Exam 3 Practice

3. What laboratory marker is indicative of disseminated intravascular coagulation (DIC)? a. Bleeding time of 10 minutes c. Thrombocytopenia b. Presence of fibrin split products d. Hyperfibrinogenemia

ANS: B Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.

20. Magnesium sulfate is given to women with preeclampsia and eclampsia to: a. Improve patellar reflexes and increase respiratory efficiency. b. Shorten the duration of labor. c. Prevent and treat convulsions. d. Prevent a boggy uterus and lessen lochial flow.

ANS: C Magnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.

34. The single most important risk factor for preterm birth includes: a. Uterine and cervical anomalies b. Infection c. Increased BMI d. Prior preterm birth

ANS: d The single most important factor is prior preterm birth with a reoccurrence rate of up to 40%.

25. A pregnant woman at 32 weeks of gestation comes to the emergency room because she has begun to experience bright red vaginal bleeding. She reports that she is experiencing no pain. The admission nurse suspects: a. abruptio placentae. b. disseminated intravascular coagulation. c. placenta previa. d. preterm labor.

25. c; the clinical manifestations of placenta previa are described; dark red bleeding with pain is characteristic of abruptio placentae; massive bleeding from many sites is associated with DIC; bleeding is not a sign of preterm labor.

33. 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. No evidence exists 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 older fetuses 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.

16. The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is: a. Hypertension. c. Hemorrhagic complications. b. Hyperemesis gravidarum. d. Infections.

ANS: A Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common.

38. A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of: a. Anxiety due to hospitalization. b. Worsening disease and impending convulsion. c. Effects of magnesium sulfate. d. Gastrointestinal upset.

ANS: B 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. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication.

36. What condition indicates concealed hemorrhage when the patient experiences an abruptio placentae? a. Decrease in abdominal pain c. Hard, boardlike abdomen b. Bradycardia d. Decrease in fundal height

ANS: C 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. Abdominal pain may increase. The patient will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height will increase.

25. Methotrexate is recommended as part of the treatment plan for which obstetric complication? a. Complete hydatidiform mole c. Unruptured ectopic pregnancy b. Missed abortion d. Abruptio placentae

ANS: C Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for complete hydatidiform mole, missed abortion, and abruptio placentae.

36. Metabolic changes during pregnancy __________ glucose tolerance. a. lower b. increase c. maintain d. alter

ANS: a Metabolic changes during pregnancy lower glucose tolerance.

47. The perinatal nurse describes for the new nurse the various risks associated with prolonged premature preterm rupture of membranes. These risks include (select all that apply): a. Chorioamnionitis b. Abruptio placentae c. Operative birth d. Cord prolapse

ANS: a, b, d Even though maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cord prolapse.

16. When measuring the BP to ensure consistency and to facilitate early detection of BP changes consistent with gestational hypertension, the nurse should: a. place the woman in a supine position. b. allow the woman to rest for at least 15 minutes before measuring her BP. c. use the same arm for each BP measurement. d. use a proper sized cuff that covers at least 50% of her upper arm.

16. c; the woman should be seated or in a lateral position, she should rest for 5 to 10 minutes, and the cuff should cover 80% of the upper arm.

17. When caring for a woman with mild preeclampsia, it is critical that during assessment the nurse is alert for signs of progress to severe preeclampsia. Progress to severe preeclampsia would be indicated by which one of the following assessment findings? a. Proteinuria of 31 or greater b. Platelet level of 200,000/mm3 c. Deep tendon reflexes 21, ankle clonus is absent d. BP of 154/94 and 156/100, 6 hours apart

17. a; with severe preeclampsia, the DTRs would be more than 31 with possible ankle clonus; the BP would be more than 160/110; thrombocytopenia with a platelet level less than150,000 mm3.

18. A woman's preeclampsia has advanced to the severe stage. She is admitted to the hospital and her primary health care provider has ordered an infusion of magnesium sulfate be started. In fulfilling this order the nurse would implement which of the following? (Circle all that apply.) a. Prepare a loading dose of 2 g of magnesium sulfate in 200 ml of 5% glucose in water to be given over 15 minutes. b. Prepare the maintenance solution by mixing 40 g of magnesium sulfate in 1000 ml of lactated Ringer's solution. c. Monitor maternal vital signs, fetal heart rate (FHR) patterns, and uterine contractions every 2 hours. d. Expect the maintenance dose to be approximately 2 g/hour. e. Report a respiratory rate of 14 breaths or less per minute to the primary health care provider immediately. f. Recognize that urinary output should be at least 25-30 ml per hour.

18. b, d, and f; the loading dose should be an IV of 4 to 6 g diluted in 100 mL of intravenous fluid; maternal assessment should occur every 15 to 30 minutes and FHR and UC continuously; respirations should be less than 12

19. The primary expected outcome for care associated with the administration of magnesium sulfate would be met if the woman exhibits which of the following? a. Exhibits a decrease in both systolic and diastolic BP b. Experiences no seizures c. States that she feels more relaxed and calm d. Urinates more frequently, resulting in a decrease in pathologic edema

19. b; magnesium sulfate is a CNS depressant given to prevent seizures.

A woman has been diagnosed with mild preeclampsia and will be treated at home. The nurse, in teaching this woman about her treatment regimen for mild preeclampsia, would tell her to do which of the following? (Circle all that apply.) a. Check her respirations before and after taking her oral dose of magnesium sulfate b. Place a dipstick into a clean-catch sample of her urine to test for protein c. Reduce her fluid intake to four to five 8-ounce glasses each day d. Do gentle exercises such as hand and feet circles and gently tensing and relaxing arm and leg muscles e. Avoid excessively salty foods f. Maintain strict bed rest in a quiet dimly lighted room with minimal stimuli

20. b, d, and e; magnesium sulfate is administered intravenously in the hospital with severe preeclampsia; a clean catch, midstream urine specimen should be used to assess urine for protein using a dipstick; fluid intake should be 6 to 8 (8 oz.) glasses a day along with roughage to prevent constipation; gentle exercise improves circulation and helps preserve muscle tone and a sense of well-being; modified bed rest with diversional activities is recommended for mild preeclampsia.

21. A woman has just been admitted with a diagnosis of hyperemesis gravidarum. She has been unable to retain any oral intake and as a result has lost weight and is exhibiting signs of dehydration with electrolyte imbalance and acetonuria. The care management of this woman would include which of the following? a. Administering labetalol to control nausea and vomiting b. Assessing the woman's urine for ketones c. Avoiding oral hygiene until the woman is able to tolerate oral fluids d. Providing small frequent meals consisting of bland foods and warm fluids together once the woman begins to respond to treatment

21. b; labetalol is a beta blocker used for hypertension; oral hygiene is important when NPO and after vomiting episodes to maintain the integrity of oral mucosa; taking fluids between, not with, meals reduces nausea, thereby increasing tolerance for oral nutrition.

22. A primigravida at 10 weeks of gestation reports slight vaginal spotting without passage of tissue and mild uterine cramping. When examined, no cervical dilation is noted. The nurse caring for this woman would: a. anticipate that the woman will be sent home and placed on bed rest with instructions to avoid stress and orgasm. b. prepare the woman for a dilation and curettage. c. inform the woman that frequent blood tests will be required to check the level of estrogen. d. tell the woman that the doctor will most likely perform a cerclage to help her maintain her pregnancy.

22. a; the woman is experiencing a threatened abortion; therefore, a conservative approach is attempted first; b reflects management of an inevitable and complete or incomplete abortion; blood tests for HCG and progesterone levels would be done; cerclage or suturing of the cervix is done for recurrent, spontaneous abortion associated with premature dilation of the cervix.

23. A woman is admitted through the emergency room with a medical diagnosis of ruptured ectopic pregnancy. The primary nursing diagnosis at this time would be: a. acute pain related to irritation of the peritoneum with blood. b. risk for infection related to tissue trauma. c. deficient fluid volume related to blood loss associated with rupture of the uterine tube. d. anticipatory grieving related to unexpected pregnancy outcome

23. c; a, b, and d are appropriate nursing diagnoses, but deficient fluid is the most immediate concern, placing the woman's well-being at greatest risk.

24. A woman diagnosed with an ectopic pregnancy is given an intramuscular injection of methotrexate. The nurse would tell the woman which of the following? a. Methotrexate is an analgesic that will relieve the dull abdominal pain she is experiencing. b. She should avoid alcohol until her primary care provider tells her the treatment is complete. c. Follow-up blood tests will be required every other month for 6 months after the injection of the methotrexate. d. She should continue to take her prenatal vitamin and folic acid to enhance healing.

24. b; methotrexate destroys rapidly growing tissue, in this case the fetus and placenta, to avoid rupture of the tube and need for surgery; follow-up with blood tests is needed for 2 to 8 weeks; alcohol and vitamins containing folic acid increase the risk for side effects with this medication or exacerbating the ectopic rupture.

26. A pregnant woman, at 38 weeks of gestation diagnosed with marginal placenta previa, has just given birth to a healthy newborn male. The nurse recognizes that the immediate focus for the care of this woman would be: a. preventing hemorrhage. b. relieving pain. c. preventing infection. d. fostering attachment of the woman with her new son.

26. a; hemorrhage is a major potential postpartum complication because the implantation site of theplacenta is in the lower uterine segment, which has a limited capacity to contract after birth; infection is another major complication, but it is not the immediate focus of care; b and d are also important but not to the same degree as hemorrhage, which is life threatening.

37. The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to: a. Assess fetal heart rate (FHR) and maternal vital signs b. Perform a venipuncture for hemoglobin and hematocrit levels c. Place clean disposable pads to collect any drainage d. Monitor uterine contractions

ANS: A Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.

42. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion? a. Chromosomal abnormalities c. Endocrine imbalance b. Infections d. Immunologic factors

ANS: A At least 50% of pregnancy losses result from chromosomal abnormalities that are incompatible with life. Maternal infection may be a cause of early miscarriage. Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss. Women who have repeated early pregnancy losses appear to have immunologic factors that play a role in spontaneous abortion incidents.

14. Your patient is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, "Why is it taking so long?" The most appropriate response by the nurse would be: a. "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor." b. "I don't know why it is taking so long." c. "The length of labor varies for different women." d. "Your baby is just being stubborn."

ANS: A Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate. "I don't know why it is taking so long" is not an appropriate statement for the nurse to make. Although the length of labor does vary in different women, the most likely reason this woman's labor is protracted is the tocolytic effect of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.

2. Because pregnant women may need surgery during pregnancy, nurses should be aware that: a. The diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy. b. Rupture of the appendix is less likely in pregnant women because of the close monitoring. c. Surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy. d. When pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.

ANS: A Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell count. Rupture of the appendix is two to three times more likely in pregnant women. Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy predisposes a woman to ovarian problems.

39. Which order should the nurse expect for a patient admitted with a threatened abortion? a. Bed rest b. Ritodrine IV c. NPO d. Narcotic analgesia every 3 hours, prn

ANS: A Decreasing the woman's activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. There is no reason for having the woman placed NPO. At times dehydration may produce contractions, so hydration is important. Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions.

10. A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: a. Hydralazine. c. Diazepam. b. Magnesium sulfate bolus. d. Calcium gluconate.

ANS: A Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.

19. In planning care for women with preeclampsia, nurses should be aware that: a. Induction of labor is likely, as near term as possible. b. If at home, the woman should be confined to her bed, even with mild preeclampsia. c. A special diet low in protein and salt should be initiated. d. Vaginal birth is still an option, even in severe cases.

ANS: A Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.

5. In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? a. Administration of blood b. Preparation of the client for invasive hemodynamic monitoring c. Restriction of intravascular fluids d. Administration of steroids

ANS: A Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a client with DIC because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

15. What nursing diagnosis would be the most appropriate for a woman experiencing severe preeclampsia? a. Risk for injury to the fetus related to uteroplacental insufficiency b. Risk for eclampsia c. Risk for deficient fluid volume related to increased sodium retention secondary to administration of MgSO4 d. Risk for increased cardiac output related to use of antihypertensive drugs

ANS: A Risk for injury to the fetus related to uteroplacental insufficiency is the most appropriate nursing diagnosis for this client scenario. Other diagnoses include Risk to fetus related to preterm birth and abruptio placentae. Eclampsia is a medical, not a nursing, diagnosis. There would be a risk for excess, not deficient, fluid volume related to increased sodium retention. There would be a risk for decreased, not increased, cardiac output related to the use of antihypertensive drugs.

4. In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder: a. Disseminated intravascular coagulation (DIC) b. Amniotic fluid embolism (AFE) c. Hemorrhage d. HELLP syndrome

ANS: A The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman's arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the postpartum client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

45. The reported incidence of ectopic pregnancy in the United States has risen steadily over the past 2 decades. Causes include the increase in STDs accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for symptoms such as (Select all that apply): a. Pelvic pain b. Abdominal pain c. Unanticipated heavy bleeding d. Vaginal spotting or light bleeding e. Missed period

ANS: A, B, D, E A missed period or spotting can easily be mistaken by the patient 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 patient often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.

44. A client who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include (Select all that apply): a. Iron supplementation. b. Resumption of intercourse at 6 weeks following the procedure. c. Referral to a support group if necessary. d. Expectation of heavy bleeding for at least 2 weeks. e. Emphasizing the need for rest.

ANS: A, C, E The woman should be advised to consume a diet high in iron and protein. For many women iron supplementation also is necessary. Acknowledge that the client has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her provider.

12. The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits: a. A sleepy, sedated affect. c. Deep tendon reflexes of 2. b. A respiratory rate of 10 breaths/min. d. Absent ankle clonus.

ANS: B A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2 and absent ankle clonus are normal findings.

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

ANS: B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred. If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted in cases of partial abruptio placentae. If the fetus has died, a vaginal delivery 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.

43. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve: a. Corticosteroids to reduce inflammation. b. IV therapy to correct fluid and electrolyte imbalances. c. An antiemetic, such as pyridoxine, to control nausea and vomiting. d. Enteral nutrition to correct nutritional deficits.

ANS: B Initially, the woman who is unable to keep down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.

34. An abortion in which the fetus dies but is retained within the uterus is called a(n): a. Inevitable abortion c. Incomplete abortion b. Missed abortion d. Threatened abortion

ANS: B Missed abortion refers to retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation.

24. The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: a. Bleeding. c. Uterine activity. b. Intense abdominal pain. d. Cramping.

ANS: B Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

26. A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure? a. Amniocentesis for fetal lung maturity b. Ultrasound for placental location c. Contraction stress test (CST) d. Internal fetal monitoring

ANS: B The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding.

23. The perinatal nurse is giving discharge instructions to a woman after suction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse would be: a. "If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available." b. "The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult." c. "If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time." d. "Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy."

ANS: B This is an accurate statement. β-Human chorionic gonadotropin (hCG) levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a "zero" hCG level. If the woman were to become pregnant, it could obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device is acceptable.

27. A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of: a. Placenta previa. b. Vasa previa. c. Severe abruptio placentae. d. Disseminated intravascular coagulation (DIC).

ANS: B Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and would be considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors and causes widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome. This woman did not have any prior risk factors.

. Women with hyperemesis gravidarum: a. Are a majority, because 80% of all pregnant women suffer from it at some time. b. Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance. c. Need intravenous (IV) fluid and nutrition for most of their pregnancy. d. Often inspire similar, milder symptoms in their male partners and mothers.

ANS: B Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 80% of pregnant women experience nausea and vomiting, fewer than 1% (0.5%) proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is seldom needed for very long. Women suffering from this condition want sympathy because some authorities believe that difficult relationships with mothers and/or partners may be the cause.

22. A woman presents to the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion? a. Incomplete c. Threatened b. Inevitable d. Septic

ANS: C A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would present with heavy bleeding, mild to severe cramping, and cervical dilation. An inevitable abortion manifests with the same symptoms as an incomplete abortion: heavy bleeding, mild to severe cramping, and cervical dilation. A woman with a septic abortion presents with malodorous bleeding and typically a dilated cervix.

28. A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the woman's umbilicus and recognizes this assessment finding as: a. Normal integumentary changes associated with pregnancy. b. Turner's sign associated with appendicitis. c. Cullen's sign associated with a ruptured ectopic pregnancy. d. Chadwick's sign associated with early pregnancy.

ANS: C Cullen's sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turner's sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwick's sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy.

7. The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of: a. Eclampsia. b. Disseminated intravascular coagulation (DIC). c. HELLP syndrome. d. Idiopathic thrombocytopenia.

ANS: C HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.

31. In providing nutritional counseling for the pregnant woman experiencing cholecystitis, the nurse would: a. Assess the woman's dietary history for adequate calories and proteins. b. Instruct the woman that the bulk of calories should come from proteins. c. Instruct the woman to eat a low-fat diet and avoid fried foods. d. Instruct the woman to eat a low-cholesterol, low-salt diet.

ANS: C Instructing the woman to eat a low-fat diet and avoid fried foods is appropriate nutritional counseling for this client. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated.

6. A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse? a. Blood pressure (BP) increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. A dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day

ANS: C Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or in diastolic pressure of 15 mm Hg. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

30. Which condition would not be classified as a bleeding disorder in late pregnancy? a. Placenta previa. c. Spontaneous abortion. b. Abruptio placentae. d. Cord insertion.

ANS: C Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Cord insertion is a cause of bleeding disorders in later pregnancy.

17. Nurses should be aware that HELLP syndrome: a. Is a mild form of preeclampsia. b. Can be diagnosed by a nurse alert to its symptoms. c. Is characterized by hemolysis, elevated liver enzymes, and low platelets. d. Is associated with preterm labor but not perinatal mortality.

ANS: C The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased, and so is perinatal mortality.

9. A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, "I'm so thirsty and warm." The nurse: a. Calls for a stat magnesium sulfate level. b. Administers oxygen. c. Discontinues the magnesium sulfate infusion. d. Prepares to administer hydralazine.

ANS: C The client is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.

40. What finding on a prenatal visit at 10 weeks could suggest a hydatidiform mole? a. Complaint of frequent mild nausea b. Blood pressure of 120/80 mm Hg 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. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the patient's history, bleeding is normally described as brownish.

21. Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors? a. A 30-year-old obese Caucasian with her third pregnancy b. A 41-year-old Caucasian primigravida c. An African-American client who is 19 years old and pregnant with twins d. A 25-year-old Asian-American whose pregnancy is the result of donor insemination

ANS: C Three risk factors are present for this woman. She is of African-American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy. In planning care for this client the nurse must monitor blood pressure frequently and teach the woman regarding early warning signs. The 30-year-old client only has one known risk factor, obesity. Age distribution appears to be U-shaped, with women less than 20 years and more than 40 years being at greatest risk. Preeclampsia continues to be seen more frequently in primigravidas; this client is a multigravida woman. Two risk factors are present for the 41-year-old client. Her age and status as a primigravida put her at increased risk for preeclampsia. Caucasian women are at a lower risk than African-American women. The Asian-American client exhibits only one risk factor. Pregnancies that result from donor insemination, oocyte donation, and embryo donation are at an increased risk of developing preeclampsia.

35. A placenta previa in which the placental edge just reaches the internal os is more commonly known as: a. Total c. Complete b. Partial 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. When the patient experiences a partial placenta 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 placenta previa is termed total. The placenta completely covers the internal cervical os.

13. Your patient has been receiving magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client? a. Absence of uterine bleeding in the postpartum period b. A fundus firm below the level of the umbilicus c. Scant lochia flow d. A boggy uterus with heavy lochia flow

ANS: D Because of the tocolytic effects of magnesium sulfate, this patient most likely would have a boggy uterus with increased amounts of bleeding and a heavy lochia flow in the postpartum period.

29. As related to the care of the patient with miscarriage, nurses should be aware that: a. It is a natural pregnancy loss before labor begins. b. It occurs in fewer than 5% of all clinically recognized pregnancies. c. It often can be attributed to careless maternal behavior such as poor nutrition or excessive exercise. d. If it occurs before the twelfth week of pregnancy, it may manifest only as moderate discomfort and blood loss.

ANS: D Before the sixth week the only evidence may be a heavy menstrual flow. After the twelfth week more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but by definition it occurs before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriage can be caused by a number of disorders or illnesses outside of the mother's control or knowledge.

18. Nurses should be aware that chronic hypertension: a. Is defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy. b. Is considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg. c. Is general hypertension plus proteinuria. d. Can occur independently of or simultaneously with gestational hypertension.

ANS: D Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks postpartum. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.

8. A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to: a. Insert an oral airway. b. Suction the mouth to prevent aspiration. c. Administer oxygen by mask. d. Stay with the client and call for help.

ANS: D If a client becomes eclamptic, the nurse should stay her and call for help. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the client's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the client's mouth. Oxygen would be administered after the convulsion has ended.

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

ANS: D Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture in order to prevent hemorrhaging. If the tube must be removed, the woman's fertility will decrease; however, she will not be infertile. D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.

11. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: a. Eclamptic seizure. c. Placenta previa. b. Rupture of the uterus. d. Placental abruption.

ANS: D Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.

True or false: 39. It is critical for the perinatal nurse to learn, as part of the facility's policies and procedures, to immediately perform a vaginal examination on a woman who presents with vaginal bleeding after 24 weeks' gestation.

ANS: False Placenta previa should be suspected in all patients who present with bleeding after 24 completed weeks of gestation. Because of the risk of placental perforation, vaginal examinations are not performed.

True or false: 37. Immediately postpartum, the insulin needs in diabetic women increase dramatically.

ANS: FalseThere is a significant decrease in the need for insulin immediately after delivery related to the loss of antagonistic placental hormones and suppression of the anterior pituitary growth hormone.

True or false: 41. A patient with hypertension who is receiving intravenous magnesium sulfate therapy has requested an epidural anesthetic. The perinatal nurse should first review the patient's complete blood count results for evidence of a decreased platelet count.

ANS: True Baseline information, including complete blood count (CBC), clotting studies, serum electrolytes, and renal function tests, is used to alert the care providers to changes in the patient's condition as additional laboratory tests are obtained.

True or false: 42. The perinatal nurse knows that the laboring diabetic patient's blood glucose level should always be less than 120 mg/dL.

ANS: True Blood glucose levels are assessed every hour, and fluid/insulin adjustments are made as needed to maintain maternal blood glucose levels between 80 and 120 mg/dL.

True or false: 38. The perinatal nurse observes the placental inspection by the health-care provider after birth. This examination may help to determine whether an abruption has occurred prior to or during labor.

ANS: True Fifty percent of abruptions occur before labor and after the 30th week, 15% occur during labor, and 30% are identified only upon inspection of the placenta after delivery.

True or false: 40. The perinatal nurse knows that the survival rate for infants born at or greater than 28 to 29 gestational weeks is greater than 90%.

ANS: True With appropriate medical care, neonatal survival dramatically improves as the gestational age increases, with over 50% of neonates surviving at 25 weeks' gestation, and over 90% surviving at 28 to 29 weeks of gestation.

4. Which of the following assessments would indicate instability in the client hospitalized for placenta previa? a. BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPM b. FHR moderate variability without accelerations c. Dark brown vaginal discharge when voiding d. Oral temperature of 99.9°F

ANS: a Feedback a. A decrease in BP accompanied by bradycardia or tachycardia is an indication of hypovolemic shock. b. FHR with moderate variability can be absent of accelerations during fetal sleep cycles or after maternal sedation. c. Bright red vaginal bleeding is an indication of current bleeding. d. Oral temperature may fluctuate based on the client's hydration status. It should be reassessed. Cause for concern is a temperature of 100.4°F or more.

32. The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized with severe hypertension at 33 weeks' gestation. The nurse is preparing to administer the second dose of beta-methasone prescribed by the physician. Marilyn asks: "What is this injection for again?" The nurse's best response is: a. "This is to help your baby's lungs to mature." b. "This is to prepare your body to begin the labor process." c. "This is to help stabilize your blood pressure." d. "This is to help your baby grow and develop in preparation for birth."

ANS: a Feedback a. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours. b. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours. c. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours. d. Antenatal glucocorticoids such as beta-methasone may be given (12 mg IM 24 hours apart) to promote fetal lung maturity if the gestational age is less than 34 weeks and childbirth can be delayed for 48 hours.

17. For the patient with which of the following medical problems should the nurse question a physician's order for beta agonist tocolytics? a. Type 1 diabetes mellitus b. Cerebral palsy c. Myelomeningocele d. Positive group B streptococci culture

ANS: a Feedback a. Beta agonists often elevate serum glucose levels. The nurse should question the order. b. Beta agonists are not contraindicated for patients with cerebral palsy. c. Beta agonists are not contraindicated for patients with myelomeningocele. d. Beta agonists are not contraindicated for patients with group B streptococci.

6. Which of the following nursing diagnoses is of highest priority for a client with an ectopic pregnancy who has developed disseminated intravascular coagulation (DIC)? a. Risk for deficient fluid volume b. Risk for family process interrupted c. Risk for disturbed identity d. High risk for injury

ANS: a Feedback a. Correct. The client is at high risk for hypovolemia which is life threatening and takes precedence over any psychosocial or less pressing diagnoses. b. This is a psychosocial diagnosis and is not life threatening. c. This is a psychosocial diagnosis and is not life threatening. d. The client is at risk for injury; however, the diagnosis of deficient fluid volume is more descriptive and has clearly defined goals and interventions.

3. Identify the hallmark of placenta previa that differentiates it from abruptio placenta. a. Sudden onset of painless vaginal bleeding b. Board-like abdomen with severe pain c. Sudden onset of bright red vaginal bleeding d. Severe vaginal pain with bright red bleeding

ANS: a Feedback a. Correct. When the placenta attaches to the lower uterine segment near or over the cervical os, bleeding may occur without the onset of contractions or pain. b. The hallmark for abruptio placenta is pain and a board-like abdomen. c. Bright red bleeding could be related to abruptio placenta, placenta previa, or other complications of pregnancy. d. Pain is not a hallmark of placenta previa.

28. A primiparous woman has been admitted at 35 weeks' gestation and diagnosed with HELLP syndrome. Which of the following laboratory changes is consistent with this diagnosis? a. Hematocrit dropped to 28%. b. Platelets increased to 300,000 cells/mm3. c. Red blood cells increased to 5.1 million cells/mm3. d. Sodium dropped to 132 mEq/dL.

ANS: a Feedback a. The nurse would expect to see a drop in the hematocrit: The H in HELLP stands for hemolysis. b. The nurse would expect to see low platelets. c. The nurse would expect to see hemolysis. d. The sodium is usually unaffected in HELLP syndrome.

15. Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae? a. Increasing abdominal girth measurements b. Profuse vaginal bleeding c. Bradycardia with an aortic thrill d. Hypothermia with chills

ANS: a Feedback a. The nurse would expect to see increasing abdominal girth measurements. b. Profuse vaginal bleeding is rarely seen in placental abruption and is never seen when the abruption is concealed. c. With excessive blood loss, the nurse would expect to see tachycardia. d. The nurse would expect to see a stable temperature.

35. Your antepartal patient is 38 weeks' gestation, has a history of thrombosis, and has been on strict bed rest for the last 12 hours. She is now experiencing shortness of breath. What about the patient may be a contributing factor for her shortness of breath? a. Physiologic changes in pregnancy result in vasodilation, which increases the tendency to form blood clots. b. Physiologic changes in pregnancy result in vasoconstriction, which increases the tendency to form blood clots. c. Physiologic changes in pregnancy result in anemia, which increases the tendency to form blood clots. d. Physiologic changes in pregnancy result in decreased perfusion to the lungs, which increases the tendency to form blood clots.

ANS: a The patient's shortness of breath, bed rest, and history of thrombosis indicate possible pulmonary embolism. Her pregnant state also increases the potential for thrombosis resulting from increased levels of coagulation factors and decreased fibrinolysis, venous dilation, and obstruction of the venous system by the gravid uterus. Thromboembolitic diseases occurring most frequently in pregnancy include deep vein thrombosis and pulmonary embolism.

43. The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta previa risk factors include (select all that apply): a. Cocaine use b. Tobacco use c. Previous caesarean birth d. Previous use of medroxyprogesterone (Depo-Provera)

ANS: a, b, c Feedback a. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years. b. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years. c. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age. d. Previous use of medroxyprogesterone (Depo-Provera) is not a risk factor for placenta previa.

46. The perinatal nurse provides a hospital tour for couples and families preparing for labor and birth in the future. Teaching is an important component of the tour. Information provided about preterm labor and birth prevention includes (select all that apply): a. Encouraging regular, ongoing prenatal care b. Reporting symptoms of urinary frequency and burning to the health-care provider c. Coming to the labor triage unit if back pain or cramping persist or become regular d. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur every 5 minutes

ANS: a, b, c Feedback a. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur. b. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider repeatedly if symptoms of preterm labor occur. c. Educating all women of childbearing age about preterm labor is a crucial component of prevention. The nurse should encourage all pregnant women to obtain prenatal care and screen for vaginal and urogenital infections and treat appropriately, and remind pregnant women to call their provider if symptoms of preterm labor occur. d. Lying on the right side; drinking fluids, not withholding fluids; and counting fetal movements if contractions occur every 5 minutes are recommended if a woman thinks she is contracting.

49. Marked hemodynamic changes in pregnancy can impact the pregnant woman with cardiac disease. Signs and symptoms of deteriorating cardiac status include (select all that apply): a. Orthopnea b. Nocturnal dyspnea c. Palpitations d. Irritation

ANS: a, b, c Signs and symptoms of deteriorating cardiac status with cardiac disease include orthopnea, nocturnal dyspnea, and palpitations, but do not include irritation.

48. Betamethasone is a steroid that is given to a pregnant woman with signs of preterm labor. The purpose of giving steroids is to (select all that apply): a. Stimulate the production of surfactant in the preterm infant b. Be given between 24 and 34 weeks' gestation c. Increase the severity of respiratory distress d. Accelerate fetal lung maturity

ANS: a, b, d Betamethasone is a steroid that is given to pregnant women with signs of preterm labor between 24 and 34 weeks' gestation. It stimulates the production of surfactant in the preterm infant and accelerates fetal lung maturity.

44. Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 weeks' gestation. An appropriate nursing action would be to (select all that apply): a. Assess the fetal heart rate b. Obtain urine for culture and sensitivity c. Assess Kerry's blood pressure and pulse d. Palpate Kerry's abdomen for contractions

ANS: a, b, d Feedback a. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient's abdomen should be palpated to assess for contractions, and the fetus's heart rate should be monitored. b. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency). The patient's abdomen should be palpated to assess for contractions, and the fetus's heart rate should be monitored. c. Assessment of blood pressure and pulse is not an important nursing action in this scenario. d. Women experiencing preterm labor may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient's abdomen should be palpated to assess for contractions and the fetus's heart rate should be monitored.

9. While educating the client with class II cardiac disease, at 28 weeks' gestation, the nurse instructs the client to notify the physician if she experiences which of the following conditions? a. Emotional stress at work b. Increased dyspnea while resting c. Mild pedal and ankle edema d. Weight gain of 1 pound in 1 week

ANS: b Feedback a. Emotional stress increases cardiac workload; however, without symptoms of cardiac decompensation, this is not immediately concerning. b. Increasing dyspnea, at rest, can be a sign of cardiac decompensation leading to increased congestive heart failure. c. Mild edema during the third trimester is normal. However, increasing edema and pitting edema should be reported as they can be a sign of increasing CHF. d. A weight gain of 1 pound per week is expected during the third trimester.

29. A labor nurse is caring for a patient, 39 weeks' gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? a. Type and cross-match her blood. b. Insert an internal fetal monitor electrode. c. Administer an oral stool softener. d. Assess her complete blood count.

ANS: b Feedback a. It would be appropriate to type and cross-match the patient for a blood transfusion. b. This action is inappropriate. When a patient has a placenta previa, nothing should be inserted into the vagina. c. To prevent constipation, it is appropriate for a patient to take a stool softener. d. It is appropriate to monitor the patient for signs of anemia.

27. A 34-weeks' gestation multigravida, G3 P1 is admitted to the labor suite. She is contracting every 7 minutes and 40 seconds. The woman has several medical problems. Which of the following of her comorbidities is most consistent with the clinical picture? a. Kyphosis b. Urinary tract infection c. Congestive heart failure d. Cerebral palsy

ANS: b Feedback a. Kyphosis is unrelated to preterm labor. b. Urinary tract infections often precipitate preterm labor. c. It is unlikely that the congestive heart failure precipitated the preterm labor. d. Cerebral palsy is unrelated to preterm labor.

5. During pregnancy, poorly controlled asthma can place the fetus at risk for: a. Hyperglycemia b. IUGR c. Hypoglycemia d. Macrosomia

ANS: b Feedback a. Maternal asthma does not place the fetus at risk for hyperglycemia. b. Compromised pulmonary function can lead to decompensation and hypoxia that decrease oxygen flow to the fetus and can cause intrauterine growth restriction (IUGR). c. Asthma does not directly affect glycemic control. d. A fetus experiencing hypoxia would be small for gestational age, not large for gestational age.

8. Which of the following medications administered to the pregnant client with GDM and experiencing preterm labor requires close monitoring of the client's blood glucose levels? a. Nifedipine b. Betamethasone c. Magnesium sulfate d. Indomethacin

ANS: b Feedback a. Nifedipine does not affect maternal blood glucose levels. b. Beta-sympathomimetics may stimulate hyperglycemia which will require an increased need for insulin. c. Magnesium sulfate does not affect blood glucose levels. d. Indomethacin does not affect blood glucose levels.

7. Which of the following laboratory values is most concerning in a client with pregnancy-induced hypertension? a. Total urine protein of 200 mg/dL b. Total platelet count of 40,000 mm c. Uric acid level of 8 mg/dL d. Blood urea nitrogen 24 mg/dL

ANS: b Feedback a. The client's urine protein is elevated. A urine protein of ≥300 mg/dL in a 24-hour collection is considered concerning. b. Correct. A platelet count of £50,000 is a critical value and should be reported to the health-care provider immediately. This client is at increased risk of hemorrhage. c. The uric acid level is only slightly elevated. d. The BUN is only slightly elevated.

23. A woman at 10 weeks' gestation is diagnosed with gestational trophoblastic disease (hydatiform mole). Which of the following findings would the nurse expect to see? a. Platelet count of 550,000/ mm3 b. Dark brown vaginal bleeding c. White blood cell count 17,000/ mm3 d. Macular papular rash

ANS: b Feedback a. The nurse would not expect to see an elevated platelet count. b. The nurse would expect to see dark brown vaginal discharge c. The nurse would not expect to see an elevated white blood cell count. d. The nurse would not expect to see a rash.

21. A woman at 32 weeks' gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome? a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of polycythemia

ANS: c Feedback a. A rise in serum creatinine indicates that the kidneys are not effectively excreting creatinine. It is a negative outcome. b. A drop in serum protein indicates that the kidneys are allowing protein to be excreted. This is a negative outcome. c. Resolution of thrombocytopenia is a positive sign. It indicates that the platelet count is returning to normal. d. Polycythemia is not related to HELLP syndrome. Rather one sees a drop in red cell and platelet counts with HELLP. A positive sign, therefore, would be a rise in the RBC count.

33. A woman who is 36 weeks pregnant presents to the labor and delivery unit with a history of congestive heart disease. Which of the following findings should the nurse report to the primary health-care practitioner? a. Presence of chloasma b. Presence of severe heartburn c. 10-pound weight gain in a month d. Patellar reflexes +1

ANS: c Feedback a. Chloasma is a normal pregnancy finding. b. Heartburn is an expected finding during the third trimester. c. The weight gain may be due to fluid retention. Fluid retention may occur in patients with pregnancy-induced hypertension and in patients with congestive heart failure. The physician should be notified. d. Although slightly hyporeflexic, patellar reflexes of +1 are within normal limits.

2. A pregnant client with a history of multiple sexual partners is at highest risk for which of the following complications: a. Premature rupture of membranes b. Gestational diabetes c. Ectopic pregnancy d. Pregnancy-induced hypertension

ANS: c Feedback a. Multiple partners do not increase a woman's risk of premature rupture of membranes. b. Genetics and client diet and weight are contributing factors to gestational diabetes. c. Correct. A history of multiple sexual partners places the client at a higher risk of having contracted a sexually transmitted disease that could have ascended the uterus to the fallopian tubes and caused fallopian tube blockage, placing the client at high risk for an ectopic pregnancy. d. Multiple sexual partners are not a risk factor for pregnancy-induced hypertension.

16. A woman who has had no prenatal care was assessed and found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings? a. Pyelonephritis b. Pregnancy-induced hypertension c. Gestational diabetes d. Abruptio placentae

ANS: c Feedback a. Pyelonephritis does not lead to the development of hydramnios or macrosomia. b. Pregnancy-induced hypertension does not lead to the development of hydramnios or macrosomia. c. Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies. d. Abruptio placentae does not lead to the development of hydramnios or macrosomia.

13. A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings? a. Patellar and biceps reflexes of +4 b. Urinary output of 50 mL/hr c. Respiratory rate of 10 rpm d. Serum magnesium level of 5 mg/dL

ANS: c Feedback a. The magnesium sulfate has been ordered because the patient has severe pregnancy-induced hypertension. Patellar and biceps reflexes of +4 are symptoms of the disease. b. The urinary output must be above 25 mL/hr. c. The drop in respiratory rate may indicate that the patient is suffering from magnesium toxicity. The nurse should report the finding to the physician. d. The therapeutic range of magnesium is 4 to 7 mg/dL.

25. A woman who is admitted to labor and delivery at 30 weeks' gestation, is 1 cm dilated, and is contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour? a. Temperature b. Pulse c. Respiratory rate d. Blood pressure

ANS: c Feedback a. The temperature should be monitored, but it is not the most important vital sign. b. The pulse rate should be monitored, but it is not the most important vital sign. c. The respiratory rate is the most important vital sign. Respiratory depression is a sign of magnesium toxicity. d. The blood pressure should be monitored, but it is not the most important vital sign.

24. After an education class, the nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed? a. "I could get an STI even if I just have oral sex." b. "Girls over 16 are less likely to get STDs than younger girls." c. "The best way to prevent an STI is to use a diaphragm." d. "Girls get human immunodeficiency virus (HIV) easier than boys do."

ANS: c Feedback a. This statement is true. Organisms that cause sexually transmitted infections can invade the respiratory and gastrointestinal tracts. b. This statement is true. Young women are especially high risk for becoming infected with sexually transmitted diseases. c. This statement is untrue. The young woman needs further teaching. Condoms protect against STDs and pregnancy. In addition, condoms can be kept in readiness for whenever sex may occur spontaneously. Using condoms does not require the teen to plan to have sex. A diaphragm is not an effective infection-control method. Plus, it would require the teen to plan for intercourse. d. This statement is true. Young women are higher risk for becoming infected with HIV than are young men.

26. You are caring for a patient who was admitted to labor and delivery at 32 weeks' gestation and diagnosed with preterm labor. She is currently on magnesium sulfate, 2 gm per hour. Upon your initial assessment you note that she has a respiratory rate of 8 with absent deep tendon reflexes. What will be your first nursing intervention? a. Elevate head of the bed b. Notify the MD c. Discontinue magnesium sulfate d. Draw a serum magnesium level

ANS: c Initial nursing intervention needs to be discontinuing magnesium sulfate because the patient is exhibiting signs of magnesium toxicity with absent deep tendon reflexes and decreased respiratory rate.

45. The perinatal nurse knows that tocolytic agents are most often used to (select all that apply): a. Prevent maternal infection b. Prolong pregnancy to 40 weeks' gestation c. Prolong pregnancy to facilitate administration of antenatal corticosteroids d. Allow for transport of the woman to a tertiary care facility

ANS: c, d Feedback a. Tocolytics are not used to treat maternal infection. b. Tocolytics are generally only effective in delaying delivery for several days. c. Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of antenatal corticosteroids to accelerate fetal lung maturity. d. Delaying the birth provides time for maternal transport to a facility equipped with a neonatal intensive care unit.

22. A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? a. High leukocyte count b. Explosive diarrhea c. Fractured pelvis d. Low platelet count

ANS: d Feedback a. High leukocyte count is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. b. Explosive diarrhea is not associated with severe PIH or HELLP syndrome. c. A fractured pelvis is not associated with severe PIH or HELLP syndrome. d. Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

1. A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure client safety. a. Assess uterine contractions continuously. b. Assess fetal heart rate continuously. c. Assess urinary output. d. Assess respiratory rate.

ANS: d Feedback a. Monitoring contractions does not indicate magnesium toxicity. b. Magnesium sulfate will decrease fetal variability and not provide an accurate assessment of magnesium toxicity. c. Urinary output does not correlate to decreased deep tendon reflexes. d. Correct. Respiratory effort and deep tendon reflexes (DTRs) are involuntary, and a decrease in DTRs could indicate the risk of magnesium sulfate toxicity and the risk for decreased respiratory effort.

18. The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? a. The patient with placenta previa b. The patient whose vagina is colonized with group B streptococci c. The patient who is hepatitis B surface antigen positive d. The patient with eclampsia

ANS: d Feedback a. Patients with placenta previa are not especially high risk for placental abruption. b. Patients colonized with group B streptococci are not especially high risk for placental abruption. c. Patients who are hepatitis B surface antigen positive are not especially high risk for placental abruption. d. Patients with eclampsia are high risk for placental abruption.

12. The perinatal nurse knows that the term to describe a woman at 26 weeks' gestation with a history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is: a. Preeclampsia b. Chronic hypertension c. Gestational hypertension d. Chronic hypertension with superimposed preeclampsia

ANS: d Feedback a. Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, and renal and central nervous systems. b. Chronic hypertension is hypertension that is present and observable prior to pregnancy or hypertension that is diagnosed before the 20th week of gestation. c. Gestational hypertension is a nonspecific term used to describe the woman who has a blood pressure elevation detected for the first time during pregnancy, without proteinuria. d. The following criteria are necessary to establish a diagnosis of superimposed preeclampsia: hypertension and no proteinuria early in pregnancy (prior to 20 weeks' gestation) and new-onset proteinuria, a sudden increase in protein—urinary excretion of 0.3 g protein or more in a 24-hour specimen, or two dipstick test results of 2+ (100 mg/dL), with the values recorded at least 4 hours apart, with no evidence of urinary tract infection; a sudden increase in blood pressure in a woman whose blood pressure has been well controlled; thrombocytopenia (platelet count lower than 100,000/mmC); and an increase in the liver enzymes alanine transaminase (ALT) or aspartate transaminase (AST) to abnormal levels.

11. The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks' gestation in her first pregnancy. She is worried about having her baby "too soon," and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal examination performed by the health-care provider reveals that the cervix is closed, long, and posterior. The most likely diagnosis would be: a. Preterm labor b. Term labor c. Back labor d. Braxton-Hicks contractions

ANS: d Feedback a. Preterm labor (PTL) is defined as regular uterine contractions and cervical dilation before the end of the 36th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor. b. Term labor occurs after 37 weeks' gestation. c. There is no indication in this scenario that this is back labor. d. Braxton-Hicks contractions are regular contractions occurring after the third month of pregnancy. They may be mistaken for regular labor, but unlike true labor, the contractions do not grow consistently longer, stronger, and closer together, and the cervix is not dilated. Some patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor.

19. The nurse is caring for a woman at 28 weeks' gestation with a history of preterm delivery. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis? a. Human relaxin levels b. Amniotic fluid levels c. Alpha-fetoprotein levels d. Fetal fibronectin levels

ANS: d Feedback a. Relaxin levels are rarely assessed. In addition, they are unrelated to the incidence of preterm labor. b. Amniotic fluid levels are not directly related to the incidence of preterm labor. c. Alpha-fetoprotein levels are not related to the incidence of preterm labor. d. A rise in the fetal fibronectin levels in cervical secretions has been associated with preterm labor.

31. According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia: a. Take the patient's blood pressure every 6 hours b. Encourage the patient to rest on her back c. Notify the physician of a urine output greater than 30 mL/hr d. Administer magnesium sulfate according to agency policy

ANS: d Feedback a. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The blood pressure is taken every 1 hour or more frequently according to physician orders or institutional protocol. b. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a side-lying position to enhance uterine perfusion. c. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria and the physician must be notified. d. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion.

14. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother? a. Serum potassium level increases b. Diarrhea c. Urticaria d. Complaints of nervousness

ANS: d Feedback a. The nurse would not expect to see a rise in the mother's serum potassium levels. b. The beta agonists are not associated with diarrhea. c. The beta agonists are not associated with urticaria. d. Complaints of nervousness are commonly made by women receiving subcutaneous beta agonists.

30. A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see? a. Postpartum hemorrhage b. Neonatal hyperglycemia c. Postpartum oliguria d. Neonatal macrosomia

ANS: d Feedback a. The patient is not especially high risk for a postpartum hemorrhage. b. The nurse would expect to see neonatal hypoglycemia, not hyperglycemia. c. The nurse would expect to see postpartum polyuria. d. The nurse would expect to see neonatal macrosomia.

10. The nurse working in a prenatal clinic is providing care to three primigravida patients. Which of the patient findings would the nurse highlight for the physician? a. 15 weeks, denies feeling fetal movement b. 20 weeks, fundal height at the umbilicus c. 25 weeks, complains of excess salivation d. 30 weeks, states that her vision is blurry

ANS: d Feedback a. This finding is normal. Quickening is usually felt between 16 and 20 weeks' gestation. b. This finding is normal. The fundal height at 20 weeks' gestation is usually at the level of the umbilicus. c. Excess salivation is a normal, albeit annoying, finding. d. Blurred vision is a sign of pregnancy-induced hypertension (PIH). This finding should be reported to the woman's health-care practitioner.

20. Which of the following statements is most appropriate for the nurse to say to a patient with a complete placenta previa? a. "During the second stage of labor you will need to bear down." b. "You should ambulate in the halls at least twice each day." c. "The doctor will likely induce your labor with oxytocin." d. "Please promptly report if you experience any bleeding or feel any back discomfort."

ANS: d Feedback a. This response is inappropriate. This patient will be delivered by cesarean section. b. This response is inappropriate. Patients with placenta previa are usually on bed rest. c. This response is inappropriate. This patient will be delivered by cesarean section. d. Labor often begins with back pain. Labor is contraindicated for a patient with complete placenta previa.