich source of calcium that is important for fetal growth." D) "Milk will strengthen your fingernails as well as be good for the baby."
Ans: D Feedback: There is a tendency to organize health instructions during pregnancy around the baby; however, this approach may be inappropriate early in pregnancy, before the fetus stirs, and before a woman is convinced not only she is pregnant but also there is a baby inside her. At early stages, a woman may be much more interested in doing things for herself because it is her body, her tiredness, and her well being that will be directly affected. The nurse should instruct the patient to drink more milk to improve fingernail strength. The statements that address fetal development are inappropriate for the nurse to use for health teaching at this time.
