Unit 2 - Care of Family Ch. 9

31. A nurse is assessing a 40-year old primigravida who is an insulin-dependent diabetic and who smokes. What does the nurse understand about these conditions related to prenatal screening tests? A. Second-trimester markers will be affected but not third-trimester markers. B. The presence of nicotine invalidates the results of most screening tests. C. The woman will have an overall effect of a higher inhibin level. D. There is no significant effect on prenatal screening test results.

ANS: C Inhibin levels are increased by about 60% in women who smoke and decreased by about 12% in insulin-dependent diabetics. The overall effect will be an increased inhibin level.

3. The clinic nurse talks with a patient about her possible pregnancy. The patient has experienced amenorrhea for 2 months, nausea during the day with vomiting every other morning, and breast tenderness. She is convinced she is pregnant and is reluctant to pay for a pregnancy test. Which action by the nurse is best? A. Agree that these signs usually signal pregnancy so no test is needed. B. Delete the order for the pregnancy test and inform the provider. C. Explain that these symptoms can be caused by other conditions. D. Inform the woman that this is standard procedure and must be done.

ANS: C Presumptive signs of pregnancy are those subjectively reported symptoms that could be caused by another condition and include amenorrhea, nausea and vomiting, frequent urination, breast tenderness, perception of fetal movement, skin changes, and fatigue. The nurse should explain this and encourage the woman to have the pregnancy test. Simply telling the woman this is standard procedure does not educate her to make an informed decision.

14. A nurse has taught a pregnant woman about good nutrition during pregnancy at her first prenatal visit. What statement by the patient indicates that more teaching is needed? A. "I buy a lot of yellow and orange vegetables." B. "I have switched to buying only 1% milk." C. "We eat a lot more poultry these days." D. "We eat salmon once a week at least."

ANS: D Healthy nutrition is important during pregnancy, and pregnant women should eat plenty of yellow and orange vegetables, low-fat dairy products, and lower-fat meats. Fish is a great source of protein; however, pregnant women should eat fish lower in mercury, such as whitefish, haddock, pollock, sole, and trout.

3. A woman is 10 weeks pregnant with her third baby. She has two living children with normal delivery histories. Using the GTPAL system, the nurse would document this woman's obstetrical history as ____________________.

ANS: G3T2P0A0L2 The woman is pregnant for the third time: G3. She has carried two pregnancies to term: T2. She has had no preterm deliveries: P0. She has not had any abortions: A0. She has two living children: L2.

1. A pregnant woman's last normal menstrual period started on June 8, 2013. Calculate her expected date of birth (EDB) using Naegle's rule. Her EDB is what date?

ANS: March 15, 2013 The calculation is based on the first date of the woman's last normal menstrual period. Add 7 days to that date (= June 15, 2013). Subtract 3 months (= March 15, 2013). Add 1 year (= March 15, 2014).

2. A pregnant woman's last normal menstrual period started on July 27, 2013. Calculate her expected date of birth (EDB) using Naegle's rule. Her EDB is what date?

ANS: May 3, 2013 The calculation is based on the first date of the woman's last normal menstrual period. Add 7 days to that date (= August 3 [remember that July has 31 days]). Subtract 3 months (= May 3). Add 1 year (= May 3, 2013).

20. A nurse is assessing a patient for Chadwick's sign. In order to do this correctly, what action does the nurse take? A. Assesses the color of the patient's vaginal mucosa and cervix. B. Feels the patient's abdomen for passive fetal movement. C. Obtains a urine specimen for a pregnancy test. D. Palpates the patient's abdomen for uterine asymmetry.

ANS: A Chadwick's sign is a bluish discoloration of the vaginal mucosa and cervix. The nurse needs to visually inspect this anatomy to determine if the patient has a positive Chadwick's sign. Ballottement is the passive movement of the unengaged fetus. Obtaining urine for a urine test is a diagnostic test, not a physical assessment. An asymmetrical uterus with a soft prominence on the implantation side is a positive Piskacek's sign.

1. The nurse places his or her hands on the maternal abdomen to gently palpate the fundal region of the uterus. This action is described as which Leopold maneuver? A. First maneuver B. Second maneuver C. Third maneuver D. Fourth maneuver

ANS: A Leopold maneuvers are a four-part clinical assessment method to determine the lie, presentation, and position of the fetus. The first maneuver determines which fetal body part (e.g., head or buttocks) occupies the uterine fundus. The examiner faces the patient's head and places the hands on the abdomen, using the palmar surface of the hands to gently palpate the fundal region of the uterus.

19. A student asks what the phrase "probable signs of pregnancy" means. The instructor provides which answer? A. Objective signs seen by an examiner; can be from other conditions B. Objective signs seen by an examiner; only caused by pregnancy C. Subjective signs reported by the patient; can be from other conditions D. Subjective signs reported by the patient; only caused by pregnancy

ANS: A Probable signs of pregnancy are objective signs observed by an examiner that usually result from physical changes in the reproductive system during pregnancy, but that can be caused by other conditions. They include abdominal enlargement, Piskacek's sign, Hegar's sign, Goodell's sign, Chadwick's sign, Braxton Hicks sign, a positive pregnancy test, and ballottement.

34. A woman asks the perinatal nurse about gestational diabetes because she has been reading about it. The nurse should inform the patient that screening for this condition is usually done at what time during the pregnancy? A. Around 24 to 28 weeks' gestation B. End of the first trimester C. Mid-pregnancy D. Normally offered around week 37

ANS: A Routine screening for gestational diabetes is usually offered around 24 to 28 weeks' gestation.

28. The nursing faculty member explains to a class of nursing students that the ethnic/cultural group with the highest rate of teen pregnancy is which group? A. African Americans B. Asian Americans C. European Americans D. Hispanic Americans

ANS: A The birth rate in African American teens is higher than in any other ethnic/cultural group.

35. A patient has had a screening test for gestational diabetes and the 1-hour result is 250 mg/dL. What does the nurse conclude about this patient? A. Results are high; the patient has gestational diabetes. B. Results are inconclusive; will repeat test in one month. C. Results are lower than expected; seek endocrine consult. D. Results are normal; no gestational diabetes.

ANS: A The normal 1-hour result for a gestational diabetes screen is less than 140 mg/dL. This patient has tested positive for gestational diabetes.

16. The perinatal nurse explains to a group of nursing students that there are positive signs of pregnancy. Which of the following does the nurse include in this explanation? (Select all that apply.) A. Fetal heartbeat B. Fetal movement palpated by the examiner C. Intermittent uterine contractions D. Positive pregnancy test E. Visualization of the fetus

ANS: A, B, E Positive signs of pregnancy are those attributable only to the presence of a fetus and include fetal heartbeat, fetal movement palpated by an examiner, and the visualization of a fetus. A positive pregnancy test and intermittent uterine contractions are presumptive signs of pregnancy and may be caused by other conditions. A positive pregnancy test can be caused by certain medications, premature menopause, choriocarcinoma, or blood in the urine. Intermittent uterine contractions (Braxton Hicks contractions) can be caused by uterine leiomyomas or other tumors.

17. A patient being seen for the first time in the perinatal clinic has multiple complaints, such as fatigue, anger outbursts, chronic pelvic pain, and feelings of anxiety. What action by the nurse is best? A. Assess the woman for a history of sexual assault. B. Document the patient's complaints on the chart. C. Refer the woman to a psychiatric nurse practitioner. D. Review the woman's past medical history with her.

ANS: A Women who have been victims of sexual assault often complain of various emotional difficulties, such as depression, anger, anxiety, and gynecologic problems. They are often reluctant to disclose their past history of abuse. When women have these complaints, the nurse should investigate the possibility of sexual assault. Documentation should be thorough; however, this answer is not complete. The patient may or may not need a referral; the nurse needs to assess the patient further. Reviewing past medical history is an important part of assessing a patient, but does not take into account the unique nature of this problem.

11. The nurse is explaining to students in the perinatal clinic that some adolescents are at higher risk of teen pregnancy than others. Which teens does the nurse include in these high-risk groups? (Select all that apply.) A. Homeless teens B. Incarcerated teens C. Teens from two-parent homes D. Teens with reliable information E. Teens with religious affiliations

ANS: A, B Teens who lack the support, security, and love of a family home are more likely to engage in high-risk behaviors, including sex at an early age. Incarcerated teens are the most vulnerable group. Teens from middle-class, two-parent homes; teens who are able to obtain reliable information and who do not receive the message that sex is a taboo subject; and teens with religious affiliations have lower rates of teen pregnancy.

18. A woman in the OB clinic complains of multiple, fluid-filled blisters in her genital area that make walking extremely painful. What information should the nurse provide this patient? (Select all that apply.) A. "There are serious adverse fetal effects of this disease." B. "There is no cure for herpes simplex virus infection." C. "Transmission to your baby causes eye infections." D. "You can start antiretroviral medications immediately." E. "We will take blood cultures for a bacterial infection."

ANS: A, B The patient's symptoms are suggestive of herpes simplex virus (HSV) infection. HSV can cause serious consequences, including increased risk of pregnancy loss (60%) and severe neurological consequences in the infants who do survive. There is no cure, but several medications are available for treatment. Unfortunately, the safety of these medications during pregnancy and lactation has not been firmly established. Gonorrhea can cause neonatal eye problems (ophthalmia neonatorum). Antiretroviral medications are used for HIV infections. Blood cultures for bacterial infection are not warranted, as HSV is a viral infection.

20. A nurse is running for public office and plans to fund a comprehensive program to prevent teen pregnancy. When asked how to justify the cost of such a venture, what information could the nurse provide? (Select all that apply.) A. A quarter of teen mothers give birth to a second child within 2 years of the first child. B. Fifty percent of teen mothers go on welfare within 5 years of the birth of their first child. C. Only a small percentage of teen mothers will complete any education beyond high school. D. The rate of teen pregnancy in America is double that of other developed countries. E. There are so many teenage mothers they are overwhelming the health-care system.

ANS: A, B, C, D Teen pregnancy has enormous social and personal repercussions, including high rates of teen mothers on welfare, high rates of teen mothers having a second child within 2 years, low rates of teen mothers gaining education beyond high school, and high rates of teen pregnancy in the United States. Teen mothers are not overwhelming the health-care system.

1. A nursing instructor informs the class of the many benefits of prenatal care. What benefits does the instructor include? (Select all that apply.) A. Allows women informed decision making B. Decreased pregnancy-related maternal death C. Improved pregnancy outcomes D. Increased cost associated with more frequent visits E. Increased early identification of abnormal findings

ANS: A, B, C, E There are many benefits to prenatal care. Nurses play a vital role in ensuring that women receive information and are able to make informed decisions regarding their pregnancy. Women who receive prenatal care have a five-fold decrease in pregnancy-related maternal death and improved pregnancy outcomes. One of the main concepts of prenatal care is early identification of deviations from the normal pregnancy. Increased immediate costs may be an outcome (not a benefit) of prenatal care as compared to women who do not receive prenatal care, but long-term costs are often higher.

15. A student nurse asks the OB clinic nurse why a pregnancy test is needed if a woman has missed several menstrual periods in a row. The nurse explains that amenorrhea can be caused by several conditions other than pregnancy, including which of the following? (Select all that apply.) A. Chronic illness B. Endocrine disorders C. Fatigue D. Infections E. Psychological factors

ANS: A, B, D, E Amenorrhea is a presumptive sign of pregnancy, meaning that the same signs can be caused by conditions other than pregnancy. Amenorrhea can be caused by chronic illness; endocrine, metabolic, or psychological factors; or infection.

9. The nurse recognizes that a pregnant adolescent must successfully complete developmental tasks to be an effective mother. Which tasks does the nurse understand this to include? (Select all that apply.) A. Accepting this pregnancy and telling parents/friends B. Growing up and accepting responsibility C. Maintaining her freedom D. Seeing herself as a mother E. Setting reasonable goals for herself

ANS: A, B, D, E For a teenager to successfully adapt and fulfill the role of being a mother, she must achieve four major developmental tasks: gain acceptance of pregnancy, set goals, view self as a mother, and grow up. Maintaining freedom is antithetical to growing up and accepting the responsibility of motherhood.

19. A nurse is teaching a group of middle school girls about the complications associated with teen pregnancy. What topics should the nurse include? (Select all that apply.) A. Anemia B. Hypertensive problems C. Gestational diabetes D. Preeclampsia E. Preterm birth

ANS: A, B, D, E Pregnant teens face an increased risk for many problems, including anemia, hypertensive problems, preeclampsia, and preterm birth. They are not at higher risk for developing gestational diabetes.

6. A woman comes for her first prenatal appointment at 31 weeks' gestation with her first pregnancy. Which of the following are appropriate statements by the nurse? (Select all that apply.) A. "Do you have questions before I begin your prenatal history and information sharing?" B. "Have you had care in another clinic? I can't believe this is your first appointment!" C. "I am interested in hearing about your life and what prompted you to begin your prenatal care today." D. "It is nice to meet you and I will try to help you get caught up in your prenatal care." E. "Now that you are finally here, we need you to come monthly for the next two visits and then weekly."

ANS: A, C, D Assessment of the patient and gathering data are important components of the first prenatal visit. However, the nurse needs to use professional communication skills in order to elicit information from the patient about personal details of her life and potentially embarrassing information. Questions that show openness and acceptance are best. Stating that you can't believe this is the patient's first prenatal visit and the comment "now that you are finally here" are judgmental and will not help to establish a trusting relationship.

13. The nurse provides increased support to a woman during her first prenatal visit for her current pregnancy. The patient's first pregnancy ended in a miscarriage. The nurse understands that the reasons the patient may be ambivalent about this baby include which of the following? (Select all that apply.) A. Awareness of a new 24-hour responsibility B. Needs related to a second pregnancy C. Potential role/relationship changes D. Previous perinatal loss E. Unresolved grief and mourning

ANS: A, C, D, E Ambivalence is a normal response to pregnancy that is in part related to the anticipated role changes that will occur. The loss of a previous pregnancy brings many emotions to a subsequent pregnancy. This patient should be counseled for her previous loss, unresolved grief and mourning, potential role changes, and new responsibilities as a parent if she carries this pregnancy to term.

21. A nurse is educating a woman who is 38 years old and experiencing her first pregnancy. When planning care for this woman, what information does the nurse take into consideration? (Select all that apply.) A. Chronic health conditions are more likely in this age group. B. Genetic screening is not recommended for women over age 30. C. Gestational diabetes is seen more frequently in this age group. D. Multiple gestations are rarely seen in women over age 35. E. Older primigravidas are at higher risk for cesarean birth.

ANS: A, C, E Older women who are pregnant have unique potential problems. These include a higher likelihood of chronic illness that impacts the pregnancy; obstetrical complications such as vaginal bleeding, preeclampsia, multiple gestation, gestational diabetes, preterm labor, dysfunctional labor, and cesarean birth; and increased incidence of Down syndrome, for which genetic screening should be offered.

22. A woman is having a triple-screen test during her second trimester of pregnancy. The nurse teaches the patient that this test includes which of the following? (Select all that apply.) A. Free beta-human chorionic gonadotropin B. Inhibin A C. Maternal serum alpha-fetoprotein D. Nuchal translucency testing E. Unconjugated estriol

ANS: A, C, E The triple screen includes maternal serum alpha-fetoprotein, unconjugated estriol, and free beta-human chorionic gonadotropin. The inhibin A is included in the quadruple screen. Nuchal translucency testing is offered in the first trimester as part of the combined screen.

8. The nurse advocates for smoking cessation during pregnancy and teaches pregnant women about the effects of tobacco exposure. Which of the following are potential harmful effects of prenatal tobacco use that the nurse should plan to include in the teaching? (Select all that apply.) A. Continued childhood respiratory problems B. Congenital diabetes C. Gestational hypertension D. Preterm labor and birth E. Small-for-gestational-age infant

ANS: A, D, E Effects of tobacco use during pregnancy are well documented and predispose to premature rupture of the membranes, preterm labor, placental abruption, placenta previa, and infants who are small for gestational age. These effects continue well into childhood and are associated with upper respiratory problems, such as infections, asthma, and wheezing. Exposure to tobacco products is not associated with congenital diabetes or gestational hypertension.

17. A pregnant woman in the perinatal clinic is a commercial sex worker and states that she frequently has unprotected sexual intercourse. The nurse should educate this woman about which complications of sexually transmitted diseases (STDs)? (Select all that apply.) A. Ectopic pregnancy B. Frequent multi-fetal pregnancy C. Gestational hypertension D. Preterm labor E. Spontaneous abortion

ANS: A, D, E STDs (sometimes referred to as sexually transmitted infections—STIs) predispose to a number of complications, including ectopic pregnancy, spontaneous abortion, preterm labor, and increased neonatal morbidity. All pregnant women should be screened for STDs. STDs are not associated with frequent multi-fetal pregnancy or gestational hypertension.

18. A woman undergoing her first prenatal visit for a current pregnancy is reluctant to discuss her past obstetrical history with the nurse. Which action by the nurse is best? A. Document the woman's refusal to answer these particular questions in the chart. B. Explain that past obstetrical experiences frequently recur in later pregnancies. C. Inform the woman that the clinic cannot provide comprehensive care without a complete history. D. Tell the woman that you need the information in order to continue with the prenatal visit.

ANS: B A complete obstetrical history should cover the current pregnancy as well as all other pregnancies because complications experienced in previous pregnancies often recur. The nurse should gently explain this in a nonthreatening, nonjudgmental manner, focusing on helping the woman obtain the best outcomes possible. Documentation is always an important nursing responsibility, but the nurse needs to act and not just document. Informing the woman that the clinic cannot provide comprehensive care without the history or telling her that she needs to provide more information to continue the visit is judgmental and sounds vaguely threatening.

5. A nurse is working with a pregnant woman who has the nursing diagnosis of altered family processes. What statement by the patient indicates that a major goal for this diagnosis has been met? A. "At least I'm getting better sleep now that I don't urinate every 2 hours." B. "My husband has been doing more around the house so I can rest more." C. "The kids are really excited about getting a new baby brother or sister." D. "We finally have the nursery painted and furnished so it's ready for baby."

ANS: B A major goal for this diagnosis is that the family recognizes the demands the pregnancy places on the woman and alters routines and activities to accommodate her. When the patient states that her husband is doing more around the house so she can rest more (a need in pregnancy), this shows resolution of the goal. The other statements are positive ones, but do not show family members adapting to new roles and responsibilities.

29. A pregnant teen is in the clinic for a prenatal visit. The nurse needs to obtain informed consent. What action by the nurse is best? A. Ask the teen to call a parent and get consent over the phone. B. Have the teen sign the consent and then place it on the chart. C. Let the teen keep her appointment, but limit it to teaching only. D. Tell the teen that she must return with her parent/guardian.

ANS: B A pregnant teen is considered emancipated, so she can sign for her own care. The nurse should obtain and document informed consent from the teen. The other actions are not necessary.

30. A 40-year old primigravida has undergone nuchal translucency screening. The results show a finding of 3.3 mm. What information should the nurse provide the parents? A. The fetus has an open neural tube defect. B. The fetus has an increased risk for genetic disorders. C. These results are inconclusive. D. These results are normal in an older mother.

ANS: B Nuchal translucency screening is performed between 11 and 14 weeks of gestation via ultrasound. A measurement greater than 3 mm indicates an increased risk for trisomies 13, 18, and 21.

13. The nurse explains that the childbearing year is an ideal time to make healthy changes for the entire family. Which action does the nurse suggest? A. Avoiding alcohol and smoking B. Creating healthy menus for family meals C. Getting plenty of sleep each night D. Planning a "parents' date night" each week

ANS: B Pregnancy and the childbearing year is an ideal time for the entire family to make healthy changes. Planning and preparing healthy foods are important parts of prenatal care that can have a positive impact on the entire family. The other options are good for the pregnant woman and her partner, but don't have as big of an impact on the whole family.

6. A nurse is reviewing the prenatal care schedule for a woman who is 10 weeks pregnant. When does the nurse advise the woman to return for her next appointment? A. 2 weeks B. 4 weeks C. 6 weeks D. 8 weeks

ANS: B Prenatal visits are usually every 4 weeks until the woman reaches 28 to 32 weeks' gestation. Then visits are scheduled every 2 weeks until the 36th week. After that point, visits are weekly until birth.

15. A pregnant woman in her first trimester is having her first prenatal visit. She tells the nurse that she takes red raspberry leaf regularly. What response by the nurse is best? A. Discuss the cardiovascular problems associated with this substance. B. Explain that it is safe to use during pregnancy. C. Inform the woman that safety has not been established. D. Tell the woman she should not use it during pregnancy.

ANS: B Red raspberry is safe to use during pregnancy, and it may be beneficial in relieving the symptoms of morning sickness and in assisting in the birth of the baby and placenta. The other statements apply to blue cohosh.

27. The nurse auscultates fetal heart tones on a woman in her third trimester of pregnancy and counts a heart rate of 92 beats/minute. Which action by the nurse is best? A. Apply oxygen at 6 L/minute. B. Assess the maternal heart rate. C. Document the findings in the chart. D. Turn the woman on her left side.

ANS: B The normal fetal heart rate is 110-160 beats/minute. If the nurse assesses a lower rate, the maternal heart rate should be assessed. If the two heart rates are similar, the nurse has inadvertently counted only the maternal rate. The nurse should attempt to locate the fetal pulse and try again. If the two rates differ (i.e., the fetal heart rate is truly 92 beats/minute), the nurse should place the woman on her left side, apply oxygen by mask, and seek assistance. Documentation should always occur.

8. The prenatal nurse believes in advocating for the patient. What action by the nurse best reflects this role? A. Documenting the patient's preferences for childbirth care B. Helping the woman formulate and vocalize questions C. Informing women of options related to labor and birth D. Teaching women about physical changes during pregnancy

ANS: B The role of the advocate includes speaking for the patient when she is unable to do so herself and ensuring that the patient's questions are answered in a thorough way that she can understand. The nurse helping a patient formulate and voice questions is the best demonstration of the advocate role. Documenting preferences is a good start, but is not comprehensive enough to encompass the role. Teaching is also part of the advocate process, but does not constitute speaking for the patient or helping her to do so.

7. A woman who is 32 weeks pregnant has concluded a prenatal visit. The nurse should schedule the next prenatal visit for which gestational week? A. 33 weeks B. 34 weeks C. 38 weeks D. 40 weeks

ANS: B Women are seen once every 4 weeks until 28 to 32 weeks' gestation, when the schedule changes to every 2 weeks. The nurse should schedule this woman's next visit at 34 weeks.

10. A nurse assesses the pregnant woman for recreational drug use as part of the first prenatal visit. What harmful effects of recreational drugs does the nurse teach the woman about? (Select all that apply.) A. Cocaine: placenta previa B. Ecstasy: cleft palate C. Marijuana: intrauterine growth restriction D. Methamphetamine: spontaneous abortion E. Heroin: macrosomia

ANS: B, C, D Approximately 3% of pregnant women use nonprescription drugs such as cocaine, Ecstasy, marijuana, methamphetamines, and heroin. Ecstasy can cause congenital abnormalities such as cleft palate. Marijuana can cause intrauterine growth restriction. Methamphetamines can cause spontaneous abortion. Cocaine can cause placental abruption (not previa). Heroin can lead to spontaneous abortion, intrauterine growth restriction, preterm labor/birth, or stillbirth.

5. The student nurse in the perinatal clinic asks why it is so important to screen women for intimate partner violence during the first prenatal visit. What information does the registered nurse provide the student? (Select all that apply.) A. Approximately one in three women has been a victim of abuse. B. Intimate partner violence is more common than preeclampsia. C. Many women may abuse substances to cope with the violence. D. Partners abuse over 300,000 pregnant women each year. E. Violence rarely occurs for the first time during pregnancy.

ANS: B, C, D Intimate partner violence (IPV) is the most common form of violence women are exposed to worldwide. In the United States, approximately 25% of women (or one in four) have been the victim of intimate partner violence, including over 324,000 pregnant women. IPV is more common than preeclampsia or gestational diabetes, both of which are significant problems in pregnant women. Many women cope with this violence by turning to substance abuse, both prescription and nonprescription. Shockingly, IPV may occur for the first time during pregnancy.

7. A nurse is caring for a woman who is positive for hepatitis B. What other screening tests does the nurse facilitate for this patient? (Select all that apply.) A. Cytomegalovirus B. Hepatitis B for household members C. Hepatitis B for intimate contacts D. Hepatitis C E. Parvovirus

ANS: B, C, D Women who are positive for hepatitis B should have screening for hepatitis C. Their household contacts and intimate contacts should also be screened for hepatitis B. There is no correlation between hepatitis B and either cytomegalovirus or parvovirus.

12. The nurse schedules a patient for her first prenatal appointment with the certified nurse-midwife (CNM) in the clinic. About what topics does the nurse help the patient formulate questions to ask the CNM? (Select all that apply.) A. An opportunity to meet other patients who have delivered with this practice B. The CNM's beliefs and practices concerning epidural anesthesia and episiotomies C. Use of complementary and alternative methods during labor and birth D. What happens if the patient gives birth when the CNM is not available E. Whether the CNM will be available by phone or Internet to answer questions

ANS: B, C, D, E A woman's journey through the pregnancy experience can have long-term effects on her self-perception and self-concept. Therefore, it is especially important that the patient choose a care provider with whom she can openly relate and who shares the same philosophical views on the management of pregnancy. Although in unusual circumstances a patient may give permission for the CNM to provide her information to a patient with a similar situation, routinely sharing personal information with other patients would be a violation of confidentiality principles and laws.

4. A nurse is using the RADAR model when working with women in the perinatal clinic. What actions does the nurse include when assessing patients with this model? (Select all that apply.) A. Ask only when injuries are suspicious. B. Assess the patient's safety. C. Document findings in the chart. D. Review options and referrals with the patient. E. Routinely screen every patient.

ANS: B, C, D, E The acronym RADAR stands for routinely screen every patient (not just when injuries seem suspicious); ask directly, kindly, and in a nonjudgmental way; document your findings, assess the patient's safety; and review options and provide referrals.

3. During the first prenatal visit, a nurse teaches a pregnant woman about emergencies for which she needs to be seen immediately. Which situations does the nurse include in this education? (Select all that apply.) A. Headache not associated with visual disturbances B. Low, dull backache or pelvic pressure C. Maternal fever over 100.5°F (38.1°C) D. Nausea and vomiting especially upon arising in the morning E. Reduction in fetal movements

ANS: B, C, E Emergency warning signs the nurse teaches the patient include reduction in fetal movement; signs of preterm labor (low, dull backache; pelvic pressure; uterine contractions; menstrual cramps); vaginal fluid loss or vaginal bleeding; maternal fever over 100.5°F; persistent headache associated with blurred vision or flashing lights in front of the eyes; continuous vomiting with weight loss, dehydration, weakness, dizziness, or fainting; or feeling that something is just not right. A headache not associated with visual disturbances and some limited nausea and vomiting without signs of dehydration are not emergencies.

32. A nurse is counseling a 40-year-old woman about her risks of giving birth to a child with Down syndrome. What information does the nurse provide? A. The risk doesn't go up until you are over 45. B. The risk is less than 1 in 1,000. C. The risk is about 1 in 85. D. The risk is about 1 in 20.

ANS: C A woman's risk of having a baby with Down syndrome is approximately 1:85 at age 40.

4. A woman in the prenatal clinical is concerned because her partner, who was supportive and excited about becoming pregnant, has suddenly become more withdrawn and seems ambivalent toward the pregnancy. What response by the nurse is best? A. "Are you in a relationship that causes you to be afraid?" B. "Oh don't worry; they all feel this way sometimes." C. "This is a normal reaction to the reality of the pregnancy." D. "Your partner will come around to being excited soon."

ANS: C Despite planning a pregnancy, many women (and their partners) become ambivalent when faced with a positive pregnancy result. The reality of the many changes soon to come often causes them to reconsider their desire to become pregnant. There is also an aspect of self-preservation involved; many women still die from complications associated with pregnancy. The best response by the nurse is to help the woman recognize that this is a normal response. There is no need to ask the woman about intimate partner violence at this point. The other two options are dismissive and do not serve to educate the woman.

16. A woman who is a Jehovah's Witness returns for a second prenatal visit and is discussing her plan of care with the nurse. The patient has returned a signed form in which she refuses all blood products. What action by the nurse is best? A. Advise the woman of potential complications. B. Inform the health-care provider of her choice. C. Place the signed form on the patient's chart. D. Refer the woman to a tertiary birthing center.

ANS: C Patients who are Jehovah's Witnesses do not usually consent to the use of blood products. When working with a patient with these beliefs, the nurse should discuss all alternatives with the patient (including all types of blood products available) and send her home with a packet containing a consent form in which she details which (if any) blood products she will accept. This signed form should be available in three places: the patient should have a copy, a copy should be placed on her chart, and the hospital where she will give birth should also have a copy. Teaching potential complications related to the woman's choices should have already been done. Informing the health-care provider is important, but without a written document, this is not a complete action. Depending on patient, provider, and facility preferences, a patient who refuses blood products may need to be referred to another facility.

24. A woman calls the prenatal clinic to inquire if she should have the seasonal influenza vaccination. What advice should the nurse provide? A. "Flu does not cause many problems in pregnancy." B. "No, vaccinations are not safe in pregnancy." C. "Yes, you should get the flu vaccination." D. "You should wait until your third trimester."

ANS: C Pregnant women who contract influenza have an increased risk of both needing medical care and requiring hospitalization. Vaccination against influenza is considered safe throughout pregnancy and preventing this disease is an essential element of prenatal care. The most effective way to prevent contracting influenza is through immunization.

33. A woman has returned to the clinic for her second prenatal visit. Her blood pressure is significantly higher than on her previous visit. What action should the nurse do first? A. Administer oxygen and inform the provider. B. Ask the woman to lie down on the table. C. Ensure that the blood pressure cuff is the appropriate size. D. Take the blood pressure again.

ANS: C Taking and recording maternal vital signs is an important component of every prenatal visit. Because this blood pressure reading is significantly different, the nurse should first ensure that the correct-sized cuff is being used and that the situation (i.e., maternal position) is consistent with the last reading. There is no need for oxygen or to have the woman lie down, unless the nurse determines that the woman was lying down for her last blood pressure measurement. The nurse should not take the blood pressure again until those factors are verified.

22. A patient in the emergency department is complaining of fever, burning with urination, bloody urine, and amenorrhea for 1 month. To evaluate her symptoms, what action by the nurse is best? A. Ask the woman if her menstrual periods are usually regular. B. Collect a urine sample for a pregnancy test. C. Instruct her in obtaining a midstream urine sample. D. Obtain an order for an intravenous pyelogram (x-ray of the urinary tract).

ANS: C This woman has symptoms of a urinary tract infection (UTI) and may be pregnant. A urine sample will help with evaluation of all of her symptoms, but blood in the urine can produce a false-positive pregnancy test. To assist the woman in providing a suitable urine specimen for laboratory testing, the nurse teaches her how to obtain a midstream urine sample. Obtaining an order for an intravenous pyelogram is not indicated at this time.

11. A nurse uses the CARE model when working with patients. How can this nurse use the model to help reduce racially related disparities in care for pregnant women? A. Ensure a clear exchange of valuable information. B. Pay due attention to another person. C. Provide resources, authority, or opportunities. D. Support or defend another individual.

ANS: C Unfortunately, racial disparities still exist in health care today. The nurse can use the CARE model to help address this issue. CARE stands for communication, advocate, respect, and enable. All options are components of the model, but the one that could best help to address this disparity is providing the resources, the authority, and the opportunity to do something. Enabling women to obtain the care they need and reducing barriers would go a long way in meeting the Healthy People 2020 objective of improving access to prenatal care for all women.

10. A prenatal nurse manager wants to help pregnant women in the clinic decrease their stress. Which action by the manager would be best? A. Conduct childbirth preparation classes on site B. Display pictures of fetal development C. Institute primary nursing care for all patients D. Partner with a counseling service for referrals

ANS: C Women release oxytocin as a response to stress and when they engage in "tend and befriend" activities. Oxytocin appears to buffer the stress response and produces a calming effect. One strategy nurses can use to employ this physiological phenomenon is to provide continuity of care. Primary nursing, in which each patient is assigned a primary nurse who sees them at each visit, is an excellent choice to capture the benefits of this effect. The other options could all help reduce stress in some women and in some situations, but providing continuity of care could benefit all patients in the clinic.

14. The nurse explains to a newly diagnosed pregnant woman at 10 weeks' gestation that her rubella titer indicates that she is not immune. Which of the following should the nurse teach the patient? (Select all that apply.) A. Avoid contact with all children until after you have given birth. B. Be retested in 3 months and obtain the vaccination if not immune. C. Do not become pregnant for 4 weeks after you receive the vaccination. D. Receive the rubella vaccine during the postpartum period. E. Seek medical care immediately for fever, runny nose, or rash.

ANS: C, D Rubella (German measles) is one of the most commonly recognized viral infections known to cause congenital problems. If a woman contracts rubella during the first 12 weeks of pregnancy, the fetus has a 90% chance of being adversely affected. A maternity patient who is not immune to rubella should be offered the rubella immunization following childbirth, ideally prior to hospital discharge. She should also be taught to avoid becoming pregnant for at least 4 weeks after the immunization. The patient should report signs or symptoms of rubella during pregnancy to her health-care provider, but she does not need to seek medical care immediately. Avoiding contact with all children is unreasonable. There is no reason to be retested in 3 months, because she cannot receive the vaccination until after she has given birth.

21. The nurse reads "positive Hegar's sign" in a patient's chart. What can the nurse conclude about the patient? A. Patient had a miscarriage B. Patient is post-partum C. Patient is pregnant D. Patient may be pregnant

ANS: D Hegar's sign is softening of the lower uterine segment and is a probable sign of pregnancy, so the nurse concludes that the patient may be pregnant. A positive Hegar's sign can also be caused by pelvic congestion.

2. The nurse includes screening for intimate partner violence in the first prenatal visit for all patients. Which of the following is an appropriate question for the nurse to ask? A. "I need to ask you, do you feel safe from abuse right now?" B. "Is your partner threatening or harming you in any way right now?" C. "This is something we ask everyone: Do you have any abuse in your life right now?" D. "We ask everyone this: Do you feel safe in your living environment and relationships?"

ANS: D Intimate partner violence is a difficult subject to discuss and the nurse may fear insulting or psychologically hurting the patient more. A nonthreatening approach is to ask patients directly whether they feel safe going home and whether they have been hurt physically, emotionally, or sexually by a past or present partner.

25. A nurse is assessing a woman who is at 29 weeks of gestation. The nurse measures the woman's fundal height, which is 58.42 cm (23 inches). What does the nurse conclude about this information? A. The nurse cannot make a conclusion. B. Fundal height is just right. C. Fundal height is too big. D. Fundal height is too small.

ANS: D Measuring fundal height is usually initiated around 22 weeks of gestation. The measurement is recorded in centimeters and should closely approximate the weeks of gestation. A woman who is 29 weeks pregnant should have a fundal height of 29 cm (11.4 inches). This woman's fundal height is too small for her gestation.

36. A nurse reads a patient's chart and sees the diagnosis "pediculosis pubis." What does the nurse understand about this condition? A. The patient has abnormal pubic hair growth. B. The patient has an old episiotomy. C. The patient has human papillomavirus. D. The patient has pubic lice.

ANS: D Pediculosis pubis is pubic lice.

9. The nursing student in the perinatal clinic asks the registered nurse why so many pregnant women seem to be stressed despite their "happy" condition. What response by the nurse is best? A. "It's the effect of all those hormones." B. "Many are afraid of labor and birth." C. "Most pregnant women don't feel well." D. "Pregnancy is a developmental crisis."

ANS: D Pregnancy, no matter how planned and wanted, is a developmental crisis for the woman and her family. It requires role changes and restructuring of tasks of daily living. This leads to stress. One benefit of prenatal care is having a nurse who can help the woman (and family) adjust and find positive ways to cope. Hormones and fear may play a part, but these answers do not provide a comprehensive explanation. There are physical discomforts associated with pregnancy, but, again, this answer is not comprehensive.

12. The nurse assesses a pregnant patient during the first prenatal visit. Which question by the nurse is the best example of therapeutic communication? A. "Do you understand the prenatal visit schedule?" B. "Do you use drugs or drink alcohol?" C. "Have you experienced quickening?" D. "To begin, what questions may I answer?"

ANS: D The first prenatal visit is extremely important and is a vital time for the nurse to use therapeutic communication to help establish a professional, caring relationship. The nurse should avoid yes-no questions and medical jargon that could be intimidating. Open-ended questions elicit the most information; when the nurse begins by asking what questions she or he can answer, that leaves an opening for the patient to express any concerns or questions at that time.

23. A nurse reads in a pregnant woman's chart that she is "para 3." What does the nurse understand about this woman's obstetrical history? A. Is now in her third trimester B. Currently pregnant with triplets C. Three babies born alive D. Three pregnancies delivered past 24 weeks of gestation

ANS: D The term "parity" means the number of pregnancies carried to a point of viability, which is generally accepted as at least 24 weeks of gestation. This woman has had three pregnancies that went past that point. Parity does not refer to trimester, the number of babies in the current pregnancy, or the outcome of previous pregnancies.

26. A nurse is performing the third Leopold maneuver on a woman who is gravida 3, para 3 and is currently 37 weeks' gestation. The nurse's fingers can be pressed together below the presenting part, which is firm to the touch. What action should the nurse take regarding this assessment data? A. Facilitate a referral to a perinatologist. B. Inform the health-care provider immediately. C. Prepare the woman for a breech delivery. D. Reassure the woman and document the findings.

ANS: D The third Leopold maneuver is performed to confirm the presentation noted in the first maneuver and to determine if the presenting part is engaged. If the presenting part moves upward so that the examiner's fingers can be pressed together, the presenting part is not engaged. In a first pregnancy, engagement usually occurs around 37 weeks' gestation; with subsequent pregnancies engagement may not occur until labor has begun. If the presenting part is firm, it is the head. If the presenting part is soft, the fetus is in the breech position. This woman is in her third pregnancy, so the lack of engagement is not abnormal. The presenting part was firm, so the baby is not breech. There is no need to inform the health-care provider immediately or facilitate a referral to a higher level of care. The nurse should reassure the woman and document the findings.

2. A pregnant woman asks a neighbor who is a nurse about using a midwife instead of a physician for her prenatal, labor, and childbirth care. What information does the neighbor share with the pregnant woman about certified nurse midwives (CNMs)? (Select all that apply.) A. CNMs are able to see women experiencing complications. B. CNM practice is physician dependent. C. There is an increased need for medical interventions with CNMs. D. There is increased patient satisfaction with CNMs. E. There is a lower rate of cesarean births with CNMs.

ANS: D, E Certified nurse midwives are educated in both nursing and midwifery and are certified by the American College of Nurse-Midwives. Midwifery practice is the independent management of women's health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn, and family planning/gynecological needs. CNMs see healthy women experiencing an uncomplicated pregnancy. These women experience a lower rate of cesarean births and medical interventions. Continuity of prenatal care has a major effect on patient satisfaction.