Chapter 7 Anatomy and Physiology of Pregnancy **

14. A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a: a. Primipara. b. Primigravida. c. Multipara. d. Nulligravida.

ANS: A A primipara is a woman who has completed one pregnancy with a viable fetus. To remember terms, keep in mind: gravida is a pregnant woman; para comes from parity, meaning a viable fetus; primi means first; multi means many; and null means none. A primigravida is a woman pregnant for the first time. A multipara is a woman who has completed two or more pregnancies with a viable fetus. A nulligravida is a woman who has never been pregnant.

2. A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely will have: a. Amenorrhea. b. Positive pregnancy test. c. Chadwick's sign. d. Hegar's sign.

ANS: A Amenorrhea is a presumptive sign of pregnancy. Presumptive signs of pregnancy are felt by the woman. A positive pregnancy test, the presence of Chadwick's sign, and the presence of Hegar's sign all are probable signs of pregnancy.

34. A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system? ___________________

ANS: 3-1-0-1-0 The correct calculation of this woman's gravidity and parity is 3-1-0-1-0. Using the GPTAL system, this client's gravidity and parity information is calculated as follows: G: Total number of times the woman has been pregnant (she is pregnant for the third time) T: Number of pregnancies carried to term (she has had only one pregnancy that resulted in a fetus at term) P: Number of pregnancies that resulted in a preterm birth (none) A: Abortions or miscarriages before the period of viability (she has had one) L: Number of children born who are currently living (she has no living children)

5. During a client's physical examination the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as: a. Hegar's sign b. McDonald's sign c. Chadwick's sign d. Goodell's sign

ANS: A At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occur; this is called Hegar's sign. McDonald's sign indicates a fast food restaurant. Chadwick's sign is the blue-violet coloring of the cervix caused by increased vascularity; this occurs around the fourth week of gestation. Softening of the cervical tip is called Goodell's sign, which may be observed around the sixth week of pregnancy.

10. A woman is in her seventh month of pregnancy. She has been complaining of nasal congestion and occasional epistaxis. The nurse suspects that: a. This is a normal respiratory change in pregnancy caused by elevated levels of estrogen. b. This is an abnormal cardiovascular change, and the nosebleeds are an ominous sign. c. The woman is a victim of domestic violence and is being hit in the face by her partner. d. The woman has been using cocaine intranasally.

ANS: A Elevated levels of estrogen cause capillaries to become engorged in the respiratory tract. This may result in edema in the nose, larynx, trachea, and bronchi. This congestion may cause nasal stuffiness and epistaxis. Cardiovascular changes in pregnancy may cause edema in lower extremities. Determining that the woman is a victim of domestic violence and was hit in the face cannot be made on the basis of the sparse facts provided. If the woman had been hit in the face, she most likely would have additional physical findings. Determination of the use of cocaine by the woman cannot be made on the basis of the sparse facts provided.

13. Appendicitis may be difficult to diagnose in pregnancy because the appendix is: a. Displaced upward and laterally, high and to the right. b. Displaced upward and laterally, high and to the left. c. Deep at McBurney point. d. Displaced downward and laterally, low and to the right.

ANS: A The appendix is displaced high and to the right, beyond McBurney point.

19. The mucous plug that forms in the endocervical canal is called the: a. Operculum. b. Leukorrhea. c. Funic souffle. d. Ballottement.

ANS: A The operculum protects against bacterial invasion. Leukorrhea is the mucus that forms the endocervical plug (the operculum). The funic souffle is the sound of blood flow

26. A first-time mother at 18 weeks of gestation comes for her regularly scheduled prenatal visit. The client tells the nurse that she is afraid that she is going into premature labor because she is beginning to have regular contractions. The nurse explains that this is the Braxton Hicks sign and teaches the client that this type of contraction: a. Is painless. b. Increases with walking. c. Causes cervical dilation. d. Impedes oxygen flow to the fetus.

ANS: A Uterine contractions can be felt through the abdominal wall soon after the fourth month of gestation. Braxton Hicks contractions are regular and painless and continue throughout the pregnancy. Although they are not painful, some women complain that they are annoying. Braxton Hicks contractions usually cease with walking or exercise. They can be mistaken for true labor; however, they do not increase in intensity or frequency or cause cervical dilation. In addition, they facilitate uterine blood flow through the intervillous spaces of the placenta and promote oxygen delivery to the fetus.

32. A woman is in for a routine prenatal checkup. You are assessing her urine for proteinuria. Which findings are considered normal (Select all that apply)? a. Dipstick assessment of trace to +1 b. <300 mg/24 hours c. Dipstick assessment of +2 d. >300 mg/24 hours

ANS: A, B Small amounts of protein in the urine are acceptable during pregnancy. The presence of protein in greater amounts may indicate renal problems. A dipstick assessment of +2 and >300 mg/24 hours are excessive amounts of protein in the urine and should be evaluated further.

31. The diagnosis of pregnancy is based on which positive signs of pregnancy (Select all that apply)? a. Identification of fetal heartbeat b. Palpation of fetal outline c. Visualization of the fetus d. Verification of fetal movement e. Positive hCG test

ANS: A, C, D Identification of fetal heartbeat, visualization of the fetus, and verification of fetal movement all are positive, objective signs of pregnancy. Palpation of fetal outline and a positive hCG test are probable signs of pregnancy. A tumor also can be palpated. Medication and tumors may lead to false-positive results on pregnancy tests.

8. The musculoskeletal system adapts to the changes that occur during pregnancy. A woman can expect to experience what change? a. Her center of gravity will shift backward. b. She will have increased lordosis. c. She will have increased abdominal muscle tone. d. She will notice decreased mobility of her pelvic joints.

ANS: B An increase in the normal lumbosacral curve (lordosis) develops, and a compensatory curvature in the cervicodorsal region develops to help the woman maintain her balance. The center of gravity shifts forward. She will have decreased muscle tone. She will notice increased mobility of her pelvic joints.

9. A 31-year-old woman believes that she may be pregnant. She took an OTC pregnancy test 1 week ago after missing her period; the test was positive. During her assessment interview, the nurse inquires about the woman's last menstrual period and asks whether she is taking any medications. The woman states that she takes medicine for epilepsy. She has been under considerable stress lately at work and has not been sleeping well. She also has a history of irregular periods. Her physical examination does not indicate that she is pregnant. She has an ultrasound scan, which reveals that she is not pregnant. What is the most likely cause of the false-positive pregnancy test result? a. She took the pregnancy test too early. b. She takes anticonvulsants. c. She has a fibroid tumor. d. She has been under considerable stress and has a hormone imbalance.

ANS: B Anticonvulsants may cause false-positive pregnancy test results. OTC pregnancy tests use enzyme-linked immunosorbent assay technology, which can yield positive results 4 days after implantation. Implantation occurs 6 to 10 days after conception. If the woman were pregnant, she would be into her third week at this point (having missed her period 1 week ago). Fibroid tumors do not produce hormones and have no bearing on hCG pregnancy tests. Although stress may interrupt normal hormone cycles (menstrual cycles), it does not affect human chorionic gonadotropin levels or produce positive pregnancy test results.

To reassure and educate pregnant clients about changes in their cardiovascular system, maternity nurses should be aware that: a. A pregnant woman experiencing disturbed cardiac rhythm, such as sinus arrhythmia requires close medical and obstetric observation, no matter how healthy she otherwise may appear. b. Changes in heart size and position and increases in blood volume create auditory changes from 20 weeks to term. c. Palpitations are twice as likely to occur in twin gestations. d. All of the above changes likely will occur.

ANS: B Auscultatory changes should be discernible after 20 weeks of gestation. A healthy woman with no underlying heart disease does not need any therapy. The maternal heart rate increases in the third trimester, but palpitations may not occur. Auditory changes are discernible at 20 weeks.

6. Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester? a. Less audible heart sounds (S1, S2) b. Increased pulse rate c. Increased blood pressure d. Decreased red blood cell (RBC) production

ANS: B Between 14 and 20 weeks of gestation, the pulse increases about 10 to 15 beats/min, which persists to term. Splitting of S1 and S2 is more audible. In the first trimester, blood pressure usually remains the same as at the prepregnancy level, but it gradually decreases up to about 20 weeks of gestation. During the second trimester, both the systolic and the diastolic pressures decrease by about 5 to 10 mm Hg. Production of RBCs accelerates during pregnancy.

24. To reassure and educate pregnant clients about the functioning of their kidneys in eliminating waste products, maternity nurses should be aware that: a. Increased urinary output makes pregnant women less susceptible to urinary infection. b. Increased bladder sensitivity and then compression of the bladder by the enlarging uterus results in the urge to urinate even if the bladder is almost empty. c. Renal (kidney) function is more efficient when the woman assumes a supine position. d. Using diuretics during pregnancy can help keep kidney function regular.

ANS: B First bladder sensitivity and then compression of the bladder by the uterus result in the urge to urinate more often. Numerous anatomic changes make a pregnant woman more susceptible to urinary tract infection. Renal function is more efficient when the woman lies in the lateral recumbent position and less efficient when she is supine. Diuretic use during pregnancy can overstress the system and cause problems.

A woman is at 14 weeks of gestation. The nurse would expect to palpate the fundus at which level? a. Not palpable above the symphysis at this time b. Slightly above the symphysis pubis c. At the level of the umbilicus d. Slightly above the umbilicus

ANS: B In normal pregnancies, the uterus grows at a predictable rate. It may be palpated above the symphysis pubis sometime between the twelfth and fourteenth weeks of pregnancy. As the uterus grows, it may be palpated above the symphysis pubis sometime between the twelfth and fourteenth weeks of pregnancy. The uterus rises gradually to the level of the umbilicus at 22 to 24 weeks of gestation.

30. A patient in her first trimester complains of nausea and vomiting. She asks, "Why does this happen?" The nurse's best response is: a. "It is due to an increase in gastric motility." b. "It may be due to changes in hormones." c. "It is related to an increase in glucose levels." d. "It is caused by a decrease in gastric secretions."

ANS: B Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Although gastric secretions decrease, this is not the main cause of nausea and vomiting.

3. The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is: a. A positive pregnancy test. b. Fetal movement palpated by the nurse-midwife. c. Braxton Hicks contractions. d. Quickening.

ANS: B Positive signs of pregnancy are attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating fetal movement. A positive pregnancy test and Braxton Hicks contractions are probable signs of pregnancy. Quickening is a presumptive sign of pregnancy.

Which finding in the urine analysis of a pregnant woman is considered a variation of normal? a. Proteinuria b. Glycosuria c. Bacteria in the urine. d. Ketones in the urine.

ANS: B Small amounts of glucose may indicate "physiologic spilling." The presence of protein could indicate kidney disease or preeclampsia. Urinary tract infections are associated with bacteria in the urine. An increase in ketones indicates that the patient is exercising too strenuously or has an inadequate fluid and food intake

15. Which time-based description of a stage of development in pregnancy is accurate? a. Viability—22 to 37 weeks since the last menstrual period (LMP) (assuming a fetal weight >500 g) b. Term—pregnancy from the beginning of week 38 of gestation to the end of week 42 c. Preterm—pregnancy from 20 to 28 weeks d. Postdate—pregnancy that extends beyond 38 weeks

ANS: B Term is 38 to 42 weeks of gestation. Viability is the ability of the fetus to live outside the uterus before coming to term, or 22 to 24 weeks since LMP. Preterm is 20 to 37 weeks of gestation. Postdate or postterm is a pregnancy that extends beyond 42 weeks or what is considered the limit of full term.

1. A woman's obstetric history indicates that she is pregnant for the fourth time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system? a. 3-1-1-1-3 b. 4-1-2-0-4 c. 3-0-3-0-3 d. 4-2-1-0-3

ANS: B The correct calculation of this woman's gravidity and parity is 4-1-2-0-4. The numbers reflect the woman's gravidity and parity information. Using the GPTAL system, her information is calculated as: G: The first number reflects the total number of times the woman has been pregnant; she is pregnant for the fourth time. T: This number indicates the number of pregnancies carried to term, not the number of deliveries at term; only one of her pregnancies has resulted in a fetus at term. P: This is the number of pregnancies that resulted in a preterm birth; the woman has had two pregnancies in which she delivered preterm. A: This number signifies whether the woman has had any abortions or miscarriages before the period of viability; she has not. L: This number signifies the number of children born that currently are living; the woman has four children.

28. The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to: a. Compensate for decreased renal plasma flow. b. Provide adequate perfusion of the placenta. c. Eliminate metabolic wastes of the mother. d. Prevent maternal and fetal dehydration.

ANS: B The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Renal plasma flow increases during pregnancy. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume.

17. To reassure and educate pregnant clients about changes in the uterus, nurses should be aware that: a. Lightening occurs near the end of the second trimester as the uterus rises into a different position. b. The woman's increased urinary frequency in the first trimester is the result of exaggerated uterine antireflexion caused by softening. c. Braxton Hicks contractions become more painful in the third trimester, particularly if the woman tries to exercise. d. The uterine souffle is the movement of the fetus.

ANS: B The softening of the lower uterine segment is called Hegar's sign. Lightening occurs in the last 2 weeks of pregnancy, when the fetus descends. Braxton Hicks contractions become more defined in the final trimester but are not painful. Walking or exercise usually causes them to stop. The uterine souffle is the sound made by blood in the uterine arteries; it can be heard with a fetal stethoscope.

29. Physiologic anemia often occurs during pregnancy as a result of: a. Inadequate intake of iron. b. Dilution of hemoglobin concentration. c. The fetus establishing iron stores. d. Decreased production of erythrocytes.

ANS: B When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman has physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. There is an increased production of erythrocytes during pregnancy.

23. Some pregnant clients may complain of changes in their voice and impaired hearing. The nurse can tell these clients that these are common reactions to: a. A decreased estrogen level. b. Displacement of the diaphragm, resulting in thoracic breathing. c. Congestion and swelling, which occur because the upper respiratory tract has become more vascular. d. Increased blood volume.

ANS: C Estrogen levels increase, causing the upper respiratory tract to become more vascular producing swelling and congestion in the nose and ears leading to voice changes and impaired hearing. The diaphragm is displaced, and the volume of blood is increased. However, the main concern is increased estrogen levels.

20. To reassure and educate pregnant clients about changes in their breasts, nurses should be aware that: a. The visibility of blood vessels that form an intertwining blue network indicates full function of Montgomery's tubercles and possibly infection of the tubercles. b. The mammary glands do not develop until 2 weeks before labor. c. Lactation is inhibited until the estrogen level declines after birth. d. Colostrum is the yellowish oily substance used to lubricate the nipples for breastfeeding

ANS: C Lactation is inhibited until after birth. The visible blue network of blood vessels is a normal outgrowth of a richer blood supply. The mammary glands are functionally complete by midpregnancy. Colostrum is a creamy, white-to-yellow premilk fluid that can be expressed from the nipples before birth.

A patient at 24 weeks of gestation contacts the nurse at her obstetric provider's office to complain that she has cravings for dirt and gravel. The nurse is aware that this condition is known as ________ and may indicate anemia. a. Ptyalism b. Pyrosis c. Pica d. Decreased peristalsis

ANS: C Pica (a desire to eat nonfood substances) is an indication of iron deficiency and should be evaluated. Ptyalism (excessive salivation), pyrosis (heartburn), and decreased peristalsis are normal findings of gastrointestinal change during pregnancy. Food cravings during pregnancy are normal.

33. During pregnancy, many changes occur as a direct result of the presence of the fetus. Which of these adaptations meet this criteria? [select all that apply] a. Leukorrhea b. Development of the operculum c. Quickening d. Ballottement e. Lightening

ANS: C, D, E Leukorrhea is a white or slightly gray vaginal discharge that develops in response to cervical stimulation by estrogen and progesterone. Quickening is the first recognition of fetal movements or "feeling life." Quickening is often described as a flutter and is felt earlier in multiparous women than in primiparas. Lightening occurs when the fetus begins to descend into the pelvis. This occurs 2 weeks before labor in the nullipara and at the start of labor in the multipara. Mucus fills the cervical canal creating a plug otherwise known as the operculum. The operculum acts as a barrier against bacterial invasion during the pregnancy. Passive movement of the unengaged fetus is referred to as ballottement.

22. To reassure and educate their pregnant clients about changes in their blood pressure, maternity nurses should be aware that: a. A blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a reading that is too high. b. Shifting the client's position and changing from arm to arm for different measurements produces the most accurate composite blood pressure reading at each visit. c. The systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant. d. Compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the later stage of term pregnancy.

ANS: D Compression of the iliac veins and inferior vena cava also leads to varicose veins in the legs and vulva. The tightness of a cuff that is too small produces a reading that is too high; similarly the looseness of a cuff that is too large results in a reading that is too low. Because maternal positioning affects readings, blood pressure measurements should be obtained in the same arm and with the woman in the same position. The systolic blood pressure generally remains constant but may decline slightly as pregnancy advances. The diastolic blood pressure first decreases and then gradually increases.

16. Human chorionic gonadotropin (hCG) is an important biochemical marker for pregnancy and the basis for many tests. A maternity nurse should be aware that: a. hCG can be detected 2.5 weeks after conception. b. The hCG level increases gradually and uniformly throughout pregnancy. c. Much lower than normal increases in the level of hCG may indicate a postdate pregnancy. d. A higher than normal level of hCG may indicate an ectopic pregnancy or Down syndrome.

ANS: D Higher levels also could be a sign of multiple gestation. hCG can be detected 7 to 8 days after conception. The hCG level fluctuates during pregnancy: peaking, declining, stabilizing, and increasing again. Abnormally slow increases may indicate impending miscarriage.

18. To reassure and educate pregnant clients about changes in the cervix, vagina, and position of the fetus, nurses should be aware that: a. Because of a number of changes in the cervix, abnormal Papanicolaou (Pap) tests are much easier to evaluate. b. Quickening is a technique of palpating the fetus to engage it in passive movement. c. The deepening color of the vaginal mucosa and cervix (Chadwick's sign) usually appears in the second trimester or later as the vagina prepares to stretch during labor. d. Increased vascularity of the vagina increases sensitivity and may lead to a high degree of arousal, especially in the second trimester.

ANS: D Increased sensitivity and an increased interest in sex sometimes go together. This frequently occurs during the second trimester. Cervical changes make evaluation of abnormal Pap tests more difficult. Quickening is the first recognition of fetal movements by the mother. Ballottement is a technique used to palpate the fetus. Chadwick's sign appears from the sixth to eighth weeks.

Which statement about a condition of pregnancy is accurate? a. Insufficient salivation (ptyalism) is caused by increases in estrogen. b. Acid indigestion (pyrosis) begins early but declines throughout pregnancy. c. Hyperthyroidism often develops (temporarily) because hormone production increases. d. Nausea and vomiting rarely have harmful effects on the fetus and may be beneficial.

ANS: D Normal nausea and vomiting rarely produce harmful effects, and nausea and vomiting periods may be less likely to result in miscarriage or preterm labor. Ptyalism is excessive salivation, which may be caused by a decrease in unconscious swallowing or stimulation of the salivary glands. Pyrosis begins in the first trimester and intensifies through the third trimester. Increased hormone production does not lead to hyperthyroidism in pregnant women.

11. The nurse caring for the pregnant client must understand that the hormone essential for maintaining pregnancy is: a. Estrogen. b. Human chorionic gonadotropin (hCG). c. Oxytocin. d. Progesterone.

ANS: D Progesterone is essential for maintaining pregnancy; it does so by relaxing smooth muscles. This reduces uterine activity and prevents miscarriage. Estrogen plays a vital role in pregnancy, but it is not the primary hormone for maintaining pregnancy. hCG levels increase at implantation but decline after 60 to 70 days. Oxytocin stimulates uterine contractions.

7. Numerous changes in the integumentary system occur during pregnancy. Which change persists after birth? a. Epulis b. Chloasma c. Telangiectasia d. Striae gravidarum

ANS: D Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. They usually fade after birth, although they never disappear completely. An epulis is a red, raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead, especially in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasia, or vascular spiders, are tiny, star-shaped or branchlike, slightly raised, pulsating end-arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. These usually disappear after birth.