Final Exam

37. Identify a goal of a patient with the following nursing diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to diet choices inadequate to meet nutrient requirements of pregnancy. a. Gain a total of 30 lb. b. Take daily supplements consistently. c. Decrease intake of snack foods. d. Increase intake of complex carbohydrates.

ANS: A A weight gain of 30 lb is one indication that the patient has gained a sufficient amount for the nutritional needs of pregnancy. A daily supplement is not the best goal for this patient. It does not meet the basic need of proper nutrition during pregnancy. Decreasing snack foods may be a problem and should be assessed; however, assessing weight gain is the best method of monitoring nutritional intake for this pregnant patient. Increasing the intake of complex carbohydrates is important for this patient, but monitoring the weight gain should be the end goal.

35. A pregnant patient would like to know a good food source of calcium other than dairy products. Your best answer is: a. Legumes b. Yellow vegetables c. Lean meat d. Whole grains

ANS: A Although dairy products contain the greatest amount of calcium, it also is found in legumes, nuts, dried fruits, and some dark green leafy vegetables. Yellow vegetables are rich in vitamin A. Lean meats are rich in protein and phosphorus. Whole grains are rich in zinc and magnesium.

Marfan syndrome is an autosomal dominant genetic disorder that displays as weakness of the connective tissue, joint deformities, ocular dislocation, and weakness to the aortic wall and root. While providing care to a client with Marfan syndrome during labor, which intervention should the nurse complete first? a. Antibiotic prophylaxis b. b-Blockers c. Surgery d. Regional anesthesia

ANS: A Because of the potential for cardiac involvement during the third trimester and after birth, treatment with prophylactic antibiotics is highly recommended. b-Blockers and restricted activity are recommended as treatment modalities earlier in the pregnancy. Regional anesthesia is well tolerated by clients with Marfan syndrome; however, it is not essential to care. Adequate labor support may be all that is necessary if an epidural is not part of the womans birth plan. Surgery for cardiovascular changes such as mitral valve prolapse, aortic regurgitation, root dilation, or dissection may be necessary. Mortality rates may be as high as 50% in women who have severe cardiac disease. PTS: 1 DIF: Cognitive Level: Analysis REF: 287 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

As related to the care of the patient with anemia, the nurse should be aware that: a. It is the most common medical disorder of pregnancy. b. It can trigger reflex brachycardia. c. The most common form of anemia is caused by folate deficiency. d. Thalassemia is a European version of sickle cell anemia.

ANS: A Combined with any other complication, anemia can result in congestive heart failure. Reflex bradycardia is a slowing of the heart in response to the blood flow increases immediately after birth. The most common form of anemia is iron deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas. PTS: 1 DIF: Cognitive Level: Knowledge REF: 290 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient: a. Eat six saltine crackers. b. Drink 8 oz of orange juice with 2 tsp of sugar added. c. Drink 4 oz of orange juice followed by 8 oz of milk. d. Eat hard candy or commercial glucose wafers.

ANS: A Crackers provide carbohydrates in the form of polysaccharides. Orange juice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharide and orange juice is a monosaccharide. They will provide an increase in blood sugar but will not sustain the level. Hard candy or commercial glucose wafers provide only monosaccharides. PTS: 1 DIF: Cognitive Level: Application REF: 274 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. Which statement regarding acronyms in nutrition is accurate? a. Dietary reference intakes (DRIs) consist of recommended dietary allowances (RDAs), adequate intakes (AIs), and upper limits (ULs). b. RDAs are the same as ULs except with better data. c. AIs offer guidelines for avoiding excessive amounts of nutrients. d. They all refer to green leafy vegetables, whole grains, and fruit.

ANS: A DRIs consist of RDAs, AIs, and ULs. AIs are similar to RDAs except that they deal with nutrients about which data are insufficient for certainty (RDA status). ULs are guidelines for avoiding excesses of nutrients for which excess is toxic. Green leafy vegetables, whole grains, and fruit are important, but they are not the whole nutritional story.

19. Which nutritional recommendation about fluids is accurate? a. A womans daily intake should be eight to ten glasses (2.3 L) of water, milk, or juice. b. Coffee should be limited to no more than two cups, but tea and cocoa can be consumed without worry. c. Of the artificial sweeteners, only aspartame has not been associated with any maternity health concerns. d. Water with fluoride is especially encouraged because it reduces the childs risk of tooth decay.

ANS: A Eight to ten glasses is the standard for fluids; however, they should be the right fluids. All beverages containing caffeine, including tea, cocoa, and some soft drinks, should be avoided or drunk only in limited amounts. Artificial sweeteners, including aspartame, have no ill effects on the normal mother or fetus; however, mothers with phenylketonuria should avoid aspartame. No evidence indicates that prenatal fluoride consumption reduces childhood tooth decay.

Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? a. Mannitol b. Epinephrine hydrochloride c. Atropine sulfate d. Sodium bicarbonate

ANS: A For increased ICP, mannitol, an osmotic diuretic, administered intravenously, is the drug used most frequently for rapid reduction. Epinephrine, atropine sulfate, and sodium bicarbonate are not used to decrease ICP.

18. With regard to protein in the diet of pregnant women, nurses should be aware that: a. Many protein-rich foods are also good sources of calcium, iron, and B vitamins. b. Many women need to increase their protein intake during pregnancy. c. As with carbohydrates and fat, no specific recommendations exist for the amount of protein in the diet. d. High-protein supplements can be used without risk by women on macrobiotic diets.

ANS: A Good protein sources such as meat, milk, eggs, and cheese have a lot of calcium and iron. Most women already eat a high-protein diet and do not need to increase their intake. Protein is sufficiently important that specific servings of meat and dairy are recommended. High-protein supplements are not recommended because they have been associated with an increased incidence of preterm births.

6. A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be most concerned that during and after tennis matches this woman consumes: a. Several glasses of fluid. b. Extra protein sources such as peanut butter. c. Salty foods to replace lost sodium. d. Easily digested sources of carbohydrate.

ANS: A If no medical or obstetric problems contraindicate physical activity, pregnant women should get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise because dehydration can trigger premature labor. The womans calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise.

In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the client states: a. I will need to increase my insulin dosage during the first 3 months of pregnancy. b. Insulin dosage will likely need to be increased during the second and third trimesters. c. Episodes of hypoglycemia are more likely to occur during the first 3 months. d. Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding.

ANS: A Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. Insulin dosage will likely need to be increased during the second and third trimesters, Episodes of hypoglycemia are more likely to occur during the first 3 months, and Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 269 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

With one exception, the safest pregnancy is one in which the woman is drug and alcohol free. For women addicted to opioids, ________________________ treatment is the current standard of care during pregnancy. a. Methadone maintenance b. Detoxification c. Smoking cessation d. 4 Ps Plus

ANS: A Methadone maintenance treatment (MMT) is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for opioid addiction treatment that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease rates of infections such as hepatitis B and C, HIV, and other sexually transmitted infections. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool designed specifically to identify pregnant women who need in-depth assessment related to substance abuse. PTS: 1 DIF: Cognitive Level: Application REF: 298 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

3. Which nutrients recommended dietary allowance (RDA) is higher during lactation than during pregnancy? a. Energy (kcal) b. Iron c. Vitamin A d. Folic acid

ANS: A Needs for energy, protein, calcium, iodine, zinc, the B vitamins, and vitamin C remain greater than nonpregnant needs.

Which statement best describes a neuroblastoma? a. Diagnosis is usually made after metastasis occurs. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. It is the most common brain tumor in young children. d. It is the most common benign tumor in young children.

ANS: A Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign; they metastasize.

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: a. Macrosomia. b. Congenital anomalies of the central nervous system. c. Preterm birth. d. Low birth weight.

ANS: A Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman. PTS: 1 DIF: Cognitive Level: Comprehension REF: 270 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Physiologic Integrity

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that: a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. b. Hydramnios occurs approximately twice as often in diabetic pregnancies. c. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. d. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

ANS: A Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild to moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being. PTS: 1 DIF: Cognitive Level: Comprehension REF: 270 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Prophylaxis of subacute bacterial endocarditis is given before and after birth when a pregnant woman has: a. Valvular disease. b. Congestive heart disease. c. Arrhythmias. d. Postmyocardial infarction.

ANS: A Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve stenosis. Prophylaxis for intrapartum endocarditis is not indicated for congestive heart disease, arrhythmias, or after myocardial infarction. PTS: 1 DIF: Cognitive Level: Comprehension REF: 285 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

14. After you complete your nutritional counseling for a pregnant woman, you ask her to repeat your instructions so you can assess her understanding of the instructions given. Which statement indicates that she understands the role of protein in her pregnancy? a. Protein will help my baby grow. b. Eating protein will prevent me from becoming anemic. c. Eating protein will make my baby have strong teeth after he is born. d. Eating protein will prevent me from being diabetic.

ANS: A Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary glands, and placenta; the increase in the maternal blood volume; and the formation of amniotic fluid. Iron intake prevents anemia. Calcium intake is needed for fetal bone and tooth development. Glycemic control is needed in diabetics; protein is one nutritional factor to consider, but this is not the primary role of protein intake.

The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an adequate airway. b. Perform neurologic assessment. c. Monitor intercranial pressure. d. Determine whether a neck injury is present.

ANS: A Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem b. Skull fracture c. Subdural hemorrhage d. Epidural hemorrhage

ANS: A Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.

26. To help a woman reduce the severity of nausea caused by morning sickness, the nurse might suggest that she: a. Try a tart food or drink such as lemonade or salty foods such as potato chips. b. Drink plenty of fluids early in the day. c. Brush her teeth immediately after eating. d. Never snack before bedtime.

ANS: A Some women can tolerate tart or salty foods when they are nauseous. The woman should avoid drinking too much when nausea is most likely, but she should make up the fluid levels later in the day when she feels better. The woman should avoid brushing her teeth immediately after eating. A small snack of cereal and milk or yogurt before bedtime may help the stomach in the morning.

A toddler fell out of a second-story window. She had brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she "seems fine." The nurse should explain that the toddler: a. May have a brain injury. b. Needs this because of her age. c. May start having seizures. d. Probably has a skull fracture.

ANS: A The child's history of the fall, brief loss of consciousness, and vomiting four times necessitate evaluation of a potential brain injury. The severity of a head injury may not be apparent on clinical examination but will be detectable on a CT scan. The need for the CT scan is related to the injury and symptoms, not the child's age, and is necessary to determine whether a brain injury has occurred.

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia b. Hypercalcemia c. Hypobilirubinemia d. Hypoinsulinemia

ANS: A The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth and release large amounts of bilirubin into the neonates circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate presents with hyperinsulinemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 272 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Which test is never performed on a child who is awake? a. Oculovestibular response b. Doll's head maneuver c. Funduscopic examination for papilledema d. Assessment of pyramidal tract lesions

ANS: A The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake.

Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. These complications include: a. Atherosclerosis. b. Retinopathy. c. IUFD. d. Nephropathy. e. Autonomcs neuropathy.

ANS: A, B, D, E These structural changes are most likely to affect a variety of systems, including the heart, eyes, kidneys, and nerves. Intrauterine fetal death (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication. PTS: 1 DIF: Cognitive Level: Comprehension REF: 268 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: a. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. b. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. c. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. d. At birth the neonate of a diabetic mother is no longer in any risk.

ANS: B Congenital malformations account for 30% to 50% of perinatal deaths. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities. PTS: 1 DIF: Cognitive Level: Comprehension REF: 271 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. The most appropriate nursing action is to: a. Discuss with parents the child's previous experiences with pain. b. Discuss with practitioner what analgesia can be safely administered. c. Explain that analgesia is contraindicated with a head injury. d. Explain that analgesia is unnecessary when child is not fully awake and alert.

ANS: B A key nursing role is to provide sedation and analgesia for the child. Consultation with the appropriate practitioner is necessary to avoid conflict between the necessity to monitor the child's neurologic status and to promote comfort and relieve anxiety. Gathering information about the child's previous experiences with pain should be obtained as part of the assessment, but because of the severity of injury, analgesia should be provided as soon as possible. Analgesia can be used safely in individuals who have sustained head injuries and can decrease anxiety and resultant increased intracranial pressure.

22. With regard to nutritional needs during lactation, a maternity nurse should be aware that: a. The mothers intake of vitamin C, zinc, and protein now can be lower than during pregnancy. b. Caffeine consumed by the mother accumulates in the infant, who may be unusually active and wakeful. c. Critical iron and folic acid levels must be maintained. d. Lactating women can go back to their prepregnant calorie intake.

ANS: B A lactating woman needs to avoid consuming too much caffeine. Vitamin C, zinc, and protein levels need to be moderately higher during lactation than during pregnancy. The recommendations for iron and folic acid are lower during lactation. Lactating women should consume about 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.

A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action? a. Provide a low-protein diet. b. Offer the vaccine. c. Discuss the recommendation to bottle-feed her baby. d. Practice respiratory isolation.

ANS: B A person who has a history of high risk behaviors should be offered the hepatitis B vaccine. Care is supportive and includes bed rest and a high-protein, low-fat diet. The first trimester is too early to discuss feeding methods with a woman in the high risk category. Hepatitis B is transmitted through blood. PTS: 1 DIF: Cognitive Level: Application REF: 298 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.

ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

7. Which statement made by a lactating woman would lead the nurse to believe that the woman might have lactose intolerance? a. I always have heartburn after I drink milk. b. If I drink more than a cup of milk, I usually have abdominal cramps and bloating. c. Drinking milk usually makes me break out in hives. d. Sometimes I notice that I have bad breath after I drink a cup of milk.

ANS: B Abdominal cramps and bloating are consistent with lactose intolerance. One problem that can interfere with milk consumption is lactose intolerance, which is the inability to digest milk sugar because of a lack of the enzyme lactose in the small intestine. Milk consumption may cause abdominal cramping, bloating, and diarrhea people who are lactose intolerant, although many affected individuals can tolerate small amounts of milk without symptoms.

38. In teaching the pregnant adolescent about nutrition, the nurse should: a. Emphasize the need to eliminate common teen snack foods because they are too high in fat and sodium. b. Determine the weight gain needed to meet adolescent growth and add 35 lb. c. Suggest that she not eat at fast-food restaurants to avoid foods of poor nutritional value. d. Realize that most adolescents are unwilling to make dietary changes during pregnancy.

ANS: B Adolescents should gain in the upper range of the recommended weight gain. They also need to gain weight that would be expected for their own normal growth. Changes in the diet should be kept at a minimum. Snack foods can be included in moderation, and other foods can be added to make up for the lost nutrients. Eliminating fast foods would make the adolescent appear different to her peers. The patient should be taught to choose foods that add needed nutrients. Adolescents are willing to make changes; however, they still have the need to be similar to their peers.

Concerning the use and abuse of legal drugs or substances, nurses should be aware that: a. Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health. b. Caucasian women are more likely to experience alcohol-related problems. c. Coffee is a stimulant that can interrupt body functions and has been related to birth defects. d. Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise, they would not have been prescribed.

ANS: B African-American and poor women are more likely to use illicit substances, particularly cocaine, whereas Caucasian and educated women are more likely to use alcohol. Cigarette smoking impairs fertility and is a cause of low birth weight. Caffeine consumption has not been related to birth defects. Psychotherapeutic drugs have some effect on the fetus, and that risk must be weighed against their benefit to the mother. PTS: 1 DIF: Cognitive Level: Knowledge REF: 297 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. A pregnant woman experiencing nausea and vomiting should: a. Drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning. b. Eat small, frequent meals (every 2 to 3 hours). c. Increase her intake of high-fat foods to keep the stomach full and coated. d. Limit fluid intake throughout the day.

ANS: B Eating small, frequent meals is the correct suggestion for a woman experiencing nausea and vomiting. A pregnant woman experiencing nausea and vomiting should avoid consuming fluids early in the day or when nauseated, but should compensate by drinking fluids at other times. A pregnant woman experiencing nausea and vomiting should reduce her intake of fried and other fatty foods.

27. Three servings of milk, yogurt, or cheese plus two servings of meat, poultry, or fish adequately supply the recommended amount of protein for a pregnant woman. Many patients are concerned about the increased levels of mercury in fish and may be afraid to include this source of nutrients in their diet. Sound advice by the nurse to assist the client in determining which fish is safe to consume would include: a. Canned white tuna is a preferred choice. b. Avoid shark, swordfish, and mackerel. c. Fish caught in local waterways are the safest. d. Salmon and shrimp contain high levels of mercury.

ANS: B As a precaution, the pregnant patient should avoid eating all of these and the less common tilefish. High levels of mercury can harm the developing nervous system of the fetus. It is essential for the nurse to assist the client in understanding the differences between numerous sources of this product. A pregnant client can 12 ounces a week of canned light tuna; however, canned white, albacore, or tuna steaks contain higher levels of mercury and should be limited to no more than 6 ounces per week. It is a common misconception that fish caught in local waterways are the safest. Pregnant women and mothers of young children should check with local advisories about the safety of fish caught by families and friends in nearby bodies of water. If no information is available, these fish sources should be avoided, limited to less than 6 ounces, or the only fish consumed that week. Commercially caught fish that are low in mercury include salmon, shrimp, pollock, or catfish.

While providing care in an obstetric setting, the nurse should understand that postpartum care of the woman with cardiac disease: a. Is the same as that for any pregnant woman. b. Includes rest, stool softeners, and monitoring of the effect of activity. c. Includes ambulating frequently, alternating with active range of motion. d. Includes limiting visits with the infant to once per day.

ANS: B Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the postpartum period is tailored to the womans functional capacity. The woman will be on bed rest to conserve energy and reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated. PTS: 1 DIF: Cognitive Level: Comprehension REF: 290 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than about her recent diagnosis of diabetes. Several nursing diagnoses are applicable to assist in planning adequate care. The most appropriate diagnosis at this time is: a. Risk for injury to the fetus related to birth trauma. b. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan. c. Deficient knowledge related to insulin administration. d. Risk for injury to the mother related to hypoglycemia or hyperglycemia.

ANS: B Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears to have greater concern for changes to her social life than adoption of a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come much later in the pregnancy. At this time the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made, and she may not participate in the plan of care until understanding takes place. PTS: 1 DIF: Cognitive Level: Analysis REF: 269 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

13. Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with: a. Spina bifida. b. Intrauterine growth restriction. c. Diabetes mellitus. d. Down syndrome.

ANS: B Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction. Spina bifida, diabetes mellitus, and Down syndrome are not associated with inadequate maternal weight gain.

Nurses caring for antepartum women with cardiac conditions should be aware that: a. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor. b. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms. c. Women with class III cardiac disease should have 8 to 10 hours of sleep every day and limit housework, shopping, and exercise. d. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.

ANS: B Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32, when homodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less than ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can carry on limited normal activities with discretion, although they still need a good amount of sleep. PTS: 1 DIF: Cognitive Level: Comprehension REF: 284 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

12. To prevent gastrointestinal upset, clients should be instructed to take iron supplements: a. On a full stomach. b. At bedtime. c. After eating a meal. d. With milk.

ANS: B Clients should be instructed to take iron supplements at bedtime. Iron supplements are best absorbed if they are taken when the stomach is empty. Bran, tea, coffee, milk, and eggs may reduce absorption. Iron can be taken at bedtime if abdominal discomfort occurs when it is taken between meals.

The nurse is preparing a school-age child for a computed tomography (CT) scan to assess cerebral function. When preparing the child for the scan, which statement should the nurse include? a. "Pain medication will be given." b. "The scan will not hurt." c. "You will be able to move once the equipment is in place." d. "Unfortunately no one can remain in the room with you during the test."

ANS: B For CT scans, the child will not be allowed to move and must be immobilized. It is important to emphasize to the child that at no time is the procedure painful. Pain medication is not required; however, sedation is sometimes necessary. Someone is able to remain with the child during the procedure.

33. The most important reason for evaluating the pattern of weight gain in pregnancy is to: a. Prevent excessive adipose tissue deposits b. Identify potential nutritional problems or complications of pregnancy c. Assess the need to limit caloric intake in obese women d. Determine cultural influences on the womans diet

ANS: B Maternal and fetal risks in pregnancy are increased when the mother is significantly overweight. Excessive adipose tissue may occur with excess weight gain; however, this is not the reason for monitoring the weight gain pattern. It is important to monitor the pattern of weight gain to identify complications. The pattern of weight gain is not influenced by cultural influences.

The use of methamphetamine (meth) has been described as a significant drug problem in the United States. In order to provide adequate nursing care to this client population the nurse must be cognizant that methamphetamine: a. Is similar to opiates. b. Is a stimulant with vasoconstrictive characteristics. c. Should not be discontinued during pregnancy. d. Is associated with a low rate of relapse.

ANS: B Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are used similarly. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is very high. PTS: 1 DIF: Cognitive Level: Comprehension REF: 299 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. Maternal nutritional status is an especially significant factor of the many factors that influence the outcome of pregnancy because: a. It is very difficult to adjust because of peoples ingrained eating habits. b. It is an important preventive measure for a variety of problems. c. Women love obsessing about their weight and diets. d. A womans preconception weight becomes irrelevant.

ANS: B Nutritional status draws so much attention not only for its effect on a healthy pregnancy and birth but also because significant changes are within relatively easy reach.

A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding? a. Hyperthyroidism b. Phenylketonuria (PKU) c. Hypothyroidism d. Thyroid storm

ANS: B PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine. A woman with hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism. PTS: 1 DIF: Cognitive Level: Comprehension REF: 283 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: a. Frequent episodes of maternal hypoglycemia. b. Congenital anomalies in the fetus. c. Polyhydramnios. d. Hyperemesis gravidarum.

ANS: B Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 270 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

The Glasgow Coma Scale consists of an assessment of: a. Pupil reactivity and motor response. b. Eye opening and verbal and motor responses. c. Level of consciousness and verbal response. d. Intracranial pressure (ICP) and level of consciousness.

ANS: B The Glasgow Coma Scale assesses eye opening and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and ICP are not part of the Glasgow Coma Scale.

The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. Eye trauma. b. Neurosurgical emergency. c. Severe brainstem damage. d. Indication of brain death.

ANS: B The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.

A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time? a. Deficient fluid volume b. Imbalanced nutrition: less than body requirements c. Imbalanced nutrition: more than body requirements d. Disturbed sleep pattern

ANS: B This clients clinical cues include weight loss, which would support the nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support the nursing diagnosis of Deficient fluid volume. This client reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the client reports nervousness, based on the clients other clinical symptoms the most appropriate nursing diagnosis would be Imbalanced nutrition: less than body requirements. PTS: 1 DIF: Cognitive Level: Analysis REF: 282 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

In terms of the incidence and classification of diabetes, maternity nurses should know that: a. Type 1 diabetes is most common. b. Type 2 diabetes often goes undiagnosed. c. Gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth. d. Type 1 diabetes may become type 2 during pregnancy.

ANS: B Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between types 1 and 2 diabetes. PTS: 1 DIF: Cognitive Level: Knowledge REF: 268 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The vector reservoir for agents causing viral encephalitis in the United States is: a. Tarantula spiders. b. Mosquitoes and ticks. c. Carnivorous wild animals. d. Domestic and wild animals.

ANS: B Viral encephalitis, not attributable to a childhood viral disease, is usually transmitted by mosquitoes and ticks. The vector reservoir for most agents pathogenic for humans and detected in the United States are mosquitoes and ticks; therefore, most cases of encephalitis appear during the hot summer months. Tarantulas, carnivorous wild animals, and domestic animals are not reservoirs for the agents that cause viral encephalitis.

Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? a. Nuclear brain scan b. Echoencephalography c. Computed tomography (CT) scan d. Magnetic resonance imaging (MRI)

ANS: C A CT scan provides visualization of the horizontal and vertical cross sections of the brain at any axis. A nuclear brain scan uses a radioisotope that accumulates where the blood-brain barrier is defective. Echoencephalography identifies shifts in midline structures of the brain as a result of intracranial lesions. MRI permits visualization of morphologic features of target structures and tissue discrimination that is unavailable with any other techniques.

Which statement is most descriptive of a concussion? a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient, reversible neuronal dysfunction. d. A slight lesion develops remote from the site of trauma.

ANS: C A concussion is a transient, reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness resulting from trauma to the head. Petechial hemorrhages along the superficial aspects of the brain along the point of impact are a type of contusion but are not necessarily associated with amnesia. A contusion is visible bruising and tearing of cerebral tissue. Contrecoup is a lesion that develops remote from the site of trauma as a result of an acceleration/deceleration injury.

The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc: a. Is now done for all pregnant women, not just those with or likely to have diabetes. b. Is a snapshot of glucose control at the moment. c. Would be considered evidence of good diabetes control with a result of 5% to 6%. d. Is done on the patients urine, not her blood.

ANS: C A score of 5% to 6% indicates good control. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood. PTS: 1 DIF: Cognitive Level: Comprehension REF: 273 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

15. Pregnant adolescents are at high risk for _____ because of lower body mass indices (BMIs) and fad dieting. a. Obesity b. Diabetes c. Low-birth-weight babies d. High-birth-weight babies

ANS: C Adolescents tend to have lower BMIs because they are still developing and may follow unsafe nutritional practices. In addition, the fetus and still-growing mother appear to compete for nutrients. These factors, along with inadequate weight gain, lend themselves to a higher incidence of low-birth-weight babies. Obesity, diabetes, and high-birth-weight babies are conditions associated with higher BMIs.

A 3-year-old child is hospitalized after a near-drowning accident. The child's mother complains to the nurse, "This seems unnecessary when he is perfectly fine." The nurse's best reply is: a. "He still needs a little extra oxygen." b. "I'm sure he is fine, but the doctor wants to make sure." c. "The reason for this is that complications could still occur." d. "It is important to observe for possible central nervous system problems."

ANS: C All children who have a near-drowning experience should be admitted to the hospital for observation. Although many children do not appear to have suffered adverse effects from the event, complications such as respiratory compromise and cerebral edema may occur up to 24 hours after the incident. Stating that, "He still needs a little extra oxygen" does not respond directly to the mother's concern. Why is her child still receiving oxygen? The nurse should clarify that different complications can occur up to 24 hours later and that observations are necessary.

Which type of fracture describes traumatic separation of cranial sutures? a. Basilar b. Compound c. Diastatic d. Depressed

ANS: C Diastatic skull fractures are traumatic separations of the cranial sutures. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A compound fracture has the bone exposed through the skin. A depressed fracture has the bone pushed inward, causing pressure on the brain.

2. Which meal would provide the most absorbable iron? a. Toasted cheese sandwich, celery sticks, tomato slices, and a grape drink b. Oatmeal, whole wheat toast, jelly, and low-fat milk c. Black bean soup, wheat crackers, orange sections, and prunes d. Red beans and rice, cornbread, mixed greens, and decaffeinated tea

ANS: C Food sources that are rich in iron include liver, meats, whole grain or enriched breads and cereals, deep green leafy vegetables, legumes, and dried fruits. In addition, the vitamin C in orange sections aids absorption. Dairy products and tea are not sources of iron.

To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by: a. Eating six small equal meals per day. b. Reducing carbohydrates in her diet. c. Eating her meals and snacks on a fixed schedule. d. Increasing her consumption of protein.

ANS: C Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates. PTS: 1 DIF: Cognitive Level: Comprehension REF: 274 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The most common clinical manifestation of brain tumors in children is a. Irritability. b. Seizures. c. Headaches and vomiting. d. Fever and poor fine motor control.

ANS: C Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Irritability, seizures, and fever and poor fine motor control are clinical manifestations of brain tumors, but headaches and vomiting are the most common.

Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin: a. Increases throughout pregnancy and the postpartum period. b. Decreases throughout pregnancy and the postpartum period. c. Varies depending on the stage of gestation. d. Should not change because the fetus produces its own insulin.

ANS: C Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. The insulin needs change throughout the different stages of pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 269 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

20. Which minerals and vitamins usually are recommended to supplement a pregnant womans diet? a. Fat-soluble vitamins A and D b. Water-soluble vitamins C and B6 c. Iron and folate d. Calcium and zinc

ANS: C Iron generally should be supplemented, and folic acid supplements often are needed because folate is so important. Fat-soluble vitamins should be supplemented as a medical prescription, as vitamin D might be for lactose-intolerant women. Water-soluble vitamin C sometimes is consumed in excess naturally; vitamin B 6 is prescribed only if the woman has a very poor diet. Zinc sometimes is supplemented. Most women obtain enough calcium through their regular diet.

25. The labor and delivery nurse is preparing a bariatric patient for an elective cesarean birth. Which piece of specialized equipment is unnecessary when providing care for this pregnant woman. a. Extra long surgical instruments b. Wide surgical table c. Temporal thermometer d. Increased diameter blood pressure cuff

ANS: C Obstetricians today are seeing more morbidly obese pregnant women weighing 400, 500, and 600 pounds. To manage their conditions and to meet their logistical needs, a new medical subspecialty bariatric obstetrics has arisen. Extra-wide blood pressure cuffs, scales that can accommodate up to 880 pounds, and extra-wide surgical tables designed to hold the weight of these women are used. Special techniques for ultrasound examination and longer surgical instruments for cesarean birth are also required. A temporal thermometer can be used for a pregnant patient of any size.

Which term is used to describe a child's level of consciousness when the child can be aroused with stimulation? a. Stupor b. Confusion c. Obtundation d. Disorientation

ANS: C Obtundation describes a level of consciousness in which the child can be aroused with stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Confusion is impaired decision making. Disorientation is confusion regarding time and place.

Which heart condition is not a contraindication for pregnancy? a. Peripartum cardiomyopathy b. Eisenmenger syndrome c. Heart transplant d. All of these contraindicate pregnancy.

ANS: C Pregnancy is contraindicated for peripartum cardiomyopathy and Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 287 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that: a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d. Maternal insulin requirements steadily decline during pregnancy.

ANS: C Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the tenth week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 270 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which factor is known to increase the risk of gestational diabetes mellitus? a. Underweight before pregnancy b. Maternal age younger than 25 years c. Previous birth of large infant d. Previous diagnosis of type 2 diabetes mellitus

ANS: C Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 279 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A woman with asthma is experiencing a postpartum hemorrhage. Which drug would not be used to treat her bleeding because it may exacerbate her asthma? a. Pitocin b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Hemabate d. Fentanyl

ANS: C Prostaglandin derivatives should not be used to treat women with asthma, because they may exacerbate symptoms. Pitocin would be the drug of choice to treat this womans bleeding because it would not exacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding. PTS: 1 DIF: Cognitive Level: Analysis REF: 292 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

8. A pregnant womans diet history indicates that she likes the following list of foods. The nurse would encourage this woman to consume more of which food to increase her calcium intake? a. Fresh apricots b. Canned clams c. Spaghetti with meat sauce d. Canned sardines

ANS: D Sardines are rich in calcium. Fresh apricots, canned clams, and spaghetti with meat sauce are not high in calcium.

_____ use/abuse during pregnancy causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications. a. Alcohol b. Caffeine c. Tobacco d. Chocolate

ANS: C Smoking in pregnancy is known to cause a decrease in placental perfusion and has serious health risks, including bleeding complications, low birth weight, prematurity, miscarriage, stillbirth, and sudden infant death syndrome. Prenatal alcohol exposure is the single greatest preventable cause of mental retardation. Alcohol use during pregnancy can cause high blood pressure, miscarriage, premature birth, stillbirth, and anemia. Caffeine and chocolate may safely be consumed in small quantities during pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge REF: 298 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. While taking a diet history, the nurse might be told that the expectant mother has cravings for ice chips, cornstarch, and baking soda. This represents a nutritional problem known as: a. Preeclampsia. b. Pyrosis. c. Pica. d. Purging.

ANS: C The consumption of foods low in nutritional value or of nonfood substances (e.g., dirt, laundry starch) is called pica.

The most common neurologic disorder accompanying pregnancy is: a. Eclampsia. b. Bells palsy. c. Epilepsy. d. Multiple sclerosis.

ANS: C The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurologic disorder accompanying pregnancy. Bells palsy is a form of facial paralysis. Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth. PTS: 1 DIF: Cognitive Level: Knowledge REF: 294 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

ANS: C The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.

32. When providing care to the prenatal patient, the nurse understands that pica is defined as: a. Intolerance of milk products b. Iron deficiency anemia c. Ingestion of nonfood substances d. Episodes of anorexia and vomiting

ANS: C The practice of eating substances not normally thought of as food is called pica. Clay or dirt and solid laundry starch are the substances most commonly ingested. Intolerance of milk products is referred to as lactose intolerance. Pica may produce iron deficiency anemia if proper nutrition is decreased. Pica is not related to anorexia and vomiting.

34. If a patients normal prepregnancy diet contains 45 g of protein daily, how many more grams of protein should she consume per day during pregnancy? a. 5 b. 10 c. 25 d. 30

ANS: C The recommended intake of protein for the pregnant woman is 70 g. Intakes of 5, 10, or 15 g would be inadequate to meet protein needs during pregnancy. A protein intake of 30 g is more than is necessary and would add extra calories.

4. A pregnant womans diet consists almost entirely of whole grain breads and cereals, fruits, and vegetables. The nurse would be most concerned about this womans intake of: a. Calcium. b. Protein. c. Vitamin B12 . d. Folic acid.

ANS: C This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because vitamin B 12 is found in foods of animal origin, this diet is deficient in vitamin B 12 .

9. A 27-year-old pregnant woman had a preconceptual body mass index (BMI) of 18.0. The nurse knows that this womans total recommended weight gain during pregnancy should be at least: a. 20 kg (44 lb). b. 16 kg (35 lb). c. 12.5 kg (27.5 lb). d. 10 kg (22 lb).

ANS: C This woman has a normal BMI and should gain 11.5 to 16 kg during pregnancy. A weight gain of 20 kg would be unhealthy for most women. A weight gain 35 lb is the high end of the range of weight this woman should gain in her pregnancy. A weight gain of 22 lb would be appropriate for an obese woman.

In caring for a pregnant woman with sickle cell anemia, the nurse is aware that signs and symptoms of sickle cell crisis include: a. Anemia. b. Endometritis. c. Fever and pain. d. Urinary tract infection.

ANS: C Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with sickle cell anemia are not iron deficient. Therefore, routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload. Women with sickle cell trait usually are at greater risk for postpartum endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis. These women are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 291 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)? a. 75 mg/dL before lunch. This is low; better eat now. b. 115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time. c. 115 mg/dL 2 hours after lunch; This is too high; it is time for insulin. d. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

ANS: D 60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 70 mg/dL. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL. PTS: 1 DIF: Cognitive Level: Application REF: 277 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

11. A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant in 3 months. She can expect the following advice: a. Discontinue all contraception now. b. Lose weight so that you can gain more during pregnancy. c. You may take any medications you have been taking regularly. d. Make sure that you include adequate folic acid in your diet.

ANS: D A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. A womans folate or folic acid intake is of particular concern in the periconception period. Neural tube defects are more common in infants of women with a poor folic acid intake. Depending on the type of contraception used, discontinuing all contraception may not be appropriate advice. Losing weight is not appropriate advice. Depending on the type of medication the woman is taking, continuing its use may not be appropriate.

29. Which pregnant woman should restrict her weight gain during pregnancy? a. Woman pregnant with twins b. Woman in early adolescence c. Woman shorter than 62 inches or 157 cm d. Woman who was 20 pounds overweight before pregnancy

ANS: D A weight gain of 5 to 9 kg will provide sufficient nutrients for the fetus. Overweight and obese women should be advised to lose weight before conception to achieve the best pregnancy outcomes. A higher weight gain in twin gestations may help prevent low birth weights. Adolescents need to gain weight toward the higher acceptable range, which provides for their own growth as well as for fetal growth. In the past, women of short stature were advised to restrict their weight gain; however, evidence to support these guidelines has not been found.

30. The major source of nutrients in the diet of a pregnant woman should be composed of: a. Simple sugars b. Fats c. Fiber d. Complex carbohydrates

ANS: D Complex carbohydrates supply the pregnant woman with vitamins, minerals, and fiber. The most common simple carbohydrate is table sugar, which is a source of energy but does not provide any nutrients. Fats provide 9 kcal in each gram, in contrast to carbohydrates and proteins, which provide only 4 kcal in each gram. Fiber is supplied primarily by complex carbohydrates.

24. When counseling a client about getting enough iron in her diet, the maternity nurse should tell her that: a. Milk, coffee, and tea aid iron absorption if consumed at the same time as iron. b. Iron absorption is inhibited by a diet rich in vitamin C. c. Iron supplements are permissible for children in small doses. d. Constipation is common with iron supplements.

ANS: D Constipation can be a problem. Milk, coffee, and tea inhibit iron absorption when consumed at the same time as iron. Vitamin C promotes iron absorption. Children who ingest iron can get very sick and even die.

Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to statistics, how often does cystic fibrosis occur in Caucasian live births? a. 1 in 100 b. 1 in 1200 c. 1 in 2500 d. 1 in 3000

ANS: D Cystic fibrosis occurs in about 1 in 3000 Caucasian live births. PTS: 1 DIF: Cognitive Level: Comprehension REF: 293 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. A woman in week 34 of pregnancy reports that she is very uncomfortable because of heartburn. The nurse would suggest that the woman: a. Substitute other calcium sources for milk in her diet. b. Lie down after each meal. c. Reduce the amount of fiber she consumes. d. Eat five small meals daily.

ANS: D Eating small, frequent meals may help with heartburn, nausea, and vomiting. Substituting other calcium sources for milk, lying down after eating, and reducing fiber intake are inappropriate dietary suggestions for all pregnant women and do not alleviate heartburn.

The mother of a 1-month-old infant tells the nurse that she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on knowing that: a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.

ANS: D H. influenzae type B meningitis has virtually been eradicated in areas of the world where the vaccine is administered routinely. Bacterial meningitis remains a serious illness in children. It is significant because of the residual damage caused by undiagnosed and untreated or inadequately treated cases. The leading causes of neonatal meningitis are the group B streptococci and Escherichia coli organisms. Meningitis is an extension of a variety of bacterial infections. No genetic predisposition exists. Vaccinations are not available for all of the potential causative organisms.

The nurse should recommend medical attention if a child with a slight head injury experiences: a. Sleepiness. b. Vomiting, even once. c. Headache, even if slight. d. Confusion or abnormal behavior.

ANS: D Medical attention should be sought if the child exhibits confusion or abnormal behavior; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.

What form of heart disease in women of childbearing years usually has a benign effect on pregnancy? a. Cardiomyopathy b. Rheumatic heart disease c. Congenital heart disease d. Mitral valve prolapse

ANS: D Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases produce pulmonary hypertension or endocarditis during pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge REF: 284 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Glucose metabolism is profoundly affected during pregnancy because: a. Pancreatic function in the islets of Langerhans is affected by pregnancy. b. The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman. c. The pregnant woman increases her dietary intake significantly. d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

ANS: D Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day. PTS: 1 DIF: Cognitive Level: Comprehension REF: 279 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include: a. A regular heart rate and hypertension. b. An increased urinary output, tachycardia, and dry cough. c. Shortness of breath, bradycardia, and hypertension. d. Dyspnea; crackles; and an irregular, weak pulse.

ANS: D Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, rapid pulse; rapid respirations; a moist, frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nail beds. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation, but increased urinary output and a dry cough would not. Shortness of breath would indicate cardiac decompensation, but bradycardia and hypertension would not. PTS: 1 DIF: Cognitive Level: Comprehension REF: 288 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

31. A pregnant womans diet may not meet her need for folates. A good source of this nutrient is: a. Chicken b. Cheese c. Potatoes d. Green leafy vegetables

ANS: D Sources of folates include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken and cheese are excellent sources of protein but are poor in folates. Potatoes contain carbohydrates and vitamins and minerals but are poor in folates.

During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of: a. Euglycemia. b. Rheumatic fever. c. Pneumonia. d. Cardiac decompensation.

ANS: D Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not manifest with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation. PTS: 1 DIF: Cognitive Level: Analysis REF: 288 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is: a. Posturing. b. Vital signs. c. Focal neurologic signs. d. Level of consciousness.

ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing indicates neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

28. Nutrition is one of the most significant factors influencing the outcome of a pregnancy. It is an alterable and important preventive measure for various potential problems, such as low birth weight and prematurity. While completing the physical assessment of the pregnant client, the nurse can evaluate the clients nutritional status by observing a number of physical signs. Which sign would indicate that the client has unmet nutritional needs? a. Normal heart rate, rhythm, and blood pressure b. Bright, clear, shiny eyes c. Alert, responsive, and good endurance d. Edema, tender calves, and tingling

ANS: D The physiologic changes of pregnancy may complicate the interpretation of physical findings. Lower extremity edema often occurs when caloric and protein deficiencies are present; however, it may also be a common physical finding during the third trimester. It is essential that the nurse complete a thorough health history and physical assessment and request further laboratory testing if indicated. A malnourished pregnant patient may display rapid heart rate, abnormal rhythm, enlarged heart, and elevated blood pressure. A patient receiving adequate nutrition has bright, shiny eyes with no sores and moist, pink membranes. Pale or red membranes, dryness, infection, dull appearance of the cornea, or blue sclerae all are signs of poor nutrition. This client is well nourished. Cachexia, listlessness, and tiring easily would be indications of poor nutritional status.

1. A 22-year-old woman pregnant with a single fetus has a preconception body mass index (BMI) of 24. When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lb) since conception. How would the nurse interpret this? a. This weight gain indicates possible gestational hypertension. b. This weight gain indicates that the womans infant is at risk for intrauterine growth restriction (IUGR). c. This weight gain cannot be evaluated until the woman has been observed for several more weeks. d. The womans weight gain is appropriate for this stage of pregnancy.

ANS: D The statement The womans weight gain is appropriate for this stage of pregnancy is accurate. This womans BMI is within the normal range. During the first trimester, the average total weight gain is only 1 to 2.5 kg. Although weight gain does indicate possible gestational hypertension, it does not apply to this patient. The desirable weight gain during pregnancy varies among women. The primary factor to consider in making a weight gain recommendation is the appropriateness of the prepregnancy weight for the womans height. A commonly used method of evaluating the appropriateness of weight for height is the BMI. Although weight gain does indicate risk for IUGR, this does not apply to this patient. Weight gain should occur at a steady rate throughout the pregnancy. The optimal rate of weight gain also depends on the stage of the pregnancy.

36. To determine the cultural influence on a patients diet, the nurse should first: a. Evaluate the patients weight gain during pregnancy b. Assess the socioeconomic status of the patient c. Discuss the four food groups with the patient d. Identify the food preferences and methods of food preparation common to that culture

ANS: D Understanding the patients food preferences and how she prepares food will assist the nurse in determining whether the patients culture is adversely affecting her nutritional intake. Evaluation of a patients weight gain during pregnancy should be included for all patients, not just for patients who are culturally different. The socioeconomic status of the patient may alter the nutritional intake but not the cultural influence. Teaching the food groups to the patient should come after assessing food preferences.

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: a. Mothers age. b. Number of years since diabetes was diagnosed. c. Amount of insulin required prenatally. d. Degree of glycemic control during pregnancy.

ANS: D Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. PTS: 1 DIF: Cognitive Level: Comprehension REF: 273 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

21. Which vitamins or minerals can lead to congenital malformations of the fetus if taken in excess by the mother? a. Zinc b. Vitamin D c. Folic acid d. Vitamin A

ANS: D Zinc, vitamin D, and folic acid are vital to good maternal and fetal health and are highly unlikely to be consumed in excess. Vitamin A taken in excess causes a number of problems. An analog of vitamin A appears in prescribed acne medications, which must not be taken during pregnancy.

You are preparing to teach an antepartum patient with gestational diabetes the correct method of administering an intermediate acting insulin (NPH) with a short acting insulin (regular). In the correct order from 1 through 6, match the step number with the action that you would take to teach the patient self-administration of this combination of insulin. a. Without adding air, withdraw the correct dose of NPH insulin. b. Gently rotate the insulin to mix it, and wipe the stopper. c. Inject air equal to the dose of NPH insulin into the vial, and remove the syringe. d. Inject air equal to the dose of regular insulin into the vial, and withdraw the medication. e. Check the insulin bottles for the expiration date. f. Wash hands.

F, E, B, C, D, A