Nursing Care Related to Assessment of a Pregnant Family. CH11

1. A 20-year-old woman you see in a prenatal clinic has an accessory nipple. Which of the following teaching points would be most important to make with her? A) The tendency for accessory nipples is familial. B) Such growths fade with menopause. C) Bleeding from such growths is not uncommon. D) Such growths deepen in color during pregnancy.

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 241 Feedback: Pigment changes can be expected during pregnancy. Alerting women to this can decrease anxiety.

3. Why is a Papanicolaou smear done at the first prenatal visit? A) It predicts whether cervical cancer will occur. B) It helps to date the pregnancy. C) It detects if uterine cancer is present. D) It identifies abnormal cervical cells.

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Understand Page: 244 Feedback: A Pap smear is a test for cervical cancer. Should abnormal cells be present, the woman may need to make a decision about her priorities of therapy for cervical disease or continuing the pregnancy.

20. A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient? A) Transverse narrow B) Ideal for childbearing C) Similar in shape to a male D) Has weaker bones than normal

Ans: A Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 249 Feedback: In an anthropoid pelvis, the transverse diameter is narrow. A gynecoid pelvis has an inlet that is well rounded forward and backward and has a wide pubic arch. This pelvic type is ideal for childbirth. An android pelvis is similar in shape to that of a male. The shape of the pelvis does not determine the strength of the bones.

7. When measuring the diagonal conjugate of a woman's pelvis, the distance between which anatomic landmarks would be used? A) anterior surface of the sacral prominence and the anterior surface of the symphysis pubis B) medial surface of the ischial tuberosities C) interior surface of the sacral prominence and the posterior surface of the symphysis pubis D) posterior surface of sacrum and the axis of the ischial tuberosities

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 247 Feedback: The diagonal conjugate measures the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis, or the anterior-posterior diameter of the pelvic inlet.

9. A woman reports to the clinic to have her IUD checked. During the visit it is determined she is 6 weeks pregnant. How will the presence of the IUD be handled? A) It will be removed to allow the pregnancy to grow. B) It will remain in place to avoid disturbing the growing embryo. C) The patient will most likely have a miscarriage so there is no need for action. D) The patient should be asked for her preference in this matter.

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 234 Feedback: The IUD must be removed to allow room for safe growth and development for the embryo.

17. The nurse manager of a prenatal clinic has implemented interventions to individualize the prenatal care experience. Which patient statement indicates that the nurse's efforts have been successful? A) "It was so nice to not have to wait long in the waiting room." B) "I really hate having my weight and blood pressure measured around other people." C) "Why does everyone push breastfeeding and natural childbirth? What about what I want?" D) "I thought you would have more reading material on labor and delivery in the waiting room."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 233 Feedback: Strategies to individualize prenatal care include trying to schedule appointments so there won't be a long wait time, providing privacy for weight and blood pressure assessments, educating on care options and encouraging participating in decisions about care, and providing materials on pregnancy in the waiting room.

22. The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed? A) "Pain with urination is expected during pregnancy." B) "I should call the doctor if I have any vaginal bleeding." C) "A sudden rush of fluid means that my membranes ruptured. D) "I should not worry if I vomit once a day for the first 12 weeks."

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 251 Feedback: Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional patient teaching is needed. The patient should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy.

23. A patient having an examination to check the placement of an intrauterine device (IUD) is diagnosed as being pregnant. For which action should the nurse prepare the patient at this time? A) Removal of the IUD B) Surgery to abort the fetus C) Potential for a spontaneous abortion D) Nothing since the IUD can remain in place

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 234 Feedback: A patient may become pregnant with an intrauterine device (IUD) in place. If this occurs, it needs to be removed to prevent infection during pregnancy. The fetus does not need to be aborted, and the patient will not spontaneously abort because the IUD is in place. The IUD cannot remain in place because of the risk for infection.

18. The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit. For what will the nurse test this patient's urine? Select all that apply. A) Protein B) Glucose C) Bacteria D) Drug levels E) White blood cells

Ans: A, B, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 250 Feedback: Urine is tested for proteinuria, glycosuria, nitrites, and pyuria. All of these can be done by means of test strips. The nurse will not test the patient's urine for drug levels as part of a routine prenatal visit.

15. The nurse in a community clinic is identifying ways to achieve the 2020 National Health Goals to support prenatal care. Which nursing actions would support the achievement of these goals? Select all that apply. A) Urge female patients to ingest an adequate intake of folic acid. B) Recommend pregnant patients attend developmental childbirth classes. C) Discuss strategies to avoid intimate partner violence with every pregnant patient. D) Provide a play area in the waiting room for the children of patients waiting to be seen. E) Support pregnant patients to achieve the recommended weight gain during pregnancy.

Ans: A, B, D, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 227 Feedback: A number of 2020 National Health Goals speak directly to the importance of prenatal care to include increasing the proportion of pregnant women who attend a series of prepared childbirth classes, increasing the proportion of women of childbearing potential who have an intake of at least 400 mcg of folic acid from fortified foods or dietary supplements before pregnancy, increasing the proportion of mothers who achieve a recommended weight gain during their pregnancies, and making sites for prenatal care "family friendly" or maximally receptive to women and families. Strategies to avoid intimate partner violence will not help the nurse achieve the 2020 National Health Goals for prenatal care.

19. At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk during the pregnancy. Which data from the patient's past illness history does the nurse use to make this decision? Select all that apply. A) Seizure disorder B) Previous cesarean birth C) Hypertension for 10 years D) History of abnormal Pap smear E) Previous treatment for gonorrhea

Ans: A, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 252 Feedback: Past illness history criteria that place a patient at risk during pregnancy include a seizure disorder, a chronic disease such as hypertension, and sexually transmitted infections. A previous cesarean birth and a history of abnormal Pap smears are criteria for the obstetrical history that can place the patient at risk during pregnancy.

4. Gynecologic health is an important part of a woman's health history. Which statement best illustrates the way to begin a menstrual history? A) "Discussing menstrual periods can be embarrassing. . ." B) "I'd like to ask you some questions about your menstrual periods." C) "I know you're probably uncomfortable talking about your health. . ." D) "I bet you have pain with menstrual periods."

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Analyze Page: 233 Feedback: Beginning any history with an open-ended question allows the woman the optimal opportunity to elaborate on her health concerns.

6. A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history? A) Ask her to complete a written questionnaire concerning her past and present status. B) Conduct an interview in a private room to obtain her health history. C) Wait until she is in the examining room and prepared for her physical examination. D) Ask her some basic questions in the waiting room before taking her to the examining room.

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 230 Feedback: Health interviewing is always conducted best in a quiet, private setting before examination procedures begin.

26. A primapara woman, 30 weeks' gestation, has no family support and frequently calls the health care provider's office with questions. Which report by the woman would alert the nurse that she may be having a complication related to the pregnancy and needs to come to the clinic today for further assessment? A) having a hard time having bowel movements and feeling like anal area is swollen B) feeling of achy, cramping in vaginal area accompanied by bleeding that has saturated 1 pad/hour C) experiencing some shortness of breath after walking up five flights of stairs D) having some discharge from nipples that has never happened before

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 251 Feedback: A woman should report vaginal bleeding, no matter how slight, because some of the serious bleeding complications of pregnancy begin with only slight spotting. Constipation followed by hemorrhoid development is common with pregnancy. Walking upstairs during the third trimester does produce some shortness of breath. It is normal to have some colostrum, or pre-milk, discharge during pregnancy.

11. During the interview portion of her first prenatal visit, a woman reports she thinks she may have a vaginal infection. When questioned, she reports the discharge is thick, greenish-yellow, and she is very uncomfortable. She reports she thinks it is "yeast." How should the nurse reply? A) "You are describing gonorrhea." B) "Yeast is usually a thick, cheesy, white discharge so we will need to evaluate it during the pelvic exam." C) "You have a sexually transmitted disease." D) "You may have chlamydia so we will need to perform a pelvic exam."

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 244 Feedback: Yeast is normally a thick, cheesy discharge. Greenish-yellow discharge is associated with gonorrhea.

8. During her first prenatal visit, a woman 18 weeks pregnant reports she did not realize she was pregnant and continued to take her birth control pills. She is concerned about their effects on her baby. Which of the following would be the best response to her concerns? A) "There are no risks to the fetus related to the ingestion of birth control pills during pregnancy." B) "Because of concerns about the estrogen exposure to the baby, we will monitor the fetal development." C) "As long as you did not take them too far into the second trimester, there is no risk." D) "Birth defects are a realistic possibility and must be monitored."

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 247 Feedback: Studies have demonstrated a correlation between fetal growth problems and increased estrogen exposure.

16. Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit? A) "Do you have a peptic ulcer?" B) "Have you ever had a heart attack?" C) "Have you had any neurologic diseases?" D) "Have you had any urinary tract infections?"

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 233 Feedback: Urinary tract infections are associated with preterm birth. If the patient has a history of this type of infection, then interventions can be directed to help the patient avoid a urinary tract infection while pregnant. Although a part of the review of systems, asking about peptic ulcers, heart attacks, and neurologic diseases may not have as significant an impact on the developing fetus as having urinary tract infections.

25. The nurse is visiting the family of a newly pregnant patient whose spouse was ambivalent about the pregnancy during the first prenatal visit. Which observation indicates that the spouse is accepting the pregnancy? A) Spouse leaves the house when the nurse arrives. B) Spouse sits with the pregnant patient during the nurse's visit. C) Spouse shouts down the stairs about the location of clean laundry. D) Spouse tells the patient what needs to be obtained from the grocery store.

Ans: B Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 230 Feedback: If childbearing is to be a family affair, it is important to determine a partner's degree of acceptance of the pregnancy and how well prepared the spouse is of assuming a new parenting role. After confirmation of pregnancy, include the partner in health care information or suggestions. The spouse sitting with the pregnant patient during the nurse's visit indicates that the spouse is accepting the pregnancy. Leaving the house, shouting down the stairs about laundry, and giving a list of grocery items could indicate indifference or no interest in the pending pregnancy. These actions do not support acceptance of the pregnancy.

13. While conducting the first prenatal health history visit, the nurse learns that a pregnant patient is taking various herbal remedies and over-the-counter medications for minor ailments. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time? A) Risk for injury to fetus related to lifestyle choices B) Deficient knowledge regarding exposure to teratogens during pregnancy C) Health-seeking behaviors related to strong cultural desire to have a healthy child D) Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 227 Feedback: The patient is taking herbal remedies and over-the-counter medications, many of which can be teratogenic to the developing fetus. This is the most appropriate nursing diagnosis for the nurse to select for this assessment finding. There is no enough information to determine if the fetus is at risk because of the patient's lifestyle choices. The patient has not asked for specific information so health-seeking behavior diagnoses would not be appropriate for the patient at this time.

2. Which of the following would you advise a woman about breast self-examination during pregnancy? A) There is no reason to continue this during pregnancy. B) Self-exams are nonproductive during pregnancy. C) She should choose a date each month to do this. D) She should do it weekly, because she no longer has menstrual periods.

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 234 Feedback: Nonpregnant women use their menstrual period as a reminder to do a self-exam. Without this reminder, pregnant women need to use another system, such as a certain day each month.

12. During a prenatal examination, the nurse learns that a pregnant patient has a supernumerary nipple. What should the nurse teach the patient about this finding? A) Such growths fade with menopause. B) Bleeding from such growths is not uncommon. C) Such growths deepen in color during pregnancy. D) The tendency for supernumerary nipples is genetic.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 241 Feedback: Breast changes may be one of the first things women notice in pregnancy. Any supernumerary nipples may become darker and enlarge in size. There is no information to support that supernumerary nipples fade with menopause or bleed. There is also no information to support that supernumerary nipples are genetic in origin.

14. When explaining what will occur during the first prenatal visit physical examination, a pregnant patient asks why a Papanicolaou smear is being done at this time. What should the nurse respond to the patient? A) It helps to date the pregnancy. B) It detects if uterine cancer is present. C) It predicts whether cervical cancer will occur. D) It detects cancer cells of the cervix, vulva, or vagina.

Ans: D Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 244 Feedback: A Pap smear is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not present. A Pap smear is not used to date a pregnancy, detect uterine cancer, or predict if cervical cancer will occur.

24. How should the nurse document a pregnant patient's gestational status using the GTPAL system after collecting the following data? Currently 18 weeks pregnant Patient's fourth pregnancy Delivered one nonviable fetus at 26 weeks Experienced one miscarriage Delivered one viable fetus at 38 weeks' gestation A) 3, 2, 1, 2, 1 B) 4, 2, 2, 1, 1 C) 3, 2, 1, 1, 1 D) 4, 1, 1, 1, 1

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 237 Feedback: GTPAL is a more comprehensive system for classifying pregnancy status. By this system, the gravida classification remains the same, but para is broken down into T: the number of full-term infants born (infants born at 37 weeks or after), P: the number of preterm infants born (infants born before 37 weeks), A: the number of spontaneous miscarriages or therapeutic abortions, and L: the number of living children. The patient has been pregnant four times. The patient delivered one viable infant at 38 weeks. The patient delivered one nonviable fetus at 26 weeks. The patient had one miscarriage. The patient has one living child.

5. Which two tests are generally performed on urine at a prenatal visit? A) protein and sodium B) pH and glucose C) occult blood and protein D) protein and glucose

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 238 Feedback: Protein is assessed to help detect hypertension of pregnancy; glucose is assessed to help detect gestational diabetes.

10. Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks' gestation. A) 3, 2, 1, 2, 1 B) 4, 2, 2, 1, 1 C) 3, 2, 1, 1, 1 D) 4, 1, 1, 1, 1

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 237 Feedback: The GTPAL system is used to classifying pregnancy status. G = gravida, T= term, P = preterm, A = number of abortions, L= number of living children.

21. The nurse is preparing to measure the diagonal conjugate of a pregnant patient's pelvis. Which anatomic landmarks will the nurse use to make this measurement? A) Medial surface of the ischial tuberosities B) Posterior surface of sacrum and the axis of the ischial tuberosities C) Interior surface of the sacral prominence and the posterior surface of the symphysis pubis D) Anterior surface of the sacral prominence and the posterior surface of the symphysis pubis

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 249 Feedback: The diagonal conjugate is the measurement between the anterior surface of the sacral prominence and the posterior surface of the symphysis pubis. The ischial tuberosity diameter measurement is the distance between the ischial tuberosities or the transverse diameter of the outlet and is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus. Measurements are not made from the posterior surface of the sacrum and the axis of the ischial tuberosities or the interior surface of the sacral prominence and the posterior surface of the symphysis pubis.