Chp 10, 25 Common Complications of Pregnancy (Book, Study Guide, Practice Questions, Evolve and Class Review)

11. What is the purpose of each of the following tests from amniotic fluid? What may alter amniotic fluid tests for fetal lung maturity? a. Phosphatidylglycerol (PG) and phosphatidylinositol (PI)

(a) Presence in the amniotic fluid confirms fetal lung maturity.

14. a. List indications for performing percutaneous umbilical blood sampling (PUBS). b. What risks are involved with percutaneous umbilical blood sampling?

(a) Management of Rh disease; genetic studies; diagnosis of abnormal fetal blood clotting factors; treatment of fetal blood diseases or delivery of therapeutic drugs that cannot be delivered to the fetus in another way. (b) Bradycardia, prolonged bleeding, cord laceration, cord hematoma, thrombo-sis, thromboembolism, preterm labor, preterm rupture of membranes, maternal blood sensitization.

11. What is the purpose of each of the following tests from amniotic fluid? What may alter amniotic fluid tests for fetal lung b. TDx assay

(b) Determines surfactant content in amniotic fluid. All tests may be affected by the presence of blood or meconium in the fluid.

7. Chorionic villus sampling (CVS) is done between _____ and _____ weeks of pregnancy. Results are usually available in what length of time?

10; 12; preliminary results in 2 to 3 hours; 2 to 4 days for improved quality of test results; 7 days for tissue culture analysis; varying time of results for tests other than karyotyping.

16. Why is initiating contractions usually necessary in a CST? Under what circumstances would the nurse not initiate contractions?

A contraction stress test indicates fetal response to periodic hypoxia that occurs as a result of uterine contractions. Contractions are usually initiated by breast stimulation or by intravenous administration of oxytocin. As contractions compress the placental arterioles that supply oxygen to the fetus, a recurrent decrease occurs in fetal oxygen levels. No breast stimulation or oxytocin infusion is needed for the CST if the woman is having three spontaneous contractions in a 10-minute time frame.

14. What is a nonstress test, and why is it so named?

A nonstress test (so-called because the fetus is not challenged or stressed to obtain data) measures acceleration of the fetal heart in response to fetal movement. Acceleration, even without fetal movement felt by the mother, provides reassurance of fetal health.

70. Rank the following interventions in the correct sequence for the client diagnosed with gestational trophoblastic disease: a. IV oxytocin b. Vacuum aspiration and curettage c. Evaluation of hCG level every week d. Lab studies for type, crossmatch, and coagulation

ANS: D, B, A, C Diagnostic studies to determine client status are completed first, followed by evacuation of the uterus by vacuum aspiration and curettage. Once the uterus is empty, IV oxytocin is given to contract the uterus and control bleeding. Evaluation of hCG levels will be done weekly until no longer detected. PTS: 1 DIF: Cognitive Level: Application REF: 510 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment: Management of Care

62. The emergency room charge nurse calls the labor and birth charge nurse and reports the ambulance is en route with a seizing pregnant patient at 36 weeks' gestation. What medication will the charge nurse most likely direct the staff nurse to prepare to administer immediately on the patient's arrival to the labor and birth unit? a. Magnesium sulfate (magnesium) b. Hydralazine (Apresoline) c. Carbamazepine (Tegretol) d. Terbutaline (Brethine)

ANS: A Magnesium sulfate is the drug most often used for preeclamptic and eclamptic patients. It is a CNS depressant. Apresoline is administered for hypertension and is often given to pregnant clients with severe preeclampsia. Tegretol is administered for seizure activity in nonpregnant patients. Brethine is a smooth muscle relaxant administered for preterm labor. PTS: 1 DIF: Cognitive Level: Application REF: 523 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

54. For the client who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to: a. 6:30 AM on January 13. b. 6:30 PM on January 13. c. 6:30 PM on January 14. d. 6:30 AM on January 15.

ANS: A Rho(D) immune globulin (RhoGAM) must be administered within 72 hours after the birth of an Rh-positive infant. 6:30 PM on January 13, 6:30 PM on January 14, and 6:30 AM on January 15 do not fall within the established time frame. PTS: 1 DIF: Cognitive Level: Application REF: 532 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

18. What are the classic signs of preeclampsia? What nonspecific sign may occur?

Hypertension (systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg) and proteinuria. Edema may occur. Expected edema of pregnancy is usually mild and remains in the feet and legs. If edema accompanies other signs of pre-eclampsia it may be preceded by sudden weight gain and may be above the waist.

60. The clinic nurse is reviewing home care dietary instructions for the patient diagnosed with mild preeclampsia at 34 weeks' gestation. The nurse determines that the client requires additional information when she makes which statement? a. "I will limit my salt intake to 2 grams per day." b. "I will drink no less than 2500 mL of fluid per day." c. "I will make sure I eat 4 sources of protein per day." d. "My overall intake of calories per day should be around 2500."

ANS: A The diet should have ample protein, no less than 6 ounces/day, and approximately 2500 calories during the second half of pregnancy. A regular diet without salt or fluid restriction is usually prescribed. Adequate amounts of protein are essential, especially because there is pathologic protein loss with preeclampsia. PTS: 1 DIF: Cognitive Level: Application REF: 530 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

56. A patient reports to the emergency room nurse that she is 10 weeks pregnant, with unilateral pelvic pain, shoulder pain, and faintness. Her color is pale, she is diaphoretic, and her heart rate is 140 bpm. What is the nurse's priority action? a. Initiate an ordered IV of lactated Ringer's at 200 mL/hr. b. Take the patient for her ordered pelvic ultrasound. c. Ask the patient if she has had any recent vaginal bleeding. d. Ask the patient if she has ever been told she has had salpingitis.

ANS: A This patient is presenting with classic signs of an ectopic pregnancy and hypovolemic shock. This is an obstetric emergency. Symptoms include sudden, severe pain in one of the lower quadrants of the abdomen as the tube tears open and the embryo is expelled into the pelvic cavity, often with profuse abdominal hemorrhage. Radiating pain under the scapula may indicate bleeding into the abdomen caused by phrenic nerve irritation. Hypovolemic shock (acute peripheral circulatory failure from loss of circulating blood) is a major concern because systemic signs of shock may be rapid and extensive without external bleeding. The nurse must first start the IV to initiate rapid fluid replacement. Further assessment will result in a delay of care. PTS: 1 DIF: Cognitive Level: Synthesis REF: 509 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

19. The biophysical profile assesses which fetal parameters?

In any order: (a) FHR activity as in the NST; (b) fetal breathing movements; (c) gross fetal movements; (d) fetal tone; (e) amniotic fluid volume

67. The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for which symptoms? (Select all that apply.) a. Pelvic pain b. Missed period c. Abdominal pain d. Unanticipated heavy bleeding e. Vaginal spotting or light bleeding

ANS: A, B, C, E A missed period or spotting can easily be mistaken by the client as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about 50% of women, shoulder and neck pain occurs because of irritation of the diaphragm from the hemorrhage. PTS: 1 DIF: Cognitive Level: Application REF: 509 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

65. Which interventions may be indicated for the clinical management of hyperemesis gravidarum (HEG)? (Select all that apply.) a. Pyridoxine b. Total parenteral nutrition (TPN) for severe cases c. Promethazine (Phenergan) d. Levaquin (Levofloxacin) e. Omeprazole (Prilosec) f. Diphenhydramine (Benadryl)

ANS: A, B, C, E, F Pyridoxine (vitamin B6) may be indicated for the treatment of HEG. TPN is indicated for severe conditions. Phenergan, an antiemetic, and Prilosec, a gastric acid inhibitor, are also used for treatment of this condition. Benadryl is also used for treatment. An antibiotic such as Levaquin is not indicated for the treatment of this disease. PTS: 1 DIF: Cognitive Level: Analysis REF: 506 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

66. The physician suspects that the client may have gestational trophoblastic disease. Which clinical manifestations support this diagnosis? (Select all that apply.) a. Increased levels of beta-hCG in the serum b. Fundal height correlating with reported gestational age c. Vaginal bleeding d. Vomiting e. Maternal hypotension

ANS: A, C, D In gestational trophoblastic disease (molar pregnancy), the following clinical manifestations would appear: increased serum beta-hCG levels, increased size of the uterus related to gestational age, nausea and vomiting, and evidence of vaginal bleeding. Development of preeclampsia earlier in the pregnancy would be noted, resulting in hypertension, not hypotension. PTS: 1 DIF: Cognitive Level: Analysis REF: 518 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. When caring for a woman who has had gestational trophoblastic tissue evacuated, the clinic nurse's priority interven-tion is to: a. Reinforce the need to delay a new pregnancy for 1 year. b. Ask the woman whether she has any cramping or bleeding. c. Observe return of her blood pressure to normal. d. Palpate the uterus for return to its normal size.

a

59. A health care provider reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurse's priority action when the patient is admitted? a. Obtain the patient's weight. b. Take the patient's vital signs. c. Start an IV with lactated Ringer's at 75 mL/hr. d. Ask support persons to leave the birthing room.

ANS: B The hallmark signs of preeclampsia are hypertension and proteinuria. These parameters must be evaluated first. Obtaining the patient's weight may indicate excess fluid gain, but fluid retention does not occur in all cases of preeclampsia. An IV will be beneficial; however, assessment precedes implementation in this case to obtain baseline data. Promoting a nonstimulating environment can help decrease blood pressure; however, loss of support during this frightening time can increase anxiety in this initial assessment phase and actually increase the patient's blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 519 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

61. A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient's magnesium level is 7.6 mg/dL. What is the nurse's priority action? a. Stop the infusion of magnesium. b. Assess the patient's respiratory rate. c. Assess the patient's deep tendon reflexes. d. Notify the health care provider of the magnesium level.

ANS: B The therapeutic serum level for magnesium is 4 to 8 mg/dL although it is elevated in terms of normal lab values. Adverse reactions to magnesium sulfate usually occur if the serum level becomes too high. The most important is CNS depression, including depression of the respiratory center. Magnesium is excreted solely by the kidneys, and the reduced urine output that often occurs in preeclampsia allows magnesium to accumulate to toxic levels in the woman. Frequent assessment of serum magnesium levels, deep tendon reflexes, respiratory rate, and oxygen saturation can identify CNS depression before it progresses to respiratory depression or cardiac dysfunction. Monitoring urine output identifies oliguria that would allow magnesium to accumulate and reach excessive levels. Discontinue magnesium if the respiratory rate is below 12 breaths/min, a low pulse oximeter level (<95%) persists, or deep tendon reflexes are absent. Additional magnesium will make the condition worse. PTS: 1 DIF: Cognitive Level: Analysis REF: 524 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

68. The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.) a. Cool, clammy skin b. Altered sensorium c. Pulse oximeter reading of 95% d. Respiratory rate of less than 12 breaths/min e. Absence of deep tendon reflexes

ANS: B, D, E Signs of magnesium toxicity include the following: • Respiratory rate of less than 12 breaths/min (hospitals may specify a rate < 14 breaths/min) • Maternal pulse oximeter reading lower than 95% • Absence of deep tendon reflexes • Sweating, flushing • Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented) • Hypotension • Serum magnesium value above the therapeutic range of 4 to 8 mg/dL Cold, clammy skin and a pulse oximeter reading of 95% would not be signs of toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 508 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

15. What is vibroacoustic stimulation and what is its expected result during the last trimester of pregnancy?

In vibroacoustic stimulation, an instrument similar to an artificial larynx is used to stimulate fetal movement and accelerations using sound and vibrations. Fetal accelerations are expected after stimulation. Otherwise, the procedure and interpretation are the same as those in a nonstress test. VAS should not be done earlier than 33 weeks' gestation.

17. In a CST, what do late decelerations of FHR indicate?

Late decelerations in a CST indicate fetal oxygen reserves are not adequate to tolerate contractions, and fetal acidosis, myocardial depression, or both may result.

18. What is the relationship between loss of fetal tone and hypoxia?

Loss of fetal tone in a biophysical profile indicates advanced hypoxia and fetal acidosis. Fetal tone develops early in gestation and is one of the parameters of the biophysical profile that is most resistant to the effects of hypoxia

63. A preeclamptic patient is receiving an IV infusion of magnesium sulfate. On assessment, the nurse notes that the patient's urinary output has been 20 mL/hr for the past 2 hours and her deep tendon reflexes are absent. The health care provider prescribes calcium gluconate, 1 g of a 10% solution. The standard rate of infusion is 1 mL/min. How many minutes will it take for the nurse to administer the prescribed calcium? a. 1 b. 5 c. 10 d. 15

ANS: C A 10% solution contains 10 g in 100 mL. X minutes = 1 minute × 100 mL × 1 g = 10 minutes 1 mL 10 g PTS: 1 DIF: Cognitive Level: Analysis REF: 528 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

53. Fraternal twins are delivered by your Rh-negative client. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the: a. direct Coombs test of twin A. b. direct Coombs test of twin B. c. indirect Coombs test of the mother. d. transcutaneous bilirubin level for both twins.

ANS: C Administration of RhoGAM is based on the results of the indirect Coombs test on the client. A negative results confirms that the mother has not been sensitized by the positive Rh factor of twin A and that RhoGAM is indicated. A direct Coombs test is a diagnostic test used to determine maternal antibodies in fetal blood and to guide treatment of the newborn when Rh and ABO incompatibilities occur. Transcutaneous bilirubin is a noninvasive measure to determine the level of bilirubin in a newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: 530 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

6. What are possible causes for low levels of AFP?

Low levels of AFP suggest chromosomal abnormalities or inaccurate gestational age and maternal weight. Gestational trophoblastic disease may also cause low AFP levels.

4. Why is MSAFP considered a screening test?

MSAFP must be viewed as the first step in a series of diagnostic procedures offered if abnormal concentrations are found.

16. List nursing measures and their rationales to promote maternal and fetal oxygenation if hemorrhage occurs or is suspected at 37 weeks of gestation.

In any order—lateral positioning with the head flat to increase cardiac return and enhance circulation to the placenta and vital organs; limited maternal movement to reduce demand for oxygen; providing explanations, reassurance, and emotional support to reduce anxiety that would increase maternal demand for oxygen.

57. The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa? a. Female fetus, Mexican-American, primigravida b. Male fetus, Asian-American, previous preterm birth c. Male fetus, African-American, previous cesarean section d. Female fetus, European-American, previous spontaneous abortion

ANS: C The rate of placenta previa is increasing. It is more common in older women, multiparous women, women who have had cesarean births, and women who had suction curettage for an induced or spontaneous abortion. It is also more likely to recur if a woman has had a placenta previa. African or Asian ethnicity also increases the risk. Cigarette smoking and cocaine use are personal habits that add to a woman's risk for a previa. Previa is more likely if the fetus is male. The Mexican-American primipara has no risk factors for developing a placenta previa. The Asian-American multipara has two risk factors for developing a previa. The African-American multipara has three risk factors for developing a previa. The European-American multigravida has one risk factor for developing a placenta previa. PTS: 1 DIF: Cognitive Level: Synthesis REF: 513 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

58. A patient presents to labor and birth with complaints of persistent acute back pain at 36 weeks' gestation. The nursing assessment reveals a taught abdomen, fundal height at 40 cm, and late decelerations, with an FHR range of 124 to 128 bpm. The nurse will implement the protocol for which obstetric condition? a. Placenta previa b. Hypovolemic shock c. Abruptio placentae or abruption d. DIC

ANS: C There are five classic signs and symptoms of abruptio placentae and include the following: bleeding, which may be evident vaginally or be concealed behind the placenta; uterine tenderness, which may be localized at the site of the abruption; uterine irritability, with frequent low-intensity contractions and poor relaxation between contractions; abdominal or low back pain that may be described as aching or dull; and high uterine resting tone identified with the use of an intrauterine pressure catheter. Additional signs include nonreassuring FHR patterns, signs of hypovolemic shock, and fetal death. With a placenta previa there is bright red and painless bleeding. Hypovolemic shock can result from an abruption; however, if the protocol for shock is initiated, some of the blood work that can confirm an abruption will be omitted (e.g., a Kleihauer-Betke test). DIC can result from an abruption. First, look for the cause. PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

What medication would you anticipate giving if your pregnant patient's blood pressure was 160/110 and was taken twice 6 hours apart?

Magnesium sulfate

9. Clonus indicates which of the following? a. The central nervous system is very irritable. b. Renal blood flow is severely reduced. c. Lungs are filling with interstitial fluid. d. Muscles of the foot are inflamed.

a

10. What factors make a pregnant woman a candidate for amniocentesis?

Amniocentesis is most often performed to detect chromosomal abnormalities and other prenatally detectable genetic disorders or to identify if maternal sensitization to Rh-negative blood has affected the fetus. Additional indications include investigating abnormal levels of MSAFP, determining fetal lung maturity, and evaluating the fetus affected by Rh isoimmunization.

55. The nurse is providing care to a patient who just learned her baby has died in utero at 26 weeks' gestation. What is the nurse's next action? a. Contact the patient's clergy member. b. Enroll the patient in a grief and loss class. c. Determine if the patient is a victim of violence. d. Ask the patient when she last felt the baby move.

ANS: D Determining fetal movement will give the nurse a basis for how long the fetus has been expired. This patient is at risk for developing DIC, and the longer the fetus has been expired, the greater the risk. All the interventions listed are worth considering for this patient; however, the nurse must meet the patient's immediate physical needs first. PTS: 1 DIF: Cognitive Level: Synthesis REF: 523 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

64. The nurse is providing care to a laboring woman who is Rh-negative. The patient has a standing prescription to receive RhoGAM, if indicated. When will the nurse plan on administering the RhoGAM, if indicated? a. Approximately 2 hours prior to birth b. At the birth of the placenta c. One hour after the birth of the infant d. Between 48 and 72 hours after birth of the infant

ANS: D If the mother is Rh-negative, umbilical cord blood is taken at birth to determine blood type, Rh factor, and antibody titer (direct Coombs test) of the newborn. Rh-negative unsensitized mothers who give birth to Rh-positive infants are given an intramuscular injection of Rho(D) immune globulin (RhoGAM) within 72 hours after birth. If RhoGAM is given to the mother in the first 72 hours after the birth of an Rh-positive infant, Rh antigens present in her blood are destroyed before she forms antibodies to the Rh factor. If the infant is Rh-negative, Rh antibodies are not formed and RhoGAM is not necessary. Patients of the Jehovah's Witness faith decline blood-based products, and RhoGAM is derived from blood. It is the responsibility of the nurse to make sure that patients of this faith understand the characteristics of RhoGAM and are fully informed of the consequences of declining the administration of RhoGAM. PTS: 1 DIF: Cognitive Level: Application REF: 530 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

17. What are the effects of magnesium sulfate, including the primary adverse effect?

Magnesium sulfate prevents seizures by reducing central nervous system irritability and decreasing vasoconstriction. The primary adverse effect is central nervous system depression, which includes depression of the respiratory center.

6. What is the possible significance of sudden pain in the area of the scapula during early pregnancy? What factors increase a woman's risk of an ectopic pregnancy?

Abrupt onset of shoulder pain may occur with a rup-tured ectopic pregnancy because blood accumulated in the abdomen irritates the phrenic nerve. Refer to Box 25-1, p. 508, to list risk factors.

25. Why do unsensitized Rh-negative expectant mothers receive RhoGAM during pregnancy and after an abortion, amniocentesis, and childbirth?

Administration of Rho(D) immunoglobulin prevents development of maternal anti-Rh antibodies and is recommended after any procedure that includes the possibility of maternal exposure to Rh-positive fetal blood.

19. What nursing assessments should be made for the woman with preeclampsia? Why?

Assessments for the woman with preeclampsia include daily weights, location and degree of edema, vital signs, hourly urinary output, urine for protein, deep tendon reflexes, and subjective signs such as headache, visual disturbances, and epigastric pain. The fetal heart rate should be assessed for nonreassuring patterns. Respiratory rate, oxygen saturation level, consciousness level, and laboratory data such as creatinine, liver enzymes, and magnesium levels should be evaluated. Psychosocial assessment should include the reaction of the woman's family and support system. Nursing assessment helps determine whether the condition is responding to medical management, is stable, or if the disease is worsening.

1. What are the signs of threatened abortion, and how do they differ from those of inevitable abortion?

Bleeding is the most common sign of threatened abortion. It may be accompanied by rhythmic cramping, backache, or feelings of pelvic pressure. Gross rupture of membranes and subsequent uterine cramping and bleeding make the abortion inevitable.

11. How do "morning sickness" and HEG compare in terms of onset, duration, and effect on the woman?

Both morning sickness and hyperemesis gravidarum begin in the first trimester. Morning sickness is self-limiting and causes no serious complications. Hyperemesis is persistent, uncontrollable vomiting that may cause excessive weight loss, dehydration, and electrolyte or acid-base imbalance

17. What two methods are used to cause uterine contractions in a contraction stress test

Breast self-stimulation, oxytocin infusion.

9. What major risks are associated with CVS?

Pregnancy loss after CVS is similar to loss rates after amniocentesis. The likelihood that chromosome findings will be questionable and lead to additional testing such as amniocentesis is greater.

8. What is the major advantage of CVS compared with amniocentesis?

CVS is performed slightly sooner than even early amniocentesis, at 10 to 12 weeks of gestation. Obtaining information about fetal anomalies earlier in the pregnancy allows the woman to make a decision about pregnancy termination before the second trimester. CVS is more expensive than amniocentesis and does not provide amniotic fluid for analysis of the AFP level that might be needed to clarify MSAFP results.

21. What is the antidote for magnesium toxicity?

Calcium gluconate

20. List signs of magnesium toxicity. When is toxicity more likely to occur?

Central nervous system depression, possibly result-ing in diminished or absent deep tendon reflexes, respiratory depression, and hypotension. Reduced urinary output can cause magnesium to accumulate to unsafe levels. Toxicity is more likely if serum level is greater than 8 mg/dL.

22. What features distinguish chronic hypertension from hypertension of pregnancy? Can the two types occur at the same time?

Chronic hypertension is present before pregnancy or before 20 weeks of gestation, may occur with hypertension of pregnancy.

15. What are the signs and symptoms of preeclampsia? Why is reduced activity one part of management?

Classic signs of preeclampsia include hypertension and possibly proteinuria. Nonspecific edema that is severe and generalized is often seen but is no longer considered a classic sign of preeclampsia. Headache, hyperreflexia, visual disturbances, and epigastric pain indicate the disease is worsening. Rest, especially in a lateral position, increases maternal cardiac return and circulatory volume, thus improving perfusion of vital organs. Increased renal perfusion decreases angiotensin II levels, thus lowering blood pressure.

13. What is the relationship between cocaine use and abruptio placentae?

Cocaine is a vasoconstrictor, including constriction of the uterine endometrial arteries, which may lead to premature placental separation.

13. List risks of midtrimester amniocentesis.

Pregnancy loss, fetal hemorrhage if the placenta or cord is pierced, Rh sensitization.

19. Why is amniotic fluid volume an important parameter in the BPP?

Decreased amniotic fluid volume is associated with prolonged fetal hypoxia, in which blood is shunted away from the fetal lungs and kidneys, which produce amniotic fluid, and toward vital organs such as the fetal heart and brain.

4. What is DIC?

Disseminated intravascular coagulation is a life-threatening disorder in which procoagulation and anticoagulation factors are activated simultaneously, resulting in profuse bleeding from any vulnerable area. It may occur with missed abortion (primarily if the pregnancy had reached the second trimester when fetal death occurred), abruptio placentae, severe pregnancy-induced hypertension, amniotic fluid embolism, and other conditions such as sepsis.

20. What is the significance of oligohydramnios?

During fetal hypoxemia, blood is shunted away from the kidneys and lungs and toward the brain, resulting in a lower amniotic fluid volume. It may indicate chronic fetal hypoxia.

13. Why is early amniocentesis sometimes chosen over standard amniocentesis for prenatal diagnosis of genetic disorders? What possible problems make the early procedure less desirable?

Early amniocentesis has the same advantage as CVS: Information is available early in the pregnancy, allowing parents to make decisions about the pregnancy as early as possible. However, the amount of amniotic fluid that can be withdrawn may be inadequate for the indicated test(s) and there is a higher fetal loss rate.

5. Why is ectopic pregnancy sometimes called a "disaster of reproduction"?

Ectopic pregnancy remains the leading cause of maternal death because of hemorrhage, and it can reduce the woman's chance of subsequent pregnancies because of damage to a fallopian tube. Also, the condition that caused the ectopic pregnancy in the tube may be present in the opposite tube.

5. What are possible causes for elevated levels of AFP?

Elevated MSAFP may be caused by open neural tube defects, esophageal obstruction, open abdominal wall defects, and undetected fetal demise. Additional causes include multifetal gestation, inaccurate fetal age or maternal weight, and maternal diabetes.

8. List the typical signs and symptoms of gestational trophoblastic disease. What is another name for this complication?

Elevated hCG level; vaginal bleeding that varies in amount and color; uterine enlargement more than expected for the gestation; undetectable fetal heart activity or ultrasound pattern with characteristic ves-icles; excessive nausea and vomiting; early onset of preeclampsia. Hydatidiform mole is another name for gestational trophoblastic disease.

19. What is the significance of epigastric pain in a woman with preeclampsia?

Epigastric pain occurs with hepatic capsule disten-tion, which often heralds an imminent seizure.

7. What teaching is needed for the woman having methotrexate therapy for an early ectopic pregnancy?

Explain the side effects, such as nausea and vomiting. Teach the woman to refrain from drinking alcohol, ingesting vitamins with folic acid, or having sexual intercourse until human chorionic gonadotropin (hCG) is not detectable in the serum (usually 2 to 4 weeks). Keeping follow-up appointments should also be emphasized.

16. The basic principle of the contraction stress test is to observe the response of the _________ to the stress of ___________.

FHR; uterine contractions.

11. How is fetal lung maturity confirmed?

Fetal lung maturity is confirmed by a 2 : 1 ratio of lecithin/sphingomyelin and the presence of other lipoproteins such as PG and PI, which comprise pulmonary surfactant. A newer test (TDx) evaluates the quantity of surfactant in the amniotic fluid.

12. What are the nursing goals in therapeutic management of HEG?

Goals of management are to maintain hydration, replace electrolytes and vitamins, maintain nutrition, and provide emotional support.

23. What does the acronym HELLP stand for? What are the prominent signs and symptoms of HELLP syndrome? Why should the liver not be palpated in a woman with HELLP syndrome?

H, Hemolysis; EL, elevated liver enzymes; LP, low platelets. Major symptoms are pain and tenderness in the right upper quadrant. Additional signs and symptoms may include nausea, vomiting, and severe edema. Laboratory data include a low hematocrit level, abnormal liver studies, coagulation abnormalities, and often abnormal renal studies. Palpating the liver could cause trauma, including rupture of a subcapsular hematoma

10. What are the major dangers to the mother and the fetus during the placental abruption?

Hemorrhagic shock is the major danger of placental abruption for the mother; anoxia, excessive blood loss, and delivery before maturity are major dangers for the fetus.

7. What is a hydatidiform mole, and why are two phases of treatment necessary?

Hydatidiform mole is a form of gestational trophoblastic disease that involves abnormal development of the placenta as the fetal part of the pregnancy fails to develop. The first phase of treatment is evacuation of the molar pregnancy from the uterus. The second phase is follow-up to detect malignant changes in remaining trophoblastic tissue.

3. What are major advantages and disadvantages of ultrasonography?

Major advantages of ultrasonography are that it allows clear visualization of the fetus and surrounding structures; it is safe, noninvasive, and relatively comfortable; and the results are available immediately. The major disadvantage is the cost. Also, ultrasonography may reveal findings that might indicate a problem but for which data are inadequate to make a clear diagnosis, thereby requiring further decisions by the woman and her support person.

1. What are the major indications for ultrasonography during the first trimester? During the second and third trimesters?

Major reasons for ultrasonography during the first trimester are to confirm pregnancy, verify gestational age, locate the embryo or fetus, determine multifetal pregnancy and gestational age, confirm viability, identify markers that suggest fetal abnormalities, and identify and guide chorionic villus sampling (CVS). Indications during the second and third trimesters are to confirm fetal viability, gestational age, and growth; evaluate fetal anatomy, umbilical cord and vessels, and placenta; evaluate multifetal pregnancies; locate the placenta; determine fetal presentation; evaluate amniotic fluid volume and fetal activity for biophysical profile; and guide needle placement for amniocentesis and umbilical cord sampling.

27. Why is the first fetus sometimes affected if ABO incompatibility occurs? Why are the effects of ABO incompatibility milder than those of Rh sensitization?

Many women with blood type O have anti-A or anti-B antibodies before they become pregnant, so the first pregnancy can be affected. The effects of ABO incompatibility are milder than Rh sensitization because fewer maternal antibodies cross into fetal blood.

26. What are the effects on the fetus of maternal Rh sensitization?

Maternal anti-Rh antibodies cross the placental barrier and destroy fetal Rh-positive red blood cells. The fetus becomes anemic, bilirubin concentration increases, and in severe cases severe neurologic disease can result.

9. What is the relationship between gestational trophoblastic disease and cancer? What precautions related to cancer detection are taken before and after evacuation of the abnormal tissue?

Most tissue in gestational trophoblastic disease is benign, but choriocarcinoma is a possibility. Before the abnormal tissue is evacuated, the woman will be evaluated for metastatic disease. The serum hCG level will be evaluated every 1 to 2 weeks until normal levels are attained and then repeated every 1 to 2 months for 1 year. Pregnancy must be avoided during this period.

14. Why is the amount of external bleeding in abruptio placentae not a reliable indicator of the true amount of blood loss?

Much or all of the blood may be trapped by the placenta, which may remain attached at the edges.

6. What is multiple-marker screening, and what is its purpose? What follow-up tests may be needed?

Multiple-marker screening includes maternal serum alpha-fetoprotein, human chorionic gonadotropin, un-conjugated estriol, and sometimes inhibin A levels. Screening increases the detection of trisomies, such as trisomy 18 and trisomy 21. Follow-up for abnormal levels may include amniocentesis with karyotyping.

7. What is multiple-marker screening? Why is it performed?

Multiple-marker screening, often called triple-marker screening or other names, determines maternal serum levels of AFP, hCG, and unconjugated estriols. Elevation of hCG level with low levels of AFP and estriols suggests chromosome abnormalities. Further testing with amniocentesis to positively identify the fetal karyotype will be offered to the woman if triple-marker screening is abnormal. A fourth marker that increases identity of chromosome abnormalities in the woman younger than 35 years is becoming more common and is often called a quad screen.

3. What interventions can nurses provide for families experiencing grief as a result of early pregnancy loss?

Nurses can facilitate the grief response by being aware that although many couples grieve over an early pregnancy loss, they often feel a lack of support from family, friends, and health care personnel. When nurses demonstrate empathy and unconditional acceptance of the feelings expressed, they support the grief response. Providing information about the grieving and referrals to additional support groups also may be helpful.

13. Why is critical thinking particularly important in the care of the woman with HEG?

Nurses must use critical thinking to examine personal biases that may result in lack of comfort and support for women with hyperemesis. Helping the woman identify any reluctance to accept her pregnancy may lead to solutions that can reduce the intensity of hyperemesis.

8. What are the signs and symptoms of placenta previa? How is it managed in the home?

Painless vaginal bleeding in the latter half of pregnancy is the classic sign of placenta previa. Strict bed rest, no sexual intercourse, an adult caregiver present at all times, and availability of emergency transportation to the hospital are essential for home care. The woman must also be taught to monitor fetal movement and to report a decrease in movement or increase in vaginal bleeding

14. What are the effects of vasospasm on the fetus?

Persistent vasospasm of uterine arterioles may result in fetal hypoxemia, intrauterine growth restriction, or even fetal death.

24. Compare preeclampsia with chronic hypertension in terms of onset and treatment.

Preeclampsia occurs only during pregnancy and the early postpartum period. Chronic hypertension is present before pregnancy or before the twentieth week of gestation and persists after the postpartum period. Hypertension that remains several weeks postpartum suggests that the woman has chronic hypertension even if her blood pressure measurements were normal when she entered care. Treatment may be similar during pregnancy; however, chronic hypertension may be treated with antihypertensive medications before and during pregnancy. Preeclampsia may further complicate chronic hypertension

8. List the risks of CVS.

Pregnancy loss, infection, limb reduction defects, Rh sensitization, expense, unexpected need for added tests.

18. What are the major complications of eclampsia?

Pulmonary edema, circulatory or renal failure, and cerebral hemorrhage are complications of eclampsia. HELLP syndrome, which demonstrates coagulation and liver function abnormalities, is more likely to occur when a woman has severe preeclampsia or eclampsia. DIC may cause unexpected bleeding as levels of coagulation factors decline.

10. What lecithin-to-sphingomyelin (L/S) ratio suggests that the fetal lungs are mature? In what maternal disorder might this ratio not be associated with fetal lung maturity?

Ratio of 2:1; diabetes mellitus

2. What are the major causes of recurrent spontaneous abortion?

Recurrent spontaneous abortions (also called miscarriages) most often occur as a result of genetic or chromosomal abnormalities of the embryo or anomalies of the maternal reproductive tract. Additional causes are believed to be hormonal and immunologic factors or systemic diseases or infections.

22. What are the signs of magnesium toxicity? How should it be managed?

Signs of magnesium toxicity include respiratory rate below 12 breaths per minute, hyporeflexia, sweating or flushing, altered sensorium (lethargy, drowsiness, disorientation), and serum magnesium level beyond the therapeutic range. If toxicity occurs, notify the physician so the dose can be altered or the drug discontinued. Calcium gluconate is an antidote for magnesium toxicity.

2. Define the term spontaneous abortion. What is another term for this occurrence?

Termination of a pregnancy without action taken by the woman or any other person. Miscarriage is a term generally used by laypeople but is becoming more common in usage by professionals.

12. Why is bilirubin in amniotic fluid evaluated?

The degree of bilirubin staining of amniotic fluid reflects the degree of erythrocyte destruction in an Rh-positive fetus whose mother is Rh-sensitized.

9. What are the signs and symptoms of abruptio placentae?

The five classic signs of abruptio placentae are (a) bleeding, which may be evident vaginally or concealed behind the placenta; (b) uterine tenderness; (c) uterine irritability, with poor relaxation between contractions; (d) abdominal pain; and (e) a high uterine resting tone if an intrauterine pressure catheter is being used.

6. Why is the incidence of ectopic pregnancy increasing in the United States? How is ectopic pregnancy treated?

The increase in incidence of ectopic pregnancy may occur as a result of pelvic inflammatory disease that may complicate untreated sexually transmitted infections. Scarring of the fallopian tubes that may result from the infection may make it difficult for the fertilized ovum to pass through the obstructed tube. Ectopic pregnancy is also more likely to occur in women who have assisted reproduction for infertility, ovulation disorders, contraceptive devices, and use of progesterone agents. Treatment for ectopic pregnancy may be medical (chemotherapeutic agent) or surgical (salpingostomy or salpingectomy).

12. List nursing teaching associated with home care when a woman has placenta previa.

The woman and family should be taught to assess the vaginal discharge, fetal movement counts, and uterine activity. She should be given guidelines for what to report. Curtailment of sexual intercourse and return physician visits should be discussed as well. Developing a plan of care suitable for the individual family improves the likelihood of safe home management and that emergency care will be started immediately if the need arises.

12. Midtrimester amniocentesis results for genetic studies are known in approximately what length of time

Three to 7 days for chromosome analysis, depending on the test. More rapid results may include analysis using DNA or fluorescent (fluorescent in situ hybrid-ization [FISH]) probes, or spectral karyotyping. Time required to test for specific disorders varies.

21. How can injury during seizure be prevented?

To prevent seizure-related injury, the side rails should be padded and raised. The bed should be in the lowest position with the wheels locked. Oxygen and suction should be readily available. Necessary equipment and medications should be kept in the room.

20. What measures may be initiated to prevent or manage seizures?

To prevent seizures, maintain a quiet environment, reduce environmental stimuli, and maintain a therapeutic level of magnesium. Nurses must remain with the woman and call for help if a seizure occurs. Attempt to turn the woman on her side before the onset of a seizure. Note the sequence and time of the seizure. Insert an airway after the seizure, and suction the woman's nose and mouth, administer oxygen, administer medications, and prepare for additional medical interventions

3. In which type of ultrasound examination, transvaginal or transabdominal, is a full bladder often needed? Why should the woman having a full bladder for this type of examination? What effect might this have on the woman?

Transabdominal; elevates the uterus and displaces the gas-filled intestines if needed; discomfort in bladder area when scanned.

2. How does the procedure for first-trimester ultrasonography differ from that performed during the second trimester?

Transvaginal ultrasonography is most often performed during the first trimester, when the uterus lies within the pelvis. A transabdominal procedure is more common during the second and third trimesters, when the uterus is above the pelvic brim and the contents are clearly visible.

15. What is the purpose of a vibroacoustic stimulation test (VAS)?

VAS identifies whether fetal heart rate (FHR) accelera-tions occur in response to sound stimulation; it shortens nonstress test (NST) or confirms a nonreac-tive NST results. VAS can be used in the intrapartum period to clarify questionable findings.

16. What is the effect of vasospasm on the brain?

Vasospasms cause rupture of cerebral capillaries and small cerebral hemorrhages.

3. Choose appropriate client teaching related to maternal serum alpha-fetoprotein (MSAFP) analysis. a. Abnormal MSAFP levels should be followed by more specific tests. b. High MSAFP levels are usually associated with chromosome abnormalities. c. Having MSAFP testing eliminates the need to perform an ultrasound examination. d. The initial MSAFP testing will be performed at 12 weeks of gestation.

a

Ultrasonography (ultrasound)

a. Imaging technique that uses high-frequency sound waves to visualize internal body structures

Products of conception

a. The embryo or fetus, plus the placenta and mem-branes

1. Choose the primary distinction between threatened and inevitable abortion. a. Presence of cramping b. Rupture of membranes c. Vaginal bleeding d. Pelvic pressure

b

1. The fetal heartbeat should be visible on ultrasound by the: a. Fourth week following the last menstrual period. b. Sixth week following the last menstrual period. c. Ninth week following the last menstrual period. d. Twelfth week following the last menstrual period.

b

6. A woman who is assessing fetal movements each day should notify her health care provider if: a. More than six movements are felt during a 30-to 60-minute period. b. Fetal movements are fewer than the minimum set by the provider. c. The movement pattern remains about the same from day to day. d. Fetal movements are more frequent during the evening than in the morning.

b

6. Nursing teaching for the woman who has hyperemesis gravidarum should include which of the following? a. Adding favorite seasonings to foods while cooking b. Eating simple foods, such as breads and fruits c. Lying down on her right side after eating d. Eating creamed soup with every meal

b

8. When providing intrapartum care for the woman with severe preeclampsia, priority nursing care is to: a. Maintain the ordered rate of anticonvulsant medications. b. Promote placental blood flow and prevent maternal injury. c. Give intravenous fluids and observe urine output. d. Reduce maternal blood pressure to the prepregnancy level.

b

Oligohydramnios

b. Less amniotic fluid than norma

Laminaria

b. Material that absorbs water and expands to dilate the cervix

11. Which woman should receive Rho(D) immune globulin after birth? a. Rh-negative mother, Rh-positive infant, positive direct Coombs' test b. Rh-positive mother, Rh-negative infant, negative direct Coombs' test c. Rh-negative mother, Rh-positive infant, negative direct Coombs' test d. Rh-positive mother, Rh-positive infant, positive direct Coombs' test

c

4. Choose the correct client teaching to follow amniocentesis. a. Drink 1 to 2 quarts of clear fluid to replace fluid taken in the procedure. b. Resume all normal activities when desired. c. Report persistent contractions, vaginal bleeding, fluid leaking, or fever. d. Eat a diet with increased iron for the 2 days after amniocentesis.

c

5. A woman who is 34 weeks pregnant is admitted with contractions every 2 minutes, lasting 60 seconds, and a high uterine resting tone. She says she had some vaginal bleeding at home, and there is a small amount of blood on her perineal pad. The priority action of the nurse is to: a. Establish whether she is in labor by performing a vaginal examination. b. Ask her whether she has had recent intercourse or a vaginal examination. c. Evaluate the maternal and fetal circulation and oxygenation. d. Determine whether this is the first episode of pain that she has had.

c

5. You are observing for fetal heart rate (FHR) accelerations in a nonstress test (NST) for a woman who is 26 weeks pregnant. The average FHR baseline is 145 to 155 beats per minute (bpm). Within 20 minutes, the FHR accelerated to 165 bpm six times, for 10 to 15 seconds. How should you interpret this information? a. Results are nonreassuring, and another 20 minutes of monitoring is needed. b. Results are nonreassuring because of too few accelerations within the time period. c. Results are reassuring because the FHR accelerated by 10 bpm for 10 seconds. d. Results are reassuring because the fetus was inactive during the monitoring.

c

HELLP

c. Erythrocyte fragmentation, hyperbilirubinemia, and thrombocytopenia that may occur in preeclampsia

Hydramnios

c. More amniotic fluid than norma

10. The feature that distinguishes preeclampsia from eclampsia is the: a. Amount of blood pressure elevation. b. Edema of the face and fingers. c. Presence of 41 proteinuria. d. Onset of one or more seizures.

d

2. A woman is admitted to the emergency department with a possible ectopic pregnancy. Choose the sign or symptom that should be immediately reported to her physician. a. Low level of beta-hCG (human chorionic gonadotropin) b. Hemoglobin level, 11.5 g/dL; hematocrit level, 34% c. Light vaginal bleeding d. Pulse rate increases from 78 to 112 beats per minute (bpm)

d

2. Fewer fetal movements than expected suggest possible: a. Intrauterine fetal growth restriction. b. Inaccurate gestational age dating. c. Rapid intrauterine fetal maturation. d. Reduced placental perfusion with fetal hypoxia.

d

4. The woman who is receiving methotrexate for an ectopic pregnancy should be cautioned to avoid: a. Driving or operating machinery. b. Eating raw vegetables or fruits. c. Using latex condoms for intercourse. d. Taking vitamins with folic acid.

d

7. The nurse makes the following assessments of a woman who is receiving intravenous magnesium sulfate: fetal heart rate (FHR), 148 to 158 bpm; pulse, 88 bpm; respirations, 9 breaths/min; blood pressure, 158/96 mm Hg. The woman is drowsy. The priority nursing action is to: a. Increase the rate of the magnesium infusion. b. Maintain the magnesium infusion at the current rate. c. Slow the rate of the magnesium infusion. d. Stop the magnesium infusion.

d

Ectopic pregnancy

d. Implantation of the fertilized ovum outside the uterine cavity

Bilirubin

d. Waste product of erythrocyte (red blood cell) breakdow

Cerclage

e. Encircling the cervix with sutures

chorionic villus sampling (CVS)

e. Procedure to obtain tissue from fetal side of the developing placenta

Kernicterus

f. Bilirubin accumulation within the brain that might cause damage

Percutaneous umbilical blood sampling

f. Sampling fetal blood using ultrasoun

Maceration

g. Degeneration of a fetus retained in the uterus after its death

Amniocentesis

g. Withdrawing amniotic fluid for laboratory exami-nation

Alpha-fetoprotein (AFP)

h. Fetal substance used to screen for specific abnor-malities

K-B test

h. Identifying presence of fetal erythrocytes into maternal circulation

Multiple-marker screen

i. Alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol, inhibin A

Match each term with the correct definition 35. Doppler ultrasound 36. Lecithin-to-sphingomyelin (L/S) ratio 37. Chorionic villus sampling (CVS) a. test for estimating fetal lung maturity b. A test to assess blood flow to identify abnormalities c. A test to diagnose fetal chromosomal, metabolic, or DNA abnormalities

35. ANS: B 36. ANS: A 37. ANS: C PTS: 1 DIF: Cognitive Level: Understanding REF: 167 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: A Doppler ultrasound can assess blood flow to identify abnormalities. A lecithin-to-sphingomyelin (L/S) ratio is a test for estimating fetal lung maturity. The chorionic villus sampling (CVS) is a test to diagnose fetal chromosomal, metabolic, or DNA abnormalities.

The feature that distinguishes preeclampsia from eclampsia is the: A)Amount of blood pressure elevation B) Edema of the face and fingers C) Presence of 4+ proteinuria D) Onset of one or more seizures

D) Onset of one or more seizures

List indications for performing percutaneous umbilical blood sampling

Diagnose & manage Rh disease Diagnose abnormal blood clotting factors Determine acid-base status of fetus Clarify results of genetic testing Treat blood diseases & deliver therapeutic drugs

What is the purpose of the CST?

Done if the NST findings are nonreactive; identifies the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of mild contractions

Why is the amount of external bleeding in abruptio placentae not a reliable indicator of the true amount of blood loss?

Much or all of the blood may be trapped by the placenta, which may be remain attached at the edges (4)Cases are divided into two main types: (a) Concealed hemorrhage: bleeding occurs behind the placenta but the margins remain intact, causing formation of a hematoma. (b) Apparent hemorrhage: bleeding separates or dissects the membranes from the endometrium and blood flows out through the vagina. NOTE: In either type, placental abruption may be complete or partial.

Why is the patient placed on her left side while on bed rest?

it helps improve the blood flow to the placenta and more effectively providing oxygen and nutrients to the fetus. (Vessels aren't pressed against)

How do "morning sickness" and HEG compare in terms of onset, duration, and effect on the woman?

persistent, uncontrollable vomiting that begins in the first weeks of pregnancy. It may continue throughout pregnancy, although its severity usually lessens. Unlike morning sickness which is self-limited and causes no serious complications, HEG can have serious consequences.

What is the disease that occurs when anti-Rh antibodies cross the placenta and destroy fetal erythrocytes? A) Erythroblastosis fetalis B) Hemolytic Coronary Bypass C) Abortion D) SIDS

A) Erythroblastosis fetalis

Your pregnant patient checks into the OB Clinic and tells you she saw bright red blood in the toilet this morning. She denies any pain. She is 30 weeks pregnant. What do you suspect? A) Placneta Previa B) Abortion C) Ecotopic pregnancy

A) Placneta Previa

You are observing for fetal heart rate (FHR) accelerations in a nonstress test (NST) for a woman who is 26 weeks pregnant. The average FHR baseline is 145 to 155 beats per minute. Within 20 minutes, the FHR accelerated to 165 six times, for 10 to 15 seconds. How should you interpret this information? A) Reassuring B) Nonreassuring C) Active D) Aborted

A) Results are reassuring because the FHR accelerated by 10 bpm for 10 seconds ** Reactive (reassuring) - at least two fetal heart accelerations with or without fetal movement , occur within a 20 minute period, peak at least 15 beats per minute above the baseline and last 15 seconds. Nonreactive (nonreassuring) - Tracing does not demonstrate the required characteristics of a reactive tracing within a 40-minute period.

8. Spontaneous termination of a pregnancy is considered to be an abortion if: a. the pregnancy is less than 20 weeks. b. the fetus weighs less than 1000 g. c. the products of conception are passed intact. d. there is no evidence of intrauterine infection.

ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some fetuses of an older age may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection. PTS: 1 DIF: Cognitive Level: Understanding REF: 505 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

32. As the triage nurse in the emergency room, you are reviewing results for the high- risk obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that: a. immediate birth is required. b. the client should be transferred to the critical care unit for closer observation. c. RhoGAM should be administered. d. a tetanus shot should be administered.

ANS: A A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and, because the client is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore, the client should be delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered, because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time because there is no evidence of penetrating trauma. The client should be transferred to the obstetric area for birth, not the critical care unit setting. PTS: 1 DIF: Cognitive Level: Analysis REF: 516 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity: Medical Emergencies

7. On which aspect of fetal diagnostic testing do parents usually place the most importance? a. Safety of the fetus b. Duration of the test c. Cost of the procedure d. Physical discomfort caused by the procedure

ANS: A Although all these are considerations, parents are usually most concerned about the safety of the fetus. Parents are concerned about the duration, but it is not the greatest concern. The cost of the procedure is important to parents, especially those without third-party payers, but is not the greatest concern. Discomfort of the procedure is important, especially for the mother, but is not the greatest concern. PTS: 1 DIF: Cognitive Level: Understanding REF: 165 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

26. A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound? a. Immediately b. In 2 weeks c. In 4 weeks d. In 6 weeks

ANS: A An embryo can be seen about 5 to 6 weeks after the last menstrual period. At this time the crown-rump length (CRL) of the embryo is the most reliable measure of gestational age. Fetal viability is confirmed by observation of fetal heartbeat, which is visible when the CRL of the embryo is 5 mm. PTS: 1 DIF: Cognitive Level: Application REF: 167 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

23. A laboratory finding indicative of DIC is: a. decreased fibrinogen. b. increased platelets. c. increased hematocrit. d. decreased thromboplastin time.

ANS: A DIC develops when the blood-clotting factor thromboplastin is released into the maternal bloodstream as a result of placental bleeding. Thromboplastin activates widespread clotting, which uses the available fibrinogen, resulting in a decreased fibrinogen level. The platelet count will decrease. The hematocrit may decrease if bleeding is pronounced. The thromboplastin time is prolonged. PTS: 1 DIF: Cognitive Level: Analysis REF: 507 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. The clinic nurse is obtaining a health history on a newly pregnant client. Which is an indication for fetal diagnostic procedures if present in the health history? a. Maternal diabetes b. Weight gain of 25 lb c. Maternal age older than 30 d. Previous infant weighing more than 3000 g at birth

ANS: A Diabetes is a risk factor in pregnancy because of possible impairment of placental perfusion. Excessive weight gain is an indication for testing. Normal weight gain is 25 to 35 lb. A maternal age older than 35 years is an indication for testing. Having had another infant weighing more than 4000 g is an indication for testing. PTS: 1 DIF: Cognitive Level: Analysis REF: 169 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

28. A female client presents to the emergency room complaining of lower abdominal cramping with scant bleeding of approximately 2 days' duration. This morning, the quality and location of the pain changed and she is now experiencing pain in her shoulder. The client's last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days. Which clinical diagnosis does the nurse suspect? a. Ectopic pregnancy b. Appendicitis c. Food poisoning d. Gastroenteritis

ANS: A Even though the client's menstrual cycle has variability, all women are considered to be pregnant until proven otherwise. The client's presenting symptoms are typical for ectopic pregnancy, so the client should be monitored for the possible complication of rupture and shock. PTS: 1 DIF: Cognitive Level: Application REF: 507, 508 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

16. What does a score of 9 on a biophysical profile signify? a. Normal b. Abnormal c. Equivocal d. Nonreactive

ANS: A Five parameters of fetal activity—fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume—are used to determine the biophysical profile. The maximum score is 2 points for each parameter. A score falling between 8 and 10 is considered normal. A score of 4 or less is considered abnormal. Equivocal and nonreactive are not terms used to describe the results of a biophysical profile. PTS: 1 DIF: Cognitive Level: Understanding REF: 178 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

4. When is the most accurate time to determine gestational age through ultrasound? a. First trimester b. Second trimester c. Third trimester d. No difference in accuracy among the trimesters

ANS: A Gestational age determination by ultrasonography is increasingly less accurate after the first trimester. Gestational age determination is best done in the first trimester. There is a difference in trimesters when doing a gestational age ultrasonography. PTS: 1 DIF: Cognitive Level: Understanding REF: 167 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

31. A high-risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean section. Which finding in the immediate postoperative period indicates that the client is at risk of developing HELLP syndrome? a. Platelet count of 50,000/µL b. Liver enzyme levels within normal range c. Negative for edema d. No evidence of nausea or vomiting

ANS: A HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels, and a low platelet count. A platelet count of 50,000/µL indicates thrombocytopenia. PTS: 1 DIF: Cognitive Level: Analysis REF: 529 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Pathophysiology

46. What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding? a. Treated 1 year ago for pelvic inflammatory disease (PID) b. Oral contraception for last 3 years c. Urinary frequency for 1 week d. Irregular cycles for 1 year prior to conception

ANS: A PID causes fallopian tube damage. Blockage of the tube prevents movement of the fertilized ovum, resulting in implantation in the tube. Oral contraception for the last 3 years, urinary frequency for 1 week, and irregular cycles for 1 year prior to conception have no effect on the development of ectopic pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 508 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity, Physiological Adaptation

4. Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome? a. Abdominal palpation b. Venous sample of blood c. Checking deep tendon reflexes d. Auscultation of the heart and lungs

ANS: A Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated. Venous blood is checked frequently to observe for thrombocytopenia. PTS: 1 DIF: Cognitive Level: Application REF: 529 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following? a. Hemorrhage is the major concern. b. She will be unable to conceive in the future. c. Bed rest and analgesics are the recommended treatment. d. A D&C will be performed to remove the products of conception.

ANS: A Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, her fertility will decrease but she will not be infertile. The recommended treatment is to remove the pregnancy before hemorrhaging. A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes. PTS: 1 DIF: Cognitive Level: Understanding REF: 507, 508 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

1. A pregnant client's biophysical profile score is 8. She asks the nurse to explain the results. What is the nurse's best response? a. "The test results are within normal limits." b. "Immediate birth by cesarean birth is being considered." c. "Further testing will be performed to determine the meaning of this score." d. "An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth."

ANS: A The normal biophysical score ranges from 8 to 10 points if the amniotic fluid volume is adequate. A normal score allows conservative treatment of high-risk patients. Birth can be delayed if fetal well-being is an issue. Scores less than 4 would be investigated, and birth could be initiated sooner than planned. This score is within normal range, and no further testing is required at this time. The results of the biophysical profile are usually available immediately after the procedure is performed. PTS: 1 DIF: Cognitive Level: Application REF: 179 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

37. Which finding should be the nurse's priority in a client suspected as having gestational trophoblastic disease? a. Uterine contractions b. Nausea and vomiting c. Blood pressure of 130/80 mm Hg d. Increase discharge of vaginal mucus

ANS: A Uterine contractions can cause trophoblastic tissue to be pulled into large venous sinusoids in the uterus, resulting in embolization of the tissue and respiratory distress. Nausea and vomiting and blood pressure of 130/80 mm Hg represent no immediate danger to the client and can be addressed later. Increased discharge of vaginal mucus is a normal finding in pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment: Management of Care

21. Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa? a. Determining cervical dilation and effacement b. Monitoring FHR and maternal vital signs c. Observing vaginal bleeding or leakage of amniotic fluid d. Determining frequency, duration, and intensity of contractions

ANS: A Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this client. Monitoring for bleeding and rupture of membranes is not contraindicated with this client. Monitoring contractions is not contraindicated with this client. PTS: 1 DIF: Cognitive Level: Analysis REF: 512 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

33. The nurse is reviewing maternal serum alpha-fetoprotein (MSAFP) results. Which conditions are associated with elevated levels of MSAFP? (Select all that apply.) a. Fetal demise b. Neural tube defects c. Abdominal wall defects d. Chromosomal trisomies e. Gestational trophoblastic disease

ANS: A, B, C Elevated levels of AFP may indicate open neural tube defects (e.g., anencephaly, spina bifida), abdominal wall defects (e.g., omphalocele, gastroschisis), or fetal demise. Low levels of AFP may indicate chromosomal trisomies (e.g., Down syndrome, trisomy 21) or gestational trophoblastic disease. PTS: 1 DIF: Cognitive Level: Analysis REF: 169 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

30. Transvaginal ultrasonography is often performed during the first trimester. A 6-week-gestation client expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be necessary to determine which of the following? (Select all that apply.) a. Multifetal gestation b. Bicornuate uterus c. Presence and location of pregnancy d. Amniotic fluid volume e. Presence of ovarian cysts

ANS: A, B, C, E A bicornuate uterus, multifetal gestation, presence of ovarian cysts, and presence and location of pregnancy can be determined by transvaginal ultrasound in the first trimester of pregnancy. This procedure is also used for estimating gestational age, confirming fetal viability, identifying fetal abnormalities or chromosomal defects, and identifying the maternal abnormalities mentioned, as well as fibroids. Amniotic fluid volume is assessed during the second and third trimesters. Conventional ultrasound would be used. PTS: 1 DIF: Cognitive Level: Analysis REF: 167 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

32. The nurse is instructing a client on how to perform kick counts. Which information should the nurse include in the teaching session? (Select all that apply.) a. Use a clock or timer when performing kick counts. b. Your bladder should be full before performing kick counts. c. Notify your health care provider if you have not felt movement in 24 hours. d. Protocols can provide a structured timetable for concentrating on fetal movements. e. You should lie on your side, place your hands on the largest part of the abdomen, and concentrate on the number of movements felt.

ANS: A, D, E The nurse should instruct the client to lie on her side, place her hands on the largest part of her abdomen, and concentrate on fetal movements. She should use a clock or timer and record the number of movements felt during that time. Protocols are not essential but may give the client a more structured timetable for when to concentrate on fetal movements. The bladder does not need to be full for kick counts; it is better to have the client empty her bladder before beginning the assessment of fetal movements. Further evaluation is recommended if the client feels no movements in 12 hours; 24 hours is too long before notifying the health care provider. PTS: 1 DIF: Cognitive Level: Application REF: 179 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

18. Which orders should the nurse expect for a client admitted with a threatened abortion? a. NPO b. Pad count c. Ritodrine IV d. Meperidine (Demerol), 50 mg now

ANS: B A client admitted with a threatened abortion should be instructed to count the number of perineal pads used and to note the quantity and color of blood on the pads. Ritodrine is not the first drug of choice for tocolytic medications. There is no reason for having the client NPO. At times, dehydration may produce contractions, so hydration is important. Demerol will not decrease the contractions but may mask the severity of the contractions. PTS: 1 DIF: Cognitive Level: Application REF: 505 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

45. Which information should the labor nurse recognize as being pertinent to a possible diagnosis of abruptio placentae? a. Low back pain b. Firm, tender uterus c. Regular uterine contractions d. Scant vaginal mucus drainage

ANS: B A firm, tender uterus is a classic sign of abruptio placentae; low back pain, regular uterine contractions, and scant vaginal mucus drainage are normal findings in a laboring client. PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment: Management of Care

44. Which explanation of a marginal placenta previa would the nurse provide to her client? a. The placenta is in the lower uterus, completely covering the internal cervical os. b. The placenta is in the lower uterus, more than 3 cm from the internal cervical os. c. The placenta is in the lower uterus, less than 3 cm from the internal cervical os. d. The placenta is in the lower uterus, at the edge and partially covering the cervical os.

ANS: B A marginal placenta, also called a low-lying placenta, is more than 3 cm from the internal cervical os. The placenta in the lower uterus, completely covering the internal cervical os, describes a total placenta previa. The placenta in the lower uterus, less than 3 cm from the internal cervical os, and the placenta in the lower uterus, at the edge and partially covering the cervical os, are both descriptions of a partial placenta previa. PTS: 1 DIF: Cognitive Level: Application REF: 513 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment: Management of Care

9. An abortion when the fetus dies but is retained in the uterus is called: a. inevitable. b. missed. c. incomplete. d. threatened.

ANS: B A missed abortion refers to a dead fetus being retained in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all the products of conception were expelled. With a threatened abortion, the client has cramping and bleeding but not cervical dilation. PTS: 1 DIF: Cognitive Level: Understanding REF: 506 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

24. For which client would an L/S ratio of 2:1 potentially be considered to be abnormal? a. A 38-year-old gravida 2, para 1, who is 38 weeks' gestation b. A 24-year-old gravida 1, para 0, who has diabetes c. A 44-year-old gravida 6, para 5, who is at term d. An 18-year-old gravida 1, para 0, who is in early labor at term

ANS: B Even though an L/S ratio of 2:1 is typically considered to be a normal finding to validate fetal lung maturity prior to 38 weeks' gestation, the result may not be accurate in determining fetal lung maturity if a client is diabetic. PTS: 1 DIF: Cognitive Level: Analysis REF: 172 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

20. The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result? a. Repeat the test in 1 week so that results can be trended based on this baseline result. b. Contact the health care provider to discuss birth options for the client. c. Send the client out for a meal and repeat the test to confirm that the results are valid. d. Ask the client to perform a fetal kick count assessment for the next 30 minutes and then reassess the client.

ANS: B A positive CST test is an abnormal finding, and the physician should be notified so that birth options can be initiated. A positive CST indicates possible fetal compromise. Intervention should not be delayed by 1 week and results do not have to be trended. Because this is an abnormal result, there is no need to repeat the test. Sending the client out for a meal will delay treatment options and may interfere with possible birth interventions if anesthesia is needed. Fetal kick count assessment is not needed at this time and will further delay treatment interventions for this abnormal result, which indicates fetal compromise. PTS: 1 DIF: Cognitive Level: Analysis REF: 176 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation/Unexpected Response to Therapies

35. Which assessment finding indicates an adverse response to magnesium sulfate? a. Urine output of 30 mL/hr b. Respiratory rate of 11 breaths/min c. Hypoactive patellar reflex d. Blood pressure reading of 110/80 mm Hg

ANS: B A respiratory rate less than 12 breaths/min indicates magnesium toxicity and requires immediate intervention. A urine output of 30 mL/hr is normal urinary output; a hypoactive patellar reflex and blood pressure reading of 110/80 mm Hg are normal findings in the client receiving magnesium sulfate. PTS: 1 DIF: Cognitive Level: Analysis REF: 525 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

52. Which intervention would be the most effective if your client who is on magnesium sulfate has a respiratory rate of 10 breaths/min? a. Give oxygen by mask at 8-10 L/min. b. Administer calcium gluconate via IV pyelogram (IVP). c. Arouse client with tactile stimulation. d. Continually assess pulse oximeter levels.

ANS: B A respiratory rate of less than 12 breaths/min in a client receiving magnesium sulfate is a sign of magnesium toxicity, which must be immediately reversed. Calcium gluconate opposes the effects of magnesium at the neuromuscular junction and is an antidote for magnesium toxicity. Oxygen by mask at 8 to 10 L/min, arousing a client with tactile stimulation, and continually assessing pulse oximeter levels will not be effective until the magnesium toxicity has been reversed. PTS: 1 DIF: Cognitive Level: Application REF: 525 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment: Management of Care

13. What does nursing care after amniocentesis include? a. Forcing fluids by mouth b. Monitoring uterine activity c. Placing the client in a supine position for 2 hours d. Applying a pressure dressing to the puncture site

ANS: B A risk with amniocentesis is the onset of spontaneous contractions. Hydration is important, but the woman has not been NPO, so this should not be a problem. The supine position may decrease uterine blood flow; the side-lying position is preferred. Pressure dressings are not necessary. PTS: 1 DIF: Cognitive Level: Application REF: 171 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

21. A pregnant client has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the client's plan of care? a. No further testing is indicated at this time because results are normal. b. Refer to the physician for additional testing. c. Validate the results with the lab facility. d. Repeat the test in 2 weeks and have the client return for her regularly scheduled prenatal visit.

ANS: B Additional genetic testing is indicated to provide the client with treatment options. A positive result on a triple-screen test is considered to be an abnormal finding so the client should be referred to the physician for additional genetic testing. Validation of the test with a lab facility is not necessary because the client provided you with a copy of the test results. There is no need to repeat the clinical test because the findings have already been determined. PTS: 1 DIF: Cognitive Level: Analysis REF: 170 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation/Unexpected Response to Therapies

12. The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to: a. monitor uterine contractions. b. assess fetal heart rate and maternal vital signs. c. place clean disposable pads to collect any drainage. d. perform a venipuncture for hemoglobin and hematocrit levels.

ANS: B Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus. Monitoring uterine contractions is important, but not the top priority. It is important to assess future bleeding, but the top priority is client and fetal well-being. The most important assessment is to check client and fetal well-being. The blood levels can be obtained later. PTS: 1 DIF: Cognitive Level: Application REF: 516 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

25. A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take? a. Increase the client's IV fluids. b. Administer calcium gluconate. c. Vigorously stimulate the client. d. Instruct the client to take deep breaths.

ANS: B Calcium gluconate reverses the effects of magnesium sulfate. Increasing the client's IV fluids will not reverse the effects of the medication. Stimulation will not increase the respirations. Deep breaths will not be successful in reversing the effects of the magnesium sulfate. PTS: 1 DIF: Cognitive Level: Application REF: 525 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

11. Which would indicate concealed hemorrhage in abruptio placentae? a. Bradycardia b. Hard boardlike abdomen c. Decrease in fundal height d. Decrease in abdominal pain

ANS: B Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. The client will have shock symptoms that include tachycardia. The fundal height will increase as bleeding occurs. Abdominal pain may increase. PTS: 1 DIF: Cognitive Level: Analysis REF: 516 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

16. Rh incompatibility can occur if the client is Rh-negative and the: a. fetus is Rh-negative. b. fetus is Rh-positive. c. father is Rh-positive. d. father and fetus are both Rh-negative.

ANS: B For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive. If the fetus is Rh-negative, the blood types are compatible and no problems should occur. The father's Rh factor is a concern only as it relates to the possible Rh factor of the fetus. If the fetus is Rh-negative, the blood type with the mother is compatible. The father's blood type does not enter into the problem. PTS: 1 DIF: Cognitive Level: Understanding REF: 530 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

6. A client is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. Which potential problem should be investigated? a. Placenta previa b. Hydatidiform mole c. Abruptio placentae d. Disseminated intravascular coagulation (DIC)

ANS: B Gestational trophoblastic disease (hydatidiform mole) is usually detected in the first trimester of pregnancy. The frequency of this condition is highest at both ends of a woman's reproductive life. Placenta previa usually occurs in the third trimester. Painless uterine bleeding is the classic symptom. Abruptio placentae usually occurs in the third trimester. Painful uterine bleeding is the classic symptom. DIC is a life-threatening complication of abruptio placentae, in which procoagulation and anticoagulation factors are simultaneously activated. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

36. Which finding could cause the nurse to suspect gestational trophoblastic disease in a client at 8 weeks' gestation? a. Blood pressure of 128/70 mm Hg b. Fundal height of 12 cm c. Nausea and vomiting d. Weight gain of 3 pounds

ANS: B Gestational trophoblastic disease is characterized by proliferation and edema of the chorionic villi. The fluid-filled villi form grapelike clusters of tissue that can rapidly grow to fill the uterus to the size of a more advanced pregnancy. Blood pressure of 128/70 mm Hg, nausea and vomiting, and weight gain of 3 pounds are all normal findings in the first trimester. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

2. Which is the only known cure for preeclampsia? a. Magnesium sulfate b. Delivery of the fetus c. Antihypertensive medications d. Administration of aspirin (ASA) every day of the pregnancy

ANS: B If the fetus is viable and near term, birth is the only known cure for preeclampsia. Magnesium sulfate is one of the medications used to treat but not cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of aspirin (60 to 80 mg) have been administered to women at high risk for developing preeclampsia. PTS: 1 DIF: Cognitive Level: Understanding REF: 519 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

7. Which maternal condition always necessitates birth by cesarean section? a. Partial abruptio placentae b. Total placenta previa c. Ectopic pregnancy d. Eclampsia

ANS: B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal birth occurred. If the client has stable vital signs and the fetus is alive, a vaginal birth can be attempted. If the fetus has died, a vaginal birth is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control. PTS: 1 DIF: Cognitive Level: Understanding REF: 512 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

19. Which data found on a client's health history would place her at risk for an ectopic pregnancy? a. Ovarian cyst 2 years ago b. Recurrent pelvic infections c. Use of oral contraceptives for 5 years d. Heavy menstrual flow of 4 days' duration

ANS: B Infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for implantation. Ovarian cysts do not cause scarring of the fallopian tubes. Oral contraceptives do not increase the risk for ectopic pregnancies. Heavy menstrual flow of 4 days' duration will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnancies. PTS: 1 DIF: Cognitive Level: Understanding REF: 508 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

27. The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks' gestation. The nurse determines that the patient understands the teaching when she mentions that which fluid will be collected for the initial screening process? a. Urine b. Blood c. Saliva d. Amniotic

ANS: B Initial screening is completed with blood. AFP can be detected in amniotic fluid; however, that procedure is more costly and invasive. Procedures progress from least invasive to most invasive. PTS: 1 DIF: Cognitive Level: Understanding REF: 169 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

50. Which assessment finding suggests that your laboring client's blood magnesium level is too high? a. Hyperactive reflexes b. Absent reflexes c. Generalized seizure d. Urine output of 60 mL/hr

ANS: B Magnesium acts as a central nervous system depressant by blocking neuromuscular transmission. Assessment of the deep tendon reflexes is an indication of the level of CNS depression. Absent reflexes indicates magnesium toxicity; hyperactive reflexes, generalized seizure, and urine output of 60 mL/hr are not symptoms of magnesium toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 526 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

2. Which analysis of maternal serum may predict chromosomal abnormalities in the fetus? a. Biophysical profile b. Multiple-marker screening c. Lecithin-to-sphingomyelin ratio d. Blood type and crossmatch of maternal and fetal serum

ANS: B Maternal serum can be analyzed for abnormal levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), inhibin A, and estriol. The multiple-marker screening may predict chromosomal defects in the fetus. The biophysical profile is used to evaluate fetal status during the antepartum period. Five variables are used, but none are concerned with chromosomal problems. The lecithin-to-sphingomyelin ratio is used to determine fetal lung maturity. The blood type and crossmatch will not predict chromosomal defects in the fetus. PTS: 1 DIF: Cognitive Level: Understanding REF: 170 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

25. Which complication could occur as a result of percutaneous umbilical blood sampling (PUBS)? a. Postdates pregnancy b. Fetal bradycardia c. Placenta previa d. Uterine rupture

ANS: B PUBS is an invasive test whereby a needle is inserted into the umbilical cord to obtain blood as the basis for diagnostic testing with the guidance of ultrasound technology. The most common complication is fetal bradycardia, which is temporary. PUBS has no effect on extending the gestation of pregnancy, the development of placenta previa, or uterine rupture. PTS: 1 DIF: Cognitive Level: Analysis REF: 173 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

23. Which factor serves as a clinical indicator for a third trimester amniocentesis? a. Sex of the fetus b. Rh isoimmunization c. Placenta previa d. Placental abruption

ANS: B Rh isoimmunization is a clinical indicator for a third-trimester amniocentesis. Although an amniocentesis can determine the sex of the fetus, this is not a primary indication for a third-trimester amniocentesis. Ultrasound imaging would be indicated for evaluation of placenta previa. Ultrasound imaging would be indicated for evaluation of placental abruption. PTS: 1 DIF: Cognitive Level: Analysis REF: 172 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

18. A biophysical profile is performed on a pregnant client. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. What would be the correct interpretation of this test result? a. A score of 10 would indicate that the results are equivocal. b. A score of 8 would indicate normal results. c. A score of 6 would indicate that birth should be considered as a possible treatment option. d. A score of 9 would indicate reassurance.

ANS: B The biophysical profile is used to assess fetal well-being. Five categories of assessment are used in this combination test: fetal monitoring NST, evaluation of FBMs, gross movements, fetal tone, and calculation of the amniotic fluid index (AFI). A maximum of 2 points is used if criteria are met successfully in each category; thus a score in the range of 8 to 10 indicates a normal or reassuring finding. A score of 6 provides equivocal results and further testing or observation is necessary. A score of 4 or less requires immediate intervention, and birth may be warranted. The provided assessments indicate a score of 8 as the only area that has not met the stated criteria in the NST. PTS: 1 DIF: Cognitive Level: Analysis REF: 178 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential/Diagnostic Tests

40. Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae? a. Saturated perineal pad in 1 hour b. Pain level 0 on a scale of 0 to 10 c. Cervical dilation at 2 cm d. Fetal heart rate at 160 bpm

ANS: B The classic sign of placenta previa is the sudden onset of painless uterine bleeding, whereas abruptio placentae results in abdominal pain and uterine tenderness; heavy bleeding, cervical dilation, and fetal heart rate of 160 bpm could be associated with both conditions. PTS: 1 DIF: Cognitive Level: Analysis REF: 513 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment: Management of Care

29. A client who was pregnant had a spontaneous abortion at approximately 4 weeks' gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the client presents at the clinic office complaining of "crampy" abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100° F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/min (bpm), and respirations, 20 breaths/min. Based on these assessment data, what does the nurse anticipate as a clinical diagnosis? a. Ectopic pregnancy b. Uterine infection c. Gestational trophoblastic disease d. Endometriosis

ANS: B The client is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and blood pressure and pulse manifesting as shock-trended vitals. Because the pregnancy test is negative, an undiagnosed ectopic pregnancy and gestational trophoblastic disease are ruled out. There is no supportive evidence to indicate a clinical diagnosis of endometriosis at this time; however, it is more likely that this is an infectious process that must be aggressively treated. PTS: 1 DIF: Cognitive Level: Analysis REF: 506 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

47. Which of these interventions should the nurse recognize as the priority for the client diagnosed with an intact tubal pregnancy? a. Assessment of pain level b. Administration of methotrexate c. Administration of Rh immune globulin d. Explanation of the common side effects of the treatment plan

ANS: B The goal of medical management of an intact tube is to preserve the tube and improve the chance of future fertility. Methotrexate (a folic acid antagonist) is used to inhibit cell division and stop growth of the embryo. Assessment of pain level, administration of Rh immune globulin, and explaining common side effects of the treatment plan should be implemented in conjunction with or soon after treatment with methotrexate has begun. PTS: 1 DIF: Cognitive Level: Analysis REF: 509 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment: Management of Care

8. The nurse's role in diagnostic testing is to provide which of the following? a. Advice to the couple b. Information about the tests c. Reassurance about fetal safety d. Assistance with decision making

ANS: B The nurse should provide the couple with all necessary information about a procedure so that the couple can make an informed decision. The nurse's role is to inform, not to advise. Ensuring fetal safety is not possible with all the diagnostic tests. To offer this is to give false reassurance to the parents. The nurse can inform the couple about potential problems so they can make an informed decision. Decision making should always lie with the couple involved. The nurse should provide information so that the couple can make an informed decision. PTS: 1 DIF: Cognitive Level: Understanding REF: 179 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

31. A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator (VAS) test. Which should the nurse include in the response? (Select all that apply.) a. The test is invasive. b. The test uses sound to elicit fetal movements. c. The test may confirm nonreactive non-stress test results. d. The test can only be performed if contractions are present. e. Vibroacoustic stimulation can be repeated at 1-minute intervals up to three times.

ANS: B, C, E Also referred to as VAS or acoustic stimulation, the vibroacoustic stimulator (similar to an electronic larynx) is applied to the maternal abdomen over the area of the fetal head. Vibration and sound are emitted for up to 3 seconds and may be repeated. A fetus near term responds by increasing the number of gross body movements, which can be easily seen and felt. The procedure can confirm reassuring NST findings and shorten the length of time necessary to obtain NST data. The test is noninvasive and contractions do not need to be present to perform the test. PTS: 1 DIF: Cognitive Level: Application REF: 176 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

What drug is administered to mom's who are RH negative? A) Oxytocin B) Estrogen C) RhoGAM

C) RhoGAM

5. The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which? a. Hemophilia b. Sickle cell anemia c. A neural tube defect d. A normal lecithin-to-sphingomyelin ratio

ANS: C An open neural tube allows a high level of AFP to seep into the amniotic fluid and enter the maternal serum. Hemophilia is a genetic defect and is best detected with chromosomal studies, such as chorionic villus sampling or amniocentesis. Sickle cell anemia is a genetic defect and is best detected with chromosomal studies such as chorionic villus sampling or amniocentesis. L/S ratios are determined with an amniocentesis and are usually done in the third trimester. PTS: 1 DIF: Cognitive Level: Understanding REF: 168 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

1. A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a: a. diuretic. b. tocolytic. c. anticonvulsant. d. antihypertensive.

ANS: C Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate. PTS: 1 DIF: Cognitive Level: Understanding REF: 523 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

22. A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered? a. Magnesium sulfate b. Prostaglandin suppository c. RhoGAM if the client is Rh-negative d. Betamethasone

ANS: C CVS can increase the likelihood of Rh sensitization if a woman in Rh-negative. There is no indication for magnesium sulfate because it is used to stop preterm labor. There is no indication for administration of a prostaglandin suppository. Betamethasone is given to pregnant women in preterm labor to improve fetal lung maturity. PTS: 1 DIF: Cognitive Level: Analysis REF: 170 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

48. Which finding in the exam of a client with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion? a. Presence of backache b. Rise in hCG level c. Clear fluid from vagina d. Pelvic pressure

ANS: C Clear fluid from the vagina indicates rupture of the membranes. Abortion is usually inevitable (cannot be stopped) when the membranes rupture, the presence of backache and pelvic pressure are common symptoms in threatened abortion, and a rise in the hCG level is consistent with a viable pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 506 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

39. Which finding in the assessment of a client following an abruption placenta could indicate a major complication? a. Urine output of 30 mL in 1 hour b. Blood pressure of 110/60 mm Hg c. Bleeding at IV insertion site d. Respiratory rate of 16 breaths/min

ANS: C DIC is a life-threatening defect in coagulation that may occur following abruptio placentae. DIC allows excess bleeding from any vulnerable area such as IV sites, incisions, gums, or nose. A urine output of 30 mL in 1 hour, blood pressure of 110/60 mm Hg, and respiratory rate of 16 breaths/min are normal findings in a postpartum client. PTS: 1 DIF: Cognitive Level: Analysis REF: 507 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

5. A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? a. +1 b. +2 c. +3 d. +4

ANS: C Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the peritoneal cavity. PTS: 1 DIF: Cognitive Level: Application REF: 526 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

6. When is the earliest that chorionic villus sampling can be performed during pregnancy? a. 4 weeks b. 8 weeks c. 10 weeks d. 12 weeks

ANS: C Fetal villus tissue can be obtained as early as 10 weeks of gestation and can be analyzed directly for chromosomal or genetic abnormalities. It is too early to be performed at 4 weeks. It is too early to be performed at 8 weeks. The test should be performed at 12 weeks, but it can be done as early as 10 weeks. PTS: 1 DIF: Cognitive Level: Understanding REF: 170 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia? a. Edema b. Proteinuria c. Glucosuria d. Hypertension

ANS: C Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign noted by the pregnant client is rapid weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension. The first indication of preeclampsia is usually an increase in the maternal blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 521 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

38. What is the priority nursing intervention for the client who has had an incomplete abortion? a. Methylergonovine (Methergine), 0.2 mg IM b. Preoperative teaching for surgery c. Insertion of IV line for fluid replacement d. Positioning of client in left side-lying position

ANS: C Initial treatment of an incomplete abortion should be focused on stabilizing the client's cardiovascular state. Methylergonovine would be administered after surgical treatment, preoperative teaching is not a priority until the client is stabilized, and the left side-lying position provides no benefit to the client in this situation. PTS: 1 DIF: Cognitive Level: Application REF: 506 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment: Management of Care

24. Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication? a. Drowsiness b. Urinary output of 20 mL/hr c. Normal deep tendon reflexes d. Respiratory rate of 10 to 12 breaths/min

ANS: C Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A urinary output of 20 mL/hr is not adequate output. A respiratory rate of 10 to 12 breaths/min is too slow and could be indicative of magnesium toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 525 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

43. In addition to obtaining vital signs and FHT, what is a priority for the client with placenta previa? a. Determining cervical dilation b. Monitoring uterine contractions c. Estimating blood loss d. Starting a Pitocin drip

ANS: C Nursing assessments for the client with placenta previa focus on determining the amount of blood loss. The nurse does not perform vaginal exams on a client with placenta previa because of the risk of perforating the placenta, the client may or may not be experiencing contractions, and induction is not indicated for a client with placenta previa. PTS: 1 DIF: Cognitive Level: Application REF: 512 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment: Management of Care

41. A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL. a. 1800 b. 450 c. 900 d. 90

ANS: C One g equals 1 mL of blood. PTS: 1 DIF: Cognitive Level: Application REF: 511 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

22. The primary symptom present in abruptio placentae that distinguishes it from placenta previa is: a. vaginal bleeding. b. rupture of membranes. c. presence of abdominal pain. d. changes in maternal vital signs.

ANS: C Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding. Both abruptio placentae and placenta previa may have vaginal bleeding. Rupture of membranes may occur with both conditions. Maternal vital signs may change with both if bleeding is pronounced. PTS: 1 DIF: Cognitive Level: Understanding REF: 515 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

51. What should the nurse recognize as evidence that the client is recovering from preeclampsia? a. 1+ protein in urine b. 2+ pitting edema in lower extremities c. Urine output >100 mL/hr d. Deep tendon reflexes +2

ANS: C Rapid reduction of the edema associated with preeclampsia results in urinary output of 4 to 6 L/day as interstitial fluids shift back to the circulatory system. 1+ protein in urine and 2+ pitting edema in lower extremities are signs of continuing preeclampsia. Deep tendon reflexes are not a reliable sign, especially if the client has been treated with magnesium. PTS: 1 DIF: Cognitive Level: Analysis REF: 525 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

11. Which is the major advantage of chorionic villus sampling over amniocentesis? a. It is not an invasive procedure. b. It does not require a hospital setting. c. It requires less time to obtain results. d. It has less risk of spontaneous abortion.

ANS: C Results from chorionic villus sampling can be known within 24 to 48 hours, whereas results from amniocentesis require 2 to 4 weeks. It is an invasive procedure. The woman has to be in a hospital setting for her and the fetus to be properly assessed during and after the procedure. The risk of an abortion is at the same level for both procedures. PTS: 1 DIF: Cognitive Level: Understanding REF: 170 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

34. The most appropriate nursing action for the client complaining of continuous headache 24 hours postpartum after a normal vaginal birth is to: a. encourage bed rest. b. administer analgesic. c. assess blood pressure. d. assess for pitting edema.

ANS: C The first indication of preeclampsia is usually hypertension. Continuous headache indicates poor cerebral perfusion and may be a precursor of seizures; encouraging bed rest, administering an analgesic, and assessing for edema are not interventions to determine the source of the client's headache. PTS: 1 DIF: Cognitive Level: Application REF: 521 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

14. What is the term for a non-stress test in which there are two or more fetal heart rate accelerations of 15 or more bpm with fetal movement in a 20-minute period? a. Positive b. Negative c. Reactive d. Nonreactive

ANS: C The non-stress test (NST) is reactive (normal) when there are two or more fetal heart rate accelerations of at least 15 bpm (each with a duration of at least 15 seconds) in a 20-minute period. A positive result is not used with an NST. The contraction stress test (CST) uses positive as a result term. A negative result is not used with an NST. The CST uses negative as a result term. A nonreactive result means that the heart rate did not accelerate during fetal movement. PTS: 1 DIF: Cognitive Level: Analysis REF: 174 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

19. In preparing a pregnant client for a non-stress test (NST), which of the following should be included in the plan of care? a. Have the client void prior to being placed on the fetal monitor because a full bladder will interfere with results. b. Maintain NPO status prior to testing. c. Position the client for comfort, adjusting the tocotransducer belt to locate fetal heart rate. d. . Have an infusion pump prepared with oxytocin per protocol for evaluation.

ANS: C The nurse must adjust the tocotransducer to find the best location to pick up and record the fetal heart rate. Positioning the client for comfort during testing is a prime concern. Although a full bladder may affect client comfort, it will not interfere with testing results. NPO status is not required for an NST. Instead, a pregnant client should maintain her normal nutritional intake to provide energy to herself and the fetus. An infusion pump with oxytocin is required for a contraction stress test (CST). PTS: 1 DIF: Cognitive Level: Analysis REF: 174 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential/Diagnostic Tests

14. A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to: a. advise her to cut down on fast foods that are high in fat. b. caution her to avoid salty foods and to return in 2 weeks. c. assess weight gain, location of edema, and urine for protein. d. recommend she stay home from school for a few days to reduce stress.

ANS: C The nurse should further assess the client for hypertension, generalized edema, and proteinuria, which are classic signs of pregnancy-induced hypertension. Cutting down on fast foods will not relieve the symptoms of pregnancy-induced hypertension. She is at risk for pregnancy-induced hypertension and should be evaluated at this visit. Rest may be the treatment at first, but she needs further assessment to determine if pregnancy-induced hypertension is the problem. PTS: 1 DIF: Cognitive Level: Application REF: 526 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

28. A patient at 36 weeks gestation is undergoing a non-stress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings? a. NST positive, nonreassuring b. NST negative, reassuring c. NST reactive, reassuring d. NST nonreactive, nonreassuring

ANS: C The presence of at least three accelerations of at least 15 beats, over at least 15 seconds, over a duration of at least 20 minutes, is considered reactive and reassuring. Nonreactive testing reveals no or fewer accelerations over the same or longer period. The NST test is not recorded as positive or negative. PTS: 1 DIF: Cognitive Level: Analysis REF: 175 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

27. You are taking care of a client who had a therapeutic abortion following an episode of vaginal bleeding and ultrasound confirmation of a blighted ovum. Lab work is ordered 2 weeks postprocedure as a follow-up to medical care. Which result indicates that additional intervention is needed? a. Hemoglobin, 13.2 mg/dL b. White blood cell count, 10,000 mm3 c. Beta-hCG detected in serum d. Fasting blood glucose level, 80 mg/dL

ANS: C The presence of beta-hCG in serum 2 weeks after the procedure is clinically significant and indicates the possibility that there may have been a molar pregnancy (hydatidiform). Thus, further examination is required. None of the other lab results warrant intervention because they are within normal limits. PTS: 1 DIF: Cognitive Level: Analysis REF: 509 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

20. Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole? a. Blood pressure of 120/80 mm Hg b. Complaint of frequent mild nausea c. Fundal height measurement of 18 cm d. History of bright red spotting for 1 day weeks ago

ANS: C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. A client with a molar pregnancy may have early-onset, pregnancy-induced hypertension. Nausea increases in a molar pregnancy because of the increased production of human chorionic gonadotropin (hCG). The history of bleeding is normally described as being of a brownish color. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

29. Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)? (Select all that apply.) a. Down syndrome b. Molar pregnancy c. Twin gestation d. Incorrect gestational age assessment of a normal fetus—estimation is earlier in the pregnancy e. Threatened abortion

ANS: C, D, E Elevated APF levels are seen in multiple gestations, underestimation of fetal age, and threatened abortion. Decreased levels are seen in Down syndrome and a molar pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 169 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation/Pathophysiology

34. The nurse is preparing a client for a non-stress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.) a. Ensure that the client has a full bladder. b. Plan approximately 15 minutes for the test. c. Have the client sit in a recliner with the head elevated 45 degrees. d. Apply electronic monitoring equipment to the client's abdomen. e. Instruct the client to press an event marker every time she feels fetal movement.

ANS: C, D, E The client may be seated in a reclining chair or have her head elevated at least 45 degrees. The nurse applies external electronic monitoring equipment to the client's abdomen to detect the fetal heart rate and any contractions. The woman may be given an event marker to press each time she senses movement. Before the NST, the client should void and her baseline vital signs should be taken. The NST takes about 40 minutes, allowing for most fetal sleep-wake cycles, although the fetus may show a reassuring pattern more quickly or need more time to awaken and become active. Fifteen minutes would not allow enough time to complete the test. PTS: 1 DIF: Cognitive Level: Application REF: 174 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

15. A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate: a. gastrointestinal upset. b. effects of magnesium sulfate. c. anxiety caused by hospitalization. d. worsening disease and impending convulsion.

ANS: D Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. Gastrointestinal upset is not an indication as severe as the headache and visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe anxiety. PTS: 1 DIF: Cognitive Level: Analysis REF: 520 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

10. A placenta previa when the placental edge just reaches the internal os is called: a. total. b. partial. c. low-lying. d. marginal.

ANS: D A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. With a partial previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete previa is termed total. The placenta completely covers the internal cervical os. PTS: 1 DIF: Cognitive Level: Understanding REF: 513 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

42. Which assessment finding on the fetal monitor strip supports a diagnosis of abruptio placentae? a. FHR of 150 bpm b. Moderate variability of FHR c. Contractions every 3 minutes d. Uterine resting tone of 30 mm Hg

ANS: D Abruptio placentae results in uterine irritability and a high resting uterine tone. A normal resting tone is from 5 to 15 mm Hg; FHR of 150 bpm, moderate variability of FHR, and contractions every 3 minutes are normal labor findings. PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

17. In which situation would a dilation and curettage (D&C) be indicated? a. Complete abortion at 8 weeks b. Incomplete abortion at 16 weeks c. Threatened abortion at 6 weeks d. Incomplete abortion at 10 weeks

ANS: D D&C is carried out to remove the products of conception from the uterus and can be done safely until week 14 of gestation. If all the products of conception have been passed (complete abortion), a D&C is not done. If the pregnancy is still viable (threatened abortion), a D&C is not done. PTS: 1 DIF: Cognitive Level: Understanding REF: 506 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

12. What is the purpose of amniocentesis for a client hospitalized at 34 weeks of gestation with pregnancy-induced hypertension? a. Determine if a metabolic disorder is genetic. b. Identify the sex of the fetus. c. Identify abnormal fetal cells. d. Determine fetal lung maturity.

ANS: D During the third trimester, amniocentesis is most often performed to determine fetal lung maturity. In cases of pregnancy-induced hypertension, preterm birth may be necessary because of changes in placental perfusion. The test is done in the early portion of the pregnancy if the metabolic disorder is genetic. Amniocentesis is done early in the pregnancy to do genetic studies and determine the sex. Identification of abnormal cells is done during the early portion of the pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 172 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

30. A client with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension do you think the client is exhibiting? a. Pregnancy-induced hypertension (PIH) b. Gestational hypertension c. Preeclampsia superimposed on chronic hypertension d. Undiagnosed chronic hypertension

ANS: D Even though the client has no documented prenatal care or medical history, she does relate a family history that is positive for heart disease. Additionally, the client's blood pressure increased following birth and was treated in the hospital and resolved. Now the client appears at the 6-week checkup with hypertension. Typically, gestational hypertension resolves by the end of the 6-week postpartum period. The fact that this has not resolved is suspicious for undiagnosed chronic hypertension. There is no evidence to suggest that the client was preeclamptic prior to the birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

49. Which assessment finding indicates the development of preeclampsia in the antepartum client? a. Slight edema of feet and ankles. b. Increased urine output c. Blood pressure of 128/80 mm Hg d. Weight gain of 3 pounds in 1 week

ANS: D Generalized edema often occurs with preeclampsia. Edema may first manifest as a rapid weight gain. Normal weight gain in the second and third trimesters is 1 pound per week; slight edema of feet and ankles, increased urine output, and blood pressure of 128/80 mm Hg are normal findings in pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 521, 522 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

9. Which should be considered a contraindication for transcervical chorionic villus sampling? a. Rh-negative mother b. Gestation less than 15 weeks c. Maternal age younger than 35 years d. Positive for group B Streptococcus

ANS: D Maternal infection is a risk with this procedure, and it is contraindicated if the client has an active infection in the cervix, vagina, or pelvic area. This procedure is done between 10 and 12 weeks. This procedure is usually done for women older than 35; however, if the woman is at high risk for fetal anomalies, her age is not a contraindication. The procedure can still be performed; however, Rh sensitization may occur if the mother is Rh-negative. Rho(D) immune globulin can be administered following the procedure. PTS: 1 DIF: Cognitive Level: Analysis REF: 170 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. What is the purpose of initiating contractions in a contraction stress test (CST)? a. Increase placental blood flow. b. Identify fetal acceleration patterns. c. Determine the degree of fetal activity. d. Apply a stressful stimulus to the fetus.

ANS: D The CST involves recording the response of the fetal heart rate to stress induced by uterine contractions. The CST records the fetal response to stress. It does not increase placental blood flow. The NST looks at fetal heart accelerations with fetal movements. The NST and biophysical profiles look at fetal movements. PTS: 1 DIF: Cognitive Level: Understanding REF: 176 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

13. A primigravida of 28 years of age is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following? a. She should be isolated from her family. b. This condition is caused by psychogenic factors. c. The treatment is similar to that for morning sickness. d. She should be assessed for signs of dehydration and starvation.

ANS: D The cause of hyperemesis gravidarum is unknown, but dehydration and starvation are the major complications. Emotional support is essential to the care of this client. She needs the opportunity to express how it feels to live with constant nausea. The cause is unknown. The first attempts to control the nausea are to treat it like morning sickness, but if treatment is not successful, further care is needed. PTS: 1 DIF: Cognitive Level: Application REF: 518 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

33. A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the following assessments. The vaginal exam is deferred until the physician is in attendance. The client is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring? a. Placental previa b. Active labor has started c. Placental abruption d. Hidden placental abruption

ANS: D The client's signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention and imminent birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity: Medical Emergencies

17. Which response by the nurse is most appropriate to the statement, "This test isn't my idea, but my husband insists?" a. "It's your decision." b. "Don't worry. Everything will be fine." c. "Why don't you want to have this test?" d. "You're concerned about having this test?"

ANS: D The nurse should clarify the statement and assist the client in exploring her feelings about the test. "It's your decision" is a closed statement and does not encourage the woman to express her feelings. "Don't worry" is false reassurance and does not deal with the concerns expressed by the woman. The woman may not be able to answer "why" questions. It may also make her defensive. PTS: 1 DIF: Cognitive Level: Application REF: 174 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity

10. Which nursing intervention is necessary prior to a second-trimester transabdominal ultrasound? a. Perform an abdominal prep. b. Administer a soap suds enema. c. Ensure the client is NPO for 12 hours. d. Instruct the client to drink 1 to 2 quarts of water.

ANS: D When the uterus is still in the pelvis, visualization may be difficult. It is necessary to perform the test when the woman has a full bladder, which provides a window through which the uterus and its contents can be viewed. An abdominal prep is not necessary for this procedure. A soap suds enema is not necessary for this procedure. The client needs a full bladder to elevate the uterus; therefore, being NPO would not be appropriate. PTS: 1 DIF: Cognitive Level: Application REF: 168 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

What is the possible significance of sudden pain in the area of the scapula during early pregnancy?

Abrupt onset of shoulder pain may occur with a ruptured ectopic pregnancy because blood accumulated in the abdomen irritates the phrenic nerve

What are the major indications for ultrasonography during the first trimester?

Confirm pregnancy, verify location of pregnancy, verify fetal viability, identify multifetal gestations, determine gestational age, identify chromosomal abnormalities, determine markers for procedures