OB 6, 7, 9, 10, 16

26. Which finding on vaginal examination would be a concern if a spontaneous rupture of the membranes has occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d. Presenting part at station

ANS: D If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Safe and Effective Care Environment/Management of Care

8. The patient has just learned that she is pregnant and overhears the gynecologist saying that she has a positive Chadwick's sign. When the patient asks the nurse what this means, how would the nurse respond? a. "Chadwick's sign signifies an increased risk of blood clots in pregnant women because of a congestion of blood." b. "That sign means the cervix has softened as the result of tissue changes that naturally occur with pregnancy." c. "This means that a mucus plug has formed in the cervical canal to help protect you from uterine infection." d. "This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix."

ANS: D Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Although Chadwick's sign occurs with hyperemia (congestion with blood), the sign does not signify an increased risk of blood clots. The softening of the cervix is called Goodell's sign, not Chadwick's sign. Although the formation of a mucus plug protects from infection, it is not called Chadwick's sign. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

10. A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b. "Let me take off the monitor belts and help you get into a more comfortable position." c. "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." d. "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."

ANS: D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation, no matter at what stage. It is important to get her into a more comfortable position and fetal monitoring should continue. An alteration in breathing pattern will not decrease the pain in this situation. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance

25. Which comment made by a new mother exhibits understanding of her toddler's response to a new sibling? a. "I can't believe he is sucking his thumb again." b. "He is being difficult and I don't have time to deal with him." c. "When we brought the baby home, we made Michael stop sleeping in the crib." d. "My husband is going to stay with the baby so I can take Michael to the park tomorrow."

ANS: D It is important for a mother to seek time alone with her toddler to reassure him that he is loved. It is normal for a child to regress when a new sibling is introduced into the home. The toddler may have feelings of jealousy and resentment toward the new baby taking attention away from him. Frequent reassurance of parental love and affection is important. Changes in sleeping arrangements should be made several weeks before the birth so the child does not feel displaced by the new baby. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance

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

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

7. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous patient with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous patient at 39 weeks of gestation who is expecting twins

ANS: D Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this patient's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

15. Which of the patient health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy? a. Sexual intercourse two or three times weekly b. Moderate exercise for 30 minutes daily c. Working 40 hours a week as a secretary in a travel agency d. Relaxing in a hot tub for 30 minutes a day, several days a week

ANS: D Pregnant women should avoid activities that might cause hyperthermia. Maternal hyperthermia, particularly during the first trimester, may be associated with fetal anomalies. She should not be in a hot tub for more than 10 minutes at less than 100F. Sexual intercourse is generally safe for the healthy pregnant woman; moderate exercise during pregnancy can strengthen muscles, reduce backache and stress, and provide a feeling of well-being; working during pregnancy is acceptable as long as the woman is not continually on her feet or exposed to environmental toxins and industrial hazards. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

14. Which physiologic findings related to gallbladder function may lead to the development of gallstones during pregnancy? a. Decrease in alkaline phosphatase levels compared with nonpregnant women b. Increase in albumin and total protein as a result of hemodilution c. Hypertonicity of gallbladder tissue d. Prolonged emptying time

ANS: D Prolonged emptying time is seen during pregnancy and may lead to the development of gallstones. In pregnancy, there is a twofold to fourfold time increase in alkaline phosphatase levels as compared with those in nonpregnant woman. During pregnancy, a decrease in albumin level and total protein is seen as a result of hemodilution. Gallbladder tissue becomes hypotonic during pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

24. A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception is a. using increased environmental stimulation as a method of distraction. b. restricting family and friends from visiting during the labor period to keep the patient focused on breathing techniques. c. medicating the patient frequently to reduce pain perception. d. assisting the patient in breathing methods aimed at taking control of pain perception based on the contraction pattern.

ANS: D Relaxation techniques are aimed at incorporating mind and body activities to maintain control over pain. Additional environmental stimuli may have the opposite effect and increase patient anxiety, which will affect pain perception. Restricting visitors may have the opposite effect, leading to increased anxiety because of isolation. Medicating a patient may not decrease pain perception but may place the patient at risk for adverse reactions and/or complications of pregnancy related to medications. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychosocial Integrity: Therapeutic Communication

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

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

21. Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor? a. Bradley b. Lamaze c. Leboyer d. Dick-Read

ANS: D The Dick-Read method helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor. The Lamaze method involves concentration and conditioning to help the woman respond to contractions with relaxation to decrease pain. Viewing childbirth as a traumatic experience, the Leboyer method uses decreased light and noise to help the newborn adapt to extrauterine life more easily. The Bradley method teaches women to use abdominal muscles to increase relaxation and breath control; it emphasizes avoidance of all medications and interventions. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

18. Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the patient for epidural administration as ordered by the physician

ANS: D The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore augmentation would not be advised at this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation

23. What does a birth plan help the parents accomplish? a. Avoidance of an episiotomy b. Determining the outcome of the birth c. Assuming complete control of the situation d. Taking an active part in planning the birth experience

ANS: D The birth plan helps the woman and her partner look at the available options and plan the birth experience to meet their personal needs. A birth plan cannot dictate the need for or avoidance of an episiotomy. The outcome of the birth is not an absolute determinant. A birth plan does not assume complete control of the situation; it allows for expanding communication. Parents who prepare a birth plan should be educated that flexibility is essential as each labor and delivery is unique and may present unexpected complications. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

6. Which finding is a positive sign of pregnancy? a. Amenorrhea b. Breast changes c. Fetal movement felt by the woman d. Visualization of fetus by ultrasound

ANS: D The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

17. A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all of the time. The patient's urine test is positive for hCG. What is the correct nursing action related to this information? a. Ask the patient if she has had any nausea or vomiting in the morning. b. Schedule the patient to be seen by a health care provider within the next 4 weeks. c. Send the patient to the maternity screening area of the clinic for a routine ultrasound. d. Determine if there are any factors that might prohibit her from seeking medical care.

ANS: D The patient has presumptive and probable indications of pregnancy. However, she has not sought out health care until late in the first or early in the second trimester. The nurse must assess for barriers to seeking health care, physical or emotional, because regular prenatal care is key to a positive pregnancy outcome. Asking if the patient has nausea or vomiting will only add to the list of presumptive signs of pregnancy, and this information will not add to the assessment data to determine whether the patient is pregnant. The patient needs to see a health care provider before the next 4 weeks because she is late in seeking early prenatal care. Ultrasound testing must be prescribed by a health care provider. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

27. A pregnant patient comes into the medical clinic stating that her family and friends are telling her that she is always talking about the pregnancy and nothing else. She is concerned that something is wrong with her. What psychological behavior is she exhibiting? a. Antepartum obsession b. Ambivalence c. Uncertainty d. Introversion

ANS: D The patient is exhibiting behaviors associated with introversion and/or narcissism. These are normal findings during pregnancy as long as they do not become obsessive to the exclusion of everything else. The patient is talking about the pregnancy but there is no evidence that it is affecting her perception of reality and/or ability to perform ADLs. It is normal for pregnant women to focus on the self as being of prime importance in their life initially during the pregnancy. Some women may feel ambivalent about their pregnancy, which is a normal reaction. However, this patient's behavior does not support this finding. Some women react with uncertainty at the news of being pregnant, which is a normal reaction. However, this patient's behavior does not support this finding. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Psychosocial Integrity

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

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

11. Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.

ANS: D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. The nurse may need to hold the presenting part away from the cord until delivery is complete. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

25. Which technique would provide the best pain relief for a pregnant woman with an occiput posterior position? a. Neuromuscular disassociation b. Effleurage c. Psychoprophylaxis d. Sacral pressure

ANS: D The use of sacral pressure may provide relief for patients who are experiencing back labor. The presentation of the fetus in a posterior position indicates this. Neuromuscular dissociation is used as a conditioned response to affect pain relief based on the mother tensing one group of muscles and focusing on releasing tension in the rest of her body. Effleurage is the process of using circular massage to effect pain relief. Psychoprophylaxis is another name for the Lamaze method of prepared childbirth. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychosocial Integrity: Sensory Perceptual Alterations

16. A pregnant woman notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products as a cleansing solution or makeup. What would the priority nursing intervention be in response to this situation? a. Refer the patient to a dermatologist for further examination. b. Ask the patient if she has been eating different types of foods. c. Take a culture swab and send to the lab for culture and sensitivity (C&S). d. Let the patient know that this is a common finding that occurs during pregnancy.

ANS: D This condition is known as chloasma or melasma (mask of pregnancy) and is a result of pigmentation changes relative to hormones. It can be exacerbated by exposure to the sun. There is no need to refer to a dermatologist. Intake of foods is not associated with exacerbation of this process. There is no need for a C&S to be taken. The patient should be assured that this is a normal finding of pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

13. Determine the obstetric history of a patient in her fifth pregnancy who has had two spontaneous abortions in the first trimester, one infant at 32 weeks' gestation, and one infant at 38 weeks' gestation. a. G5T1P2A2L2 b. G5T1P1A1L2 c. G5T0P2A2L2 d. G5T1P1A2L2

ANS: D This patient is in her fifth pregnancy, which is G5, she had one viable term infant (between 38 and 42 weeks' gestation), which is T1, she had one viable preterm infant (between 20 and 37 weeks' gestation), which is P1, two spontaneous abortions (before 20 weeks' gestation), which is A2, and she has two living children, which is L2. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

2. What is the rationale for a woman in her first trimester of pregnancy to expect to visit her health care provider every 4 weeks? a. Problems can be eliminated. b. She develops trust in the health care team. c. Her questions about labor can be answered. d. The conditions of the expectant mother and fetus can be monitored.

ANS: D This routine allows for monitoring maternal health and fetal growth and ensures that problems will be identified early. All problems cannot be eliminated because of prenatal visits; however, they can be identified early. Developing a trusting relationship should be established during these visits, but that is not the primary reason. Most women do not have questions concerning labor until the last trimester of the pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

3. While providing education to a primiparous patient regarding the normal changes of pregnancy, what is an important information for the nurse to share regarding Braxton Hicks contractions? a. These contractions may indicate preterm labor. b. These are contractions that never cause any discomfort. c. Braxton Hicks contractions only start during the third trimester. d. These occur throughout pregnancy, but you may not feel them until the third trimester.

ANS: D Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance

26. An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe for the baby. What information should the nurse provide? a. Intercourse is safe until the third trimester. b. Safer sex practices should be used once the membranes rupture. c. Intercourse should be avoided if any spotting from the vagina occurs afterward. d. Intercourse and orgasm are often contraindicated if a history of or signs of preterm labor are present.

ANS: D Uterine contractions that accompany orgasm can stimulate labor and would be problematic if the woman is at risk for or has a history of preterm labor. Intercourse can continue as long as the pregnancy is progressing normally. Rupture of the membranes may require abstaining from intercourse. Safer sex practices are always recommended. Some spotting can normally occur as a result of the increased fragility and vascularity of the cervix and vagina during pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance

46. A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her? a. Her two children should be treated with acyclovir before she goes home from the hospital. b. The baby will acquire immunity from her and will not be susceptible to chickenpox. c. The children can visit their mother and baby in the hospital as planned but must wear gowns and masks. d. She must make arrangements to stay somewhere other than her home until the children are no longer contagious.

ANS: D Varicella (chickenpox) is highly contagious. Although the baby inherits immunity from the mother, it would not be safe to expose either the mother or the baby. Acyclovir is used to treat varicella pneumonia. The baby is already born and has received the immunity. If the mother never had chickenpox, she cannot transmit the immunity to the baby. Varicella infection occurring in a newborn may be life-threatening. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care Environment

24. A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks' gestation on admission to the labor and birth unit. The patient is not in labor at the current time; however, she has been sent over by the physician to be admitted for the induction of labor. The patient indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the patient's request? a. There is no way to tell if any complications would arise. Because the patient is not presenting with any problems, the nurse should call the health care provider and inform her or him of the patient's decision to go home and wait. b. Inform the patient that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. c. Tell the patient that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the patient will be sent home. d. Tell the patient that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physician's directions.

ANS: B The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the patient wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore it is best for the patient to remain in a supervised clinical setting. Indicating that the patient could possibly go home would place the patient at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency

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

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

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

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

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

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

20. What is the term for the step in maternal role attainment that relates to the woman giving up certain aspects of her previous life? a. Fantasy b. Grief work c. Role playing d. Looking for a fit

ANS: B The woman experiences sadness as she realizes that she must give up certain aspects of her previous self and that she can never go back. This is called grief work. Fantasies allow the woman to try on a variety of possibilities or behaviors. This usually deals with how the child will look and the characteristics of the child. Role playing involves searching for opportunities to provide care for infants in the presence of another person. Looking for a fit is when the woman observes the behaviors of mothers and compares them with her own expectations. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

15. Which of these findings would indicate a potential complication related to renal function during pregnancy? a. Increase in glomerular filtration rate (GFR) b. Increase in serum creatinine level c. Decrease in blood urea nitrogen (BUN) d. Mild proteinuria

ANS: B With pregnancy, one would expect the serum creatinine and BUN levels to decrease. An elevation in the serum creatinine level should be investigated. With pregnancy, the GFR increases because of increased renal blood flow and is thus a normal expected finding. A decrease in the blood urea nitrogen level and mild proteinuria is expected findings in pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

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

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

2. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.) a. Increased risk for placenta previa b. Painful uterine contractions c. Increased resting tone d. Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction

ANS: B,C,E Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus there is an increased risk for placental abruption as compared with placenta previa, which is based upon malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Pathophysiologic Integrity

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

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

51. The nurse is reviewing the instructions given to a patient at 24 weeks' gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement? a. "I have to fast the night before the test." b. "I will drink a sugary solution containing 100 g of glucose." c. "I will have blood drawn at 1 hour after I drink the glucose solution." d. "I should keep track of my baby's movements between now and the test."

ANS: C A GCT is administered between 24 and 28 weeks of gestation, often to low- and high-risk antepartum patients. Fasting is not necessary for a GCT, and the woman is not required to follow any pretest dietary instructions. The woman should ingest 50 g of oral glucose solution, and 1 hour later a blood sample is taken. Fetal surveillance with kick counts is an ongoing evaluation for pregnant women; they should contact their health care provider if there is a noticeable decrease in fetal movement. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance

27. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/minute. b. Stop the Pitocin infusion. c. Position the patient in the knee-chest position. d. Increase the main line infusion to 150 mL/hour.

ANS: C A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Safe and Effective Care Environment/Management of Care

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

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

41. Which disease process improves during pregnancy? a. Epilepsy b. Bell's palsy c. Rheumatoid arthritis d. Systemic lupus erythematosus (SLE)

ANS: C Although the reason is unclear, marked improvement is seen with rheumatoid arthritis in pregnancy. Unfortunately relapse occurs within 36 months postpartum. With epilepsy, the effect of pregnancy is variable and unpredictable. Seizures may increase, decrease, or remain the same. Bell's palsy was thought to be the result of infection by a virus three times more common during pregnancy and generally occurring in the third trimester. The patient with SLE can have a normal pregnancy but must be treated as high risk because 50% of all births will be premature. Pregnancy can exacerbate SLE. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

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

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

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

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

45. Anti-infective prophylaxis is indicated for a pregnant patient with a history of mitral valve stenosis related to rheumatic heart disease because the patient is at risk of developing a. hypertension. b. postpartum infection. c. bacterial endocarditis. d. upper respiratory infections.

ANS: C Because of vegetations on the leaflets of the mitral valve and the increased demands of pregnancy, the patient is at greater risk of bacterial endocarditis. Pulmonary hypertension may occur with mitral valve stenosis, but anti-infective medications will not prevent it from occurring. Women with cardiac problems must be observed for possible infections during the postpartum period but are not given prophylactic antibiotics to prevent them. Women are not put on prophylactic antibiotics to prevent upper respiratory infections. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity

13. Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of -3 d. Meconium-stained amniotic fluid

ANS: C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the patient at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the patient at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

1. During vital sign assessment of a pregnant patient in her third trimester, the patient complains of feeling faint, dizzy, and agitated. Which nursing intervention is most appropriate? a. Have the patient stand up and retake her blood pressure. b. Have the patient sit down and hold her arm in a dependent position. c. Have the patient turn to her left side and recheck her blood pressure in 5 minutes. d. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms.

ANS: C Blood pressure is affected by positioning during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

5. A patient, gravida 2, para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is palpated 3 cm below the umbilicus. This finding is a. appropriate for gestational age. b. a sign of impending complications. c. lower than normal for gestational age. d. higher than normal for gestational age.

ANS: C By 20 weeks, the fundus should reach the umbilicus. The fundus should be at the umbilicu s at 20 weeks, so 3 cm below the umbilicus is an inappropriate height and needs further assessment. This is lower than expected at this date. It may be a complication, but it may also be because of incorrect dating of the pregnancy. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

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

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

6. When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks

ANS: C CVS is normally performed between 10 and 13 weeks gestation. The fetal villus tissue can be analyzed directly for chromosomal, metabolic, or DNA abnormalities. It is too early to perform CVS at 4 or 8 weeks of pregnancy. The test can no longer be performed a 14 weeks gestation. Results are available within 24 to 48 hours. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

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

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

22. Which situation best describes a man trying on fathering behaviors? a. Reading books on newborn care b. Spending more time with his siblings c. Coaching a little league baseball team d. Exhibiting physical symptoms related to pregnancy

ANS: C Coaching a little league baseball team shows interaction with children and assuming the behavior and role of a father. This best describes a man trying on the role of being a father. Men do not normally read information that is provided in advance. The nurse should be prepared to present information after the baby is born, when it is more relevant. The man will normally seek closer ties with his father. Exhibiting physical symptoms related to pregnancy is called couvade. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

7. A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include? a. Palpation of the lumbar spine b. Exercise pattern and duration c. Observation of posture and body mechanics d. Ability to sleep for at least 6 hours uninterrupted

ANS: C Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis. Pregnancy should not cause alterations in the spine. Any assessment for malformation should be done early in pregnancy. Certain exercises can help relieve back pain. Rest is important for overall well-being; however, the primary concern related to back pain is a thorough evaluation of posture and body mechanics. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

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

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

20. Which information is covered by early pregnancy classes offered in the first and second trimesters? a. Methods of pain relief b. The phases and stages of labor c. Coping with common discomforts of pregnancy d. Prebirth and postbirth care of a patient having a cesarean birth

ANS: C Early pregnancy classes focus on the first two trimesters and cover information on adapting to pregnancy, dealing with early discomforts, and understanding what to expect in the months ahead. Methods of pain relief are discussed in a childbirth preparation class. The phases and stages of labor are usually covered in a childbirth preparation class. Cesarean birth preparation classes discuss prebirth and postbirth of a patient having a cesarean birth. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

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

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

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

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

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

ANS: C Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A urinary output of 20 mL/hour is inadequate output. A respiratory rate of 10 to 12 breaths per minute is too slow and could be indicative of magnesium toxicity. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

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

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

36. After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse's concern regarding this risk? a. Hypovolemia b. Iron-deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency

ANS: C Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential MULTIPLE RESPONSE

17. A patient with an IUD in place has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action? a. A therapeutic abortion will need to be scheduled since fetal damage is inevitable. b. Hormonal analyses will be done to determine the underlying cause of the false-positive test result. c. The IUD will need to be removed to avoid complications such as miscarriage or infection. d. The IUD will need to remain in place to avoid injuring the fetus.

ANS: C Pregnancy with an intrauterine device (IUD) in place is unusual; however, it can occur and cause complications such as spontaneous abortion and infection. A therapeutic abortion is not indicated unless infection occurs. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential

28. A patient relates a story of how her boyfriend is feeling her aches and pains associated with her pregnancy. She is concerned that her boyfriend is making fun of her concerns. How would you respond to this patient statement? a. Tell her not to worry because it is natural for her boyfriend to make her feel better by identifying with her pregnancy. b. Refer the patient to a psychologist for counseling to deal with this problem because it is clearly upsetting her. c. Explain that her boyfriend may be experiencing couvade syndrome and that this is a normal finding seen with male partners. d. Ask the patient specifically to define her concerns related to her relationship with her boyfriend and suggest methods to stop this type of behavior by her significant other.

ANS: C Provide factual information that will help reduce stress and modify acceptance. Telling her not to worry does not address the possibility that her boyfriend may be experiencing couvade syndrome. The patient is expressing concern but does not have all the facts related to couvade syndrome and requires education, rather than referral. Couvade syndrome is not an abnormal condition and should be treated with acceptance and understanding. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Psychosocial Integrity MULTIPLE RESPONSE

10. What is the best explanation that the nurse can provide to a patient who is concerned that she has "pseudoanemia" of pregnancy? a. Have her write down her concerns and tell her that you will ask the physician to respond once the lab results have been evaluated. b. Tell her that this is a benign self-limiting condition that can be easily corrected by switching to a high-iron diet. c. Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition. d. Contact the physician and get a prescription for iron pills to correct this condition.

ANS: C Providing factual information based on physiologic mechanisms is the best option. Although having the patient write down her concerns is reasonable, the nurse should not refer this conversation to the physician but rather address the patient's specific concerns. Switching to a high-iron diet will not correct this condition. This physiologic pattern occurs during pregnancy as a result of hemodilution from excess blood volume. Iron medication is not indicated for correction of this condition. There is no need to contact the physician for a prescription. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

18. The health care provider reports that the primigravida's fundus can be palpated at the umbilicus. Which priority question will the nurse include in the patient's assessment? a. "Have you noticed that it is easier for you to breathe now?" b. "Would you like to hear the baby's heartbeat for the first time?" c. "Have you felt a fluttering sensation in your lower pelvic area yet?" d. "Have you recently developed any unusual cravings, such as for chalk or dirt?"

ANS: C Quickening is the first maternal sensation of fetal movement and is often described as a fluttering sensation. Quickening is detected at approximately 20 weeks in the primigravida and as early as 16 weeks in the multigravida. The fundus is at the umbilicus at 20 weeks' gestation. Lightening is associated with descent of the fetal head into the maternal pelvis and is associated with improved lung expansion. Lightening occurs approximately 2 weeks before birth in the primipara. Fetal heart tones can be detected by Doppler as early as 9 to 12 weeks of gestation. Pica is the craving for nonnutritive substances such as chalk, dirt, clay, or sand. It can develop at any time during pregnancy. It can be associated with malnutrition and the health care provider should monitor the patient's hematocrit/hemoglobin, zinc, and iron levels. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

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

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

4. What is the gravida and para for a patient who delivered triplets 2 years ago and is now pregnant again? a. 2,3 b. 1,2 c. 2,1 d. 1,3

ANS: C She has had two pregnancies (gravida 2); para refers to the outcome of the pregnancy rather than the number of infants from that pregnancy. She is pregnant now, so that would make her a gravida 2. She is para 1 because she had one pregnancy that progressed to the age of viability. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

29. A dose of dexamethasone 12 mg was administered to a patient in preterm labor at 0830 hours on March 12. The nurse knows that the next dose must be scheduled for a. 1430 hours on March 12th. b. 2030 hours on March 12th. c. 0830 hours on March 13th. d. 1430 hours on March 13th.

ANS: C The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 1430 hours on March 12th, 2030 hours on March 12th, and 1430 hours on March 13th do not fall within this recommendation. The next dose should be scheduled for 0830 hours on March 13th. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

12. What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period? a. Positive b. Negative c. Reactive d. Nonreactive

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

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

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

38. Which factor is most important in diminishing maternal, fetal, and neonatal complications in a pregnant patient with diabetes? a. Evaluation of retinopathy by an ophthalmologist b. The patient's stable emotional and psychological status c. Degree of glycemic control before and during the pregnancy d. Total protein excretion and creatinine clearance within normal limits

ANS: C The occurrence of complications can be greatly diminished by maintaining normal blood glucose levels before and during the pregnancy. Even nonpregnant diabetics should have an annual eye examination. Assessing a patient's emotional status is helpful. Coping with a pregnancy superimposed on preexisting diabetes can be very difficult for the whole family; however, it is not the top priority. Baseline renal function is assessed with a 24-hour urine collection and does not diminish the patient's risk for complications. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

22. A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate? a. Vaginal birth with vacuum extraction b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d. Insertion of Foley catheter into empty bladder to provide more room for fetal descent

ANS: C The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the patient should be prepped for a cesarean section. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency

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

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

12. A pregnant woman complains of frequent heartburn. The patient states that she has never had these symptoms before and wonders why this is happening now. The most appropriate response by the nurse is to a. examine her dietary intake pattern and tell her to avoid certain foods. b. tell her that this is a normal finding during early pregnancy and will resolve as she gets closer to term. c. explain to the patient that physiologic changes caused by the pregnancy make her more likely to experience these types of symptoms. d. refer her to her health care provider for additional testing because this is an abnormal finding.

ANS: C The presentation of heartburn is a normal abnormal finding that can occur in pregnant woman because of relaxation of the lower esophageal sphincter as a result of the physiologic effects of pregnancy. Although foods may contribute to the heartburn, the patient is asking why this presentation is occurring, so the nurse should address the cause first. It is independent of gestation. There is no need to refer to the physician at this time because this is a normal abnormal finding. There is no evidence of complications ensuing from this presentation. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

4. What is the physiologic reason for vascular volume increasing by 40% to 60% during pregnancy? a. Prevents maternal and fetal dehydration b. Eliminates metabolic wastes of the mother c. Provides adequate perfusion of the placenta d. Compensates for decreased renal plasma flow

ANS: C The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

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

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

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

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

5. Physiologic anemia often occurs during pregnancy due to a. inadequate intake of iron. b. the fetus establishing iron stores. c. dilution of hemoglobin concentration. d. decreased production of erythrocytes.

ANS: C When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

3. A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? a. Fetal heart rate, 150 beats/minute b. Maternal temperature, 37.2C (99F) c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates

ANS: C Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38C (100.4F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Physiologic Integrity

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

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

20. A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test? a. Patient must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Patient should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.

ANS: C Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation

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

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

2. The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.) a. Breech presentation b. Ectopic pregnancy c. Birth defects d. Venous thromboembolism e. Postpartum anemia

ANS: C,D,E Maternal complications associated with pregnancy include: Gestational diabetes, preeclampsia, venous thromboembolism, Caesarean delivery, wound infection, respiratory complications, preterm birth, birth trauma and postpartum anemia. Obese women also have an increased risk of spontaneous abortions and stillbirth. Complications for infants of obese mothers have an increased risk of neural tube defects, hydrocephaly, cardiovascular defects, macrosomia, hypoglycemia, and birth injuries from shoulder dystocia. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity

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

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

17. Which clinical finding during assessment indicates uterine rupture? a. Fetal tachycardia occurs. b. The patient becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.

ANS: D A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

1. The capacity of the uterus in a term pregnancy is how many times its prepregnant capacity? Record your answer as a whole number. ______ times

ANS: 500 The prepregnant capacity of the uterus is about 10 mL, and it reaches 5000 mL (5 L) by the end of the pregnancy, which reflects a 500-fold increase. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

52. The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse's next action? a. Ask the patient when she last had anything to eat or drink. b. Take a culture of the lesions to verify the involved organism. c. Ask the patient if she has had unprotected sex since her outbreak. d. Use electronic fetal surveillance to determine a baseline fetal heart rate.

ANS: A A cesarean birth is recommended for women with active lesions in the genital area, whether recurrent or primary, at the time of labor. The patient's dietary intake is needed to prepare for surgery. This patient is in active labor and the fetus is at risk for infection if the membranes rupture. The health care provider needs to be notified, and a cesarean birth needs to be performed as soon as possible. There is no need to validate the infection because the patient is well aware of the symptoms of an active infection. Although transmission to sexual partners is valid information, it is not necessary information in an urgent situation such as depicted in this scenario. Electronic fetal surveillance is the standard of care. DIF: Cognitive Level: Synthesis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE

8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs

ANS: A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

32. Which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction

ANS: A A patient attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Safe and Effective Care Environment/Management of Care

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

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

15. A patient who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "You should come into the office and let the doctor check you." b. "Acetaminophen is acceptable during pregnancy. You should not take aspirin, however." c. "Back pain is common at this time during pregnancy because you tend to stand with a sway back." d. "Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication."

ANS: A A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The patient needs to be assessed for preterm labor before providing pain relief. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

8. Which laboratory result would be a cause for concern if exhibited by a patient at her first prenatal visit during the second month of her pregnancy? a. Rubella titer, 1:6 b. Platelets, 300,000/mm3 c. White blood cell count, 6000/mm3 d. Hematocrit 38%, hemoglobin 13 g/dL

ANS: A A rubella titer of less than 1:8 indicates a lack of immunity to rubella, a viral infection that has the potential to cause teratogenic effects on fetal development. Arrangements should be made to administer the rubella vaccine after birth during the postpartum period because administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women receiving the vaccine during the postpartum period should be cautioned to avoid pregnancy for 3 months. The lab values for WBCs, platelets, and hematocrit/hemoglobin are within the expected range for pregnant women. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

6. Which complaint made by a patient at 35 weeks of gestation requires additional assessment? a. Abdominal pain b. Ankle edema in the afternoon c. Backache with prolonged standing d. Shortness of breath when climbing stairs

ANS: A Abdominal pain at 35 weeks gestation may indicate preeclampsia, or abruptio placentae. Ankle edema in the afternoon is a normal finding at this stage of the pregnancy. Backaches while standing is a normal finding in the later stages of pregnancy. Shortness of breath is an expected finding at 35 weeks. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

23. A 36-year-old divorcee with a successful modeling career finds out that her 18-year-old daughter is expecting her first child. Which is a major factor in determining how this woman will respond to becoming a grandmother? a. Her age b. Her career c. Being divorced d. Age of the daughter

ANS: A Age is a major factor in determining the emotional response of prospective grandparents. Young grandparents may not be happy with the stereotype of grandparents as being old. Career responsibilities may have demands that make the grandparents not as accessible but are not a major factor in determining the woman's response to becoming a grandmother. Being divorced is not a major factor that determines the adaptation of grandparents. The age of the daughter is not a major factor that determines the adaptation of grandparents. The age of the grandparent is a major factor. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

7. Which aspect of fetal diagnostic testing is most important to expectant parents? a. Safety of the fetus b. Duration of the test c. Cost of the procedure d. Physical discomfort caused by the procedure

ANS: A Although all of these are considerations, parents are usually most concerned about the safety of the fetus. Parents are concerned about the duration of the test; however, it is not the greatest concern. The cost of the procedure is important to parents, especially those without third-party payers; but again, this is not the greatest concern. With adequate preparation for the procedure by the nurse physical discomfort can be allayed. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

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

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

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

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

9. After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should a. palpate the infant's clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.

ANS: A Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

6. Birth for the nulliparous patient with a fetus in a breech presentation is usually a. cesarean birth. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.

ANS: A Birth for the nulliparous patient with a fetus in breech presentation is almost always cesarean birth. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

18. A laboratory finding indicative of DIC is one that shows a. decreased fibrinogen. b. increased platelets. c. increased hematocrit. d. decreased thromboplastin time.

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

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

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

26. The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions? a. During labor, when she can no longer talk through contractions b. During the first stage of labor, when the contractions are 3 to 4 minutes apart c. Between contractions, during the transitional phase of the first stage of labor d. Between her efforts to push to facilitate relaxation between contractions

ANS: A Focused breathing techniques should not be used in labor until they are actually needed, which is usually when the woman can no longer walk and talk during a contraction. If breathing techniques are used too early, the woman tends to move through the different techniques too quickly, and she may stop using them. In addition, the use of the more complex breathing patterns in latent labor may increase fatigue. Women should be encouraged to adapt the techniques to their own comfort and needs. Breathing deeply between contractions or pushing can increase the possibility of carbon dioxide retention and make the patient dizzy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance

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

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

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

ANS: A HELLP syndrome is characterized by Hemolysis, Elevated Liver enzyme levels, and a Low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Pathophysiology

42. Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is a. varied depending on the stage of gestation. b. increased throughout pregnancy and the postpartum period. c. decreased throughout pregnancy and the postpartum period. d. should not change because the fetus produces its own insulin.

ANS: A Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs change during pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

12. A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the patient with her hips slightly elevated.

ANS: A Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the patient at high risk for uterine rupture. The patient is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the patient with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

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

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

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

ANS: A Prior birth of a large infant suggests gestational diabetes mellitus. A patient younger than 25 is not at risk for gestational diabetes mellitus. Obesity (>90 kg [198 lb]) creates a higher risk for gestational diabetes. The person with type 2 diabetes mellitus already is a diabetic and will continue to be so after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

30. When reviewing the prenatal record of a patient at 42 weeks' gestation, the nurse recognizes that induction of labor is based upon which indication a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-lb weight gain at each of the last two weekly visits.

ANS: A Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-lb weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

27. In a prenatal education class, the nurse is reviewing the importance of using relaxation techniques during labor. Which patient statement will the nurse need to correct? a. "We will practice relaxation techniques only in a quiet setting so I can focus." b. "Relaxation is important during labor because it will help me conserve my energy." c. "If I relax in between contractions, my baby will get more oxygen during labor." d. "My partner and I will practice relaxation throughout the remainder of my pregnancy."

ANS: A Relaxation exercises must be practiced frequently to be useful during labor. Couples begin practice sessions in a quiet, comfortable setting. Later, they practice in other places that simulate the noise and unfamiliar setting of the hospital. The ability to relax during labor is an important component of coping effectively with childbirth. Relaxation conserves energy, decreases oxygen use, and enhances other pain relief techniques. Women learn exercises to help them recognize and release tension. The labor partner assists the woman by providing feedback during exercise sessions and labor. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE

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

ANS: A Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, the patient's fertility will decrease; however, she will be able to achieve a future pregnancy. The recommended treatment is to remove the pregnancy before hemorrhage occurs. A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity

10. When a pregnant woman develops ptyalism, which guidance should the nurse provide? a. Chew gum or suck on lozenges between meals. b. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals. c. Take short walks to stimulate circulation in the legs and elevate the legs periodically. d. Use pillows to support the abdomen and back during sleep.

ANS: A Some women experience ptyalism, or excessive salivation. The cause of ptyalism may be decreased swallowing associated with nausea or stimulation of the salivary glands by the ingestion of starch. Small frequent meals and use of chewing gum and oral lozenges offer limited relief for some women. All other options include recommendations for pregnant women; however, they do not address ptyalism. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity: Basic Care and Comfort

34. Which patient is most at risk for a uterine rupture? a. A gravida 4 who had a classic cesarean incision b. A gravida 5 who had two vaginal births and one cesarean birth c. A gravida 3 who has had two low-segment transverse cesarean births d. A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant

ANS: A The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The patient who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Low-segment incisions do not raise the risk of uterine ruptures. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

21. An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy. Currently, she is at 32 weeks' gestation and has two other children at home, ages 3 and 6. The patient's husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal? a. The patient and husband will be able to adapt their schedules accordingly to meet activities of daily living until the patient's next scheduled antepartum visit the following week. b. The patient and husband will hire a nanny to act as an additional caregiver for the next month. c. The patient will continue to take care of her children at home, taking frequent rest periods. d. The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.

ANS: D A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified timeframe. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the patient to take care of her children at home with rest period because the patient will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance

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

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

11. When documenting a patient encounter, which term will the nurse use to describe the woman who is in the 28th week of her first pregnancy? a. Multigravida b. Multipara c. Nullipara d. Primigravida

ANS: D A primigravida is a woman pregnant for the first time. A multigravida has been pregnant more than once. A nullipara is a woman who has never been pregnant or has not completed a pregnancy of 20 weeks or more. A primipara has delivered one pregnancy of at least 20 weeks. A multipara has delivered two or more pregnancies of at least 20 weeks. DIF: Cognitive Level: Knowledge OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance

16. Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure

ANS: D All assessments are important; however, those most relevant to tocolytic therapy include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured; however, these are not relevant to the medication. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance

18. Which comment made by a patient in her first trimester indicates ambivalent feelings? a. "My body is changing so quickly." b. "I haven't felt well since this pregnancy began." c. "I'm concerned about the amount of weight I've gained." d. "I wanted to become pregnant, but I'm scared about being a mother."

ANS: D Ambivalence refers to conflicting feelings. Expressing a concern about being a mother indicates possible ambivalent feelings. Not feeling well since the pregnancy began does not reflect conflicting feelings. The woman is trying to confirm the pregnancy when she is stating the rapid changes to her body. She is not expressing conflicting feelings. By expressing concerns over gaining weight, which is normal, the woman is trying to confirm the pregnancy. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

1. Which suggestion is most helpful for the pregnant patient who is experiencing heartburn? a. Drink plenty of fluids at bedtime. b. Eat only three meals a day so the stomach is empty between meals. c. Drink coffee or orange juice immediately on arising in the morning. d. Use Tums or Rolaids to obtain relief, as directed by the health care provider.

ANS: D Antacids high in calcium (e.g., Tums, Rolaids) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the patient to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach and may need to be eliminated from the diet. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

2. A pregnant woman has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider? a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. b. These conditions are abnormal. Refer the patient to an ear, nose, and throat specialist. c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.

ANS: D As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy. Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone levels increase during pregnancy. The patient should be reassured that these symptoms are within normal limits. No referral is needed at this time. Relaxation of the smooth muscles in the respiratory tract is affected by progesterone. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity

9. A patient in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse provide regarding safe travel during pregnancy? a. "Only travel by car during pregnancy." b. "Avoid use of the seat belt during the third trimester." c. "You can travel by plane until your 38th week of gestation." d. "If you are traveling by car stop to walk every 1 to 2 hours."

ANS: D Car travel is safe during normal pregnancies. Suggest that the woman stop to walk every 1 to 2 hours so she can empty her bladder. Walking also helps decrease the risk of thrombosis that is elevated during pregnancy. Seat belts should be worn throughout the pregnancy. Instruct the woman to fasten the seat belt snugly, with the lap belt under her abdomen and across her thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her uterus. Travel by plane is generally safe up to 36 weeks if there are no complications of the pregnancy, so only traveling by car is an inaccurate statement. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

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

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

13. Which physiologic adaptation of pregnancy may lead to increased constipation during the pregnancy? a. Increased emptying time in the intestines b. Abdominal distention and bloating c. Decreased absorption of water d. Decreased motility in the intestines

ANS: D Decreased motility in the intestines leading to increased water absorption would cause constipation. Increased emptying time in the intestines leads to increased nutrient absorption. Abdominal distention and bloating are a result of increased emptying time in the intestines. Decreased absorption of water would not cause constipation. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

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

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

33. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurse's next action? a. Palpate the patient's bladder for fullness. b. Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d. Reassure the patient that she is making adequate progress.

ANS: A The fetal presenting part is expected to descend at a minimal rate of 1 cm/hour in the nullipara and 2 cm/hour in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder. DIF: Cognitive Level: Synthesis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

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

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, leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Because fetal insulin production is accelerated during pregnancy, the neonate shows hyperinsulinemia. Excess erythrocytes are broken down after birth, releasing large amounts of bilirubin into the neonate's circulation, which results in hyperbilirubinemia. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance

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

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

49. Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality? a. Rubella b. Cytomegalovirus (CMV) c. Syphilis d. HIV

ANS: A Transmission of congenital rubella causes serious complications in the fetus that may manifest as cataracts, cardiac defects, microcephaly, deafness, intrauterine growth restriction (IUGR), and developmental delays. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation

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

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

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

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

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

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

1. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/minute b. Maternal change of position to knee-chest c. Administration of tocolytic agent d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area

ANS: A,B,C,E Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency

2. The nurse is teaching a pregnant patient about signs of possible pregnancy complications. Which should the nurse include in the teaching plan? (Select all that apply.) a. Report watery vaginal discharge. b. Report puffiness of the face or around the eyes. c. Report any bloody show when you go into labor. d. Report visual disturbances, such as spots before the eyes. e. Report any dependent edema that occurs at the end of the day.

ANS: A,B,D Watery vaginal discharge could mean that the membranes have ruptured. Puffiness of the face or around the eyes and visual disturbances may indicate preeclampsia or eclampsia. These three signs should be reported. Bloody show as labor starts may mean the mucus plug has been expelled. One of the earliest signs of labor may be bloody show, which consists of the mucus plug and a small amount of blood. This is a normal occurrence. Up to 70% of women have dependent edema during pregnancy. This is not a sign of a pregnancy complication. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

3. Which findings are presumptive signs of pregnancy? (Select all that apply.) a. Quickening b. Amenorrhea c. Ballottement d. Goodell's sign e. Chadwick's sign

ANS: A,B,E Quickening, amenorrhea, and Chadwick's sign are presumptive signs of pregnancy. Ballottement and Goodell's sign are probable signs of pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance COMPLETION

1. The nurse is assessing a patient in her 37th week of pregnancy for the psychological responses commonly experienced as birth nears. Which psychological responses should the nurse expect to evaluate? (Select all that apply.) a. The patient is excited to see her baby. b. The patient has not started to prepare the nursery for the new baby. c. The patient expresses concern about how to know if labor has started. d. The patient and her spouse are concerned about getting to the birth center in time. e. The patient and her spouse have not discussed how they will share household tasks.

ANS: A,C,D As birth nears, the expectant patient will express a desire to see the baby. Most pregnant patients are concerned with their ability to determine when they are in labor. Many couples are anxious about getting to the birth facility in time for the birth. As birth nears, a nesting behavior occurs, which means getting the nursery ready. Not preparing the nursery at this stage is not a response that the nurse should expect to assess. Negotiation of tasks is done during this stage. Discussion regarding the division of household chores is not a response that the nurse should expect to assess at this stage. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Psychosocial Integrity

1. A pregnant patient reports that she works in a long-term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine. As the nurse, you are aware that some immunizations are safe to administer during pregnancy, whereas others are not. Which vaccines could this patient receive? (Select all that apply.) a. Tetanus b. Varicella c. Influenza d. Hepatitis A and B e. Measles, mumps, rubella (MMR)

ANS: A,C,D Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe to administer to women who have a risk for contracting or developing the disease. Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance

4. The prenatal nurse educator is teaching couples the technique of applying sacral pressure during labor. Which should be included in the teaching session? (Select all that apply.) a. The technique can be combined with heat to the area. b. A jiggling motion should be used while applying the pressure. c. Tennis balls may be used to apply the pressure to the sacral area. d. The pressure against the sacrum should be intermittent during the contraction. e. The hand may be moved slowly or remain positioned directly over the sacrum.

ANS: A,C,E Sacral pressure can be combined with thermal stimulation to increase effectiveness. The hand may be moved slowly over the area or remain positioned directly over the sacrum, but pressure should be continuous and firm throughout the contraction. Care should be taken not to jiggle the woman, which may be irritating. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

2. The nurse is planning care for a patient in her first trimester of pregnancy. The patient is experiencing nausea and vomiting. Which interventions should the nurse plan to share with this patient? (Select all that apply.) a. Suck on hard candy. b. Take prenatal vitamins in the morning. c. Try some herbal tea to relieve the nausea. d. Drink fluids frequently but separate from meals. e. Eat crackers or dry cereal before arising in the morning.

ANS: A,D,E A patient experiencing nausea and vomiting should be taught to suck on hard candy, drink fluids frequently but separately from meals, and eat crackers, dry toast, or dry cereal before arising in the morning. Prenatal vitamins should be taken at bedtime because they may increase nausea if taken in the morning. Before taking herbal tea, the patient should check with her health care provider. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity

3. Which factors contribute to the presence of edema in the pregnant patient? (Select all that apply.) a. Diet consisting of processed foods b. Hemoconcentration c. Increase in colloid osmotic pressure d. Last trimester of pregnancy e. Decreased venous return

ANS: A,D,E Processed foods, which are high in sodium content, can contribute to edema formation. As the pregnancy progresses, because of the weight of the uterus, compression takes place, leading to decreased venous return and an increase in edema formation. A decrease in colloid osmotic pressure would contribute to edema formation and fluid shifting. Hemodilution would also lead to edema formation. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

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

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

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

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

25. Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b. Fetal distress c. Maternal comfort during labor d. Irregular labor contraction pattern

ANS: B A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and patients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Pathophysiologic Integrity

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

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

47. A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate? a. Practice respiratory isolation. b. Plan for retesting during the third trimester. c. Discuss the recommendation to bottle feed her baby. d. Anticipate administering the vaccination for hepatitis B as soon as possible.

ANS: B A person who has a history of high-risk behaviors should be rescreened during the third trimester. Hepatitis B is transmitted through blood. The first trimester is too early to discuss feeding methods with a woman in the high-risk category. The vaccine may not have time to affect a person with high-risk behaviors. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance

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

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

4. A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the patient in a high Fowler position.

ANS: B A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

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

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

44. Which instructions should the nurse include when teaching a pregnant patient with Class II heart disease? a. Advise her to gain at least 30 lb. b. Instruct her to avoid strenuous activity. c. Inform her of the need to limit fluid intake. d. Explain the importance of a diet high in calcium.

ANS: B Activity may need to be limited so that cardiac demand does not exceed cardiac capacity. Weight gain should be kept at a minimum with heart disease. Iron and folic acid are important to prevent anemia. Fluid intake is necessary to prevent fluid deficits. Fluid intake should not be limited during pregnancy. The patient may also be put on a diuretic. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

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

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

14. The fetus in a breech presentation is often born by cesarean birth because a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the patient delivers vaginally.

ANS: B After the fetal legs and trunk emerge from the patient's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

23. A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care? a. Administration of antihypertensive medication b. Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d. Internal fetal monitoring

ANS: B Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated. The patient with this condition will be hypotensive, not hypertensive. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Pathophysiologic Integrity/Medical Emergency

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

ANS: B Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the patient and fetus. Monitoring uterine contractions is important; however, not the top priority. It is important to assess future bleeding, but the top priority is patient and fetal well-being. The most important assessment is to check patient and fetal well-being. The blood levels can be obtained later. DIF: Cognitive Level: Application

2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the patient is in active labor

ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care Environment

12. You are performing assessments for an obstetric patient who is 5 months pregnant with her third child. Which finding would cause you to suspect that the patient was at risk? a. Patient states that she doesn't feel any Braxton Hicks contractions like she had in her prior pregnancies. b. Fundal height is below the umbilicus. c. Cervical changes, such as Goodell's sign and Chadwick's sign, are present. d. She has increased vaginal secretions.

ANS: B Based on gestational age (20 weeks), the fundal height should be at the umbilicus. This finding is abnormal and warrants further investigation about potential risk. With subsequent pregnancies, multiparas may not perceive Braxton Hicks contractions as being evident compared with their initial pregnancy. Cervical changes such as Goodell's and Chadwick's signs should be present and are considered a normal finding. Increased vaginal secretions are normal during pregnancy as a result of increased vascularity. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential

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

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

11. Which physiologic finding is consistent with normal pregnancy? a. Systemic vascular resistance increases as blood pressure decreases. b. Cardiac output increases during pregnancy. c. Blood pressure remains consistent independent of position changes. d. Maternal vasoconstriction occurs in response to increased metabolism.

ANS: B Cardiac output increases during pregnancy as a result of increased stroke volume and heart rate. Systemic vascular resistance decreases while blood pressure remains the same. Maternal blood pressure changes in response to patient positioning. In response to increased metabolism, maternal vasodilation is seen during pregnancy. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Physiologic Adaptation

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

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

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

ANS: B Delivery of the infant is the only known intervention to halt the progression of preeclampsia. Magnesium sulfate is one of the medications used to treat but not cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of aspirin (81 mg/day) have been administered to women at high risk for developing preeclampsia. This intervention appears to have little benefit. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

21. An expectant patient in her third trimester reports that she developed a strong tie to her baby from the beginning and now is really in tune to her baby's temperament. The nurse interprets this as the development of which maternal task of pregnancy? a. Learning to give of herself b. Developing attachment with the baby c. Securing acceptance of the baby by others d. Seeking safe passage for herself and her baby

ANS: B Developing a strong tie in the first trimester and progressing to be in tune is the process of commitment, attachment, and interconnection with the infant. This stage begins in the first trimester and continues throughout the neonatal period. Learning to give of herself is the task that occurs during pregnancy as the woman allows her body to give space to the fetus. She continues with giving to others in the form of food and presents. Securing acceptance of the baby is a process that continues throughout pregnancy as the woman reworks relationships. Seeking safe passage is the task that ends with birth. During this task, the woman seeks health care and carries out cultural practices. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance

22. Which type of cutaneous stimulation involves massage of the abdomen? a. Imagery b. Effleurage c. Mental stimulation d. Thermal stimulation

ANS: B Effleurage is massage usually performed on the abdomen during contractions. Imagery exercises enhance relaxation by teaching the woman to imagine herself in a relaxing setting. Mental stimulation is a group of methods to decrease pain by increasing mental stimulation. Thermal stimulation decreases pain by using applications of heat and cold. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

3. Which advice to the patient is one of the most effective methods for preventing venous stasis? a. Sit with the legs crossed. b. Rest often with the feet elevated. c. Sleep with the foot of the bed elevated. d. Wear elastic stockings in the afternoon.

ANS: B Elevating the feet and legs improves venous return and prevents venous stasis. Sitting with the legs crossed will decrease circulation in the legs and increase venous stasis. Elevating the legs at night may cause pressure on the diaphragm and increase breathing problems. Elastic stockings should be applied before lowering the legs in the morning. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity

19. A patient who is 7 months pregnant states, "I'm worried that something will happen to my baby." Which is the nurse's best response? a. "Your baby is doing fine." b. "Tell me about your concerns." c. "There is nothing to worry about." d. "The doctor is taking good care of you and your baby."

ANS: B Encouraging the patient to discuss her feelings is the best approach. The nurse should not disregard or belittle the patient's feelings. Responding that your baby is doing fine disregards the patient's feelings and treats them as unimportant. Responding that there is nothing to worry about does not answer the patient's concerns. Saying that the doctor is taking good care of you and your baby is belittling the patient's concerns. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Psychosocial Integrity

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

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

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

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

50. Which postpartum patient requires further assessment? a. G4 P4 who has had four saturated pads during the last 12 hours b. G1 P1 with Class II heart disease who complains of frequent coughing c. G2 P2 with gestational diabetes whose fasting blood sugar level is 100 mg/dL d. G3 P2 postcesarean patient who has active herpes lesions on the labia

ANS: B Frequent coughing may be a sign of congestive heart failure in the postpartum patient with heart disease. Four saturated pads in a 4-hour period is acceptable postpartum blood loss, a fasting blood sugar is a normal value, and the patient with identified active herpes does not require further assessment. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

19. The nurse is scheduling the next appointment for a healthy primigravida currently at 28 weeks gestation. When will the nurse schedule the next prenatal visit? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks

ANS: B From 29 to 36 weeks, routine prenatal assessment is every 2 weeks. If the pregnancy is high risk, the patient will see the health care provider more frequently. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance

19. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the patient not to push until you prepare the vacuum extraction device for physician. d. Reposition the patient to facilitate birth.

ANS: B In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it may cause additional problems. Vacuum extraction will not help to resolve the birth issue and may lead to further complications. Repositioning of the patient may not be effective to relieve this condition and facilitate birth. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Safe and Effective Care Environment/Establishing Priorities

31. Which assessment finding in the postpartum patient following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b. Urine output >30 mL/hour c. Rebound skin turgor <5 seconds d. Pulse rate <120 beats/minute

ANS: B In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hour; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/minute may be indications of hypovolemia. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Physiologic Adaptation

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

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

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

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

24. Which comment made by a new mother to her own mother is most likely to encourage the grandmother's participation in the infant's care? a. "Could you help me with the housework today?" b. "The baby is spitting up a lot. What should I do?" c. "I know you are busy, so I'll get John's mother to help me." d. "The baby has a stomachache. I'll call the nurse to find out what to do."

ANS: B Looking to the grandmother for advice encourages her to become involved in the care of the infant. Housework does not encourage the grandmother to participate in the infant's care. Getting John's mother to help and calling the nurse about advice excludes the grandmother. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance

5. Which technique is least effective for the patient with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees

ANS: B Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance

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

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

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

ANS: B 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 will produce pulmonary hypertension or endocarditis during pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity

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

ANS: B Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause of nausea and vomiting. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity

14. Use Nägele's rule to determine the EDD (estimated day of birth) for a patient whose last menstrual period started on April 12. a. February 19 b. January 19 c. January 21 d. February 7

ANS: B Nägele's rule subtracts 3 months from the month of the last menstrual period (month 4 - 3 = January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days = April 19), so the correct answer is January 19 of the following calendar year. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance

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

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

16. A patient who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition? a. Congenital anomalies b. Death before or after birth c. Neonatal hypoglycemia d. Neonatal withdrawal syndrome

ANS: B Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight, abruptio placentae, placenta previa, preterm birth, perinatal mortality, and SIDS. Smoking does not appear to cause congenital anomalies, hypoglycemia, or withdrawal syndrome. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential

28. Which finding would be indicative of an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL

ANS: B Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

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

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

29. Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae? a. Saturated perineal pad in 1 hour b. Painlevel0onascaleof0to10 c. Cervical dilation at 2 cm d. Fetal heart rate at 160 bpm

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

48. A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis? a. "I know I will need to have an abortion as soon as possible." b. "Even though my test is positive, my baby might not be affected." c. "My baby is certain to have AIDS and die within the first year of life." d. "This pregnancy will probably decrease the chance that I will develop AIDS."

ANS: B The fetus is likely to test positive for HIV in the first 6 months, until the inherited immunity from the mother wears off. Many of these babies will convert to HIV-negative status. With the newer drugs, the risk for infection of the fetus has decreased. Also, the life span of an infected newborn has increased. The pregnancy will increase the chance of converting. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Physiologic Integrity

31. Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy? a. Assessment of pain level b. Administration of methotrexate c. Administration of Rh immune globulin d. Explanation of the common side effects of the treatment plan

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

1. Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid

ANS: B The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

9. An expected change during pregnancy is a darkly pigmented vertical midabdominal line. The nurse recognizes this alteration as a. epulis. b. linea nigra. c. melasma. d. striae gravidarum.

ANS: B The linea nigra is a dark pigmented line from the fundus to the symphysis pubis. Epulis refers to gingival hypertrophy. Melasma is a different kind of dark pigmentation that occurs on the face. Striae gravidarum (stretch marks) are lines caused by lineal tears that occur in connective tissue during periods of rapid growth. DIF: Cognitive Level: Knowledge OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance

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

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

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

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

35. A pregnant woman develops hypertension. The nurse monitors the patient's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow

ANS: D Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential