Chapter 12: Nursing Care to Promote Fetal and Maternal Health
16. A pregnant patient is experiencing a vaginal discharge and wants to douche. What should the nurse instruct the patient about this health practice? A) Avoid routine douching. B) Use an alkaline solution. C) Use only a commercial solution. D) Use a solution that has been chilled.
Ans: A Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 260 Feedback: Douching while pregnant is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix and lead to uterine infection. In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth. The alkalinity, purchase type, or temperature of the solution does not matter. The pregnant patient should not douche.
1. Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management? A) episodes of double vision B) increased lumbar curvature C) nasal congestion and swollen nasal membranes D) palpitations when lying on her back
Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 257 Feedback: Difficulty with vision can occur from cerebral edema or is a symptom of hypertension of pregnancy.
7. A woman in early pregnancy asks you why she has palmar erythema. Your reply would be based on the principle that palmar erythema is most likely caused by which of the following? A) An increased estrogen level B) An allergy to fetal protein C) Reduced serum protein D) Chorionic gonadotropin hormone secretion
Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 265 Feedback: The cause of palmar erythema during early pregnancy is unknown but is attributed to the increasing estrogen level.
8. At midpoint during pregnancy, you review beginning signs of labor with a patient. One of the beginning signs of labor you would review is A) a sudden gush of clear fluid from the vagina. B) excessive fatigue and headache. C) sharp, right-sided abdominal pain. D) an increased pulse rate and upper abdominal pain.
Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Remember Page: 279 Feedback: A sudden gush of fluid from the vagina may signal that membranes have ruptured. Labor pains usually begin in the back and are described as nagging or cramping.
33. A pregnant patient has a history of genital herpes lesions and has experienced outbreaks periodically throughout the pregnancy. What should the nurse instruct the patient regarding this virus if lesions are present at the time of delivery? A) A cesarean section will be advised at the time of birth. B) There are no precautions needed at the time of birth. C) The patient will need medication immediately after birth. D) The baby will be given a vaccination against the virus at birth.
Ans: A Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 272 Feedback: If genital lesions are present at the time of birth, a fetus may contract the virus from direct exposure. A woman who has existing genital lesions at the time of birth will be advised to have a cesarean birth to reduce the risk of infecting the baby. There are precautions that need to be undertaken if lesions are present at the time of birth. The use of medication will depend on the patient's and infant's exposure to the virus.
29. What advice should the nurse provide to a pregnant patient who admits to continuing to drink alcohol one to two times a week? A) Avoid all alcohol while pregnant. B) Avoid alcohol in the first trimester. C) The effects of alcohol on the fetus are not fully understood. D) An occasional drink is permitted only after the first trimester.
Ans: A Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 274 Feedback: There is evidence to confirm that women who consume large quantities of alcohol during pregnancy can have babies with congenital craniofacial deformities. It is impossible to define a safe level of alcohol consumption. Women should be screened for alcohol use at a first prenatal visit and advised to abstain from alcohol completely for the remainder of their pregnancy. Refer pregnant women with alcohol addiction to an alcohol treatment program as early in pregnancy as possible to help them reduce their alcohol intake.
18. A pregnant patient is experiencing leg cramps. What should the nurse include in the patient's teaching plan as a relief measure? (Select all that apply.) A) Avoid full leg extension. B) Elevate lower extremities. C) Elevate the legs on two pillows. D) Stand on each leg and perform a squat. E) Bend the knee and perform dorsiflexion.
Ans: A, B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 266 Feedback: If a pregnant woman is experiencing frequent leg cramps, she may be advised to elevate lower extremities frequently during the day to improve circulation and avoiding full leg extension. Elevating the legs on two pillows may or may not help the patient. The patient should not be instructed to perform squats or dorsiflexion to help with the leg cramps.
15. The nurse is planning a seminar that focuses on the 2020 National Health Goals during pregnancy for patients who are in the first trimester of pregnancy. Which information should the nurse include in this seminar? (Select all that apply.) A) Refusing alcohol B) Importance to stop smoking C) Maintaining health appointments D) Seeking alternative care approaches E) Abstaining from drugs and substances
Ans: A, B, C, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 257 Feedback: The 2020 National Health Goals for pregnancy include objectives to abstain from social and binge alcohol intake, avoid smoking, receive prenatal care, and abstain from illicit drugs. Seeking alternative care approaches is not a 2020 National Health Goal for pregnancy.
30. A patient enjoys exercising and wants to know if it can continue to be done while pregnant. What should the nurse instruct the patient about exercising at this time? (Select all that apply.) A) Drink plenty of liquids to prevent dehydration. B) Limit strenuous exercise to no longer than 20 minutes. C) Eat a low-protein, simple carbohydrate snack before exercising. D) Warm up for 5 minutes by walking or cycling on low resistance. E) Avoid exercises that require jumping or rapid changes in direction.
Ans: A, B, D, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 260-261 Feedback: The nurse should instruct the patient to drink liquids to prevent dehydration, limit strenuous exercise to 20 minutes, warm up before beginning an exercise session, and avoid exercises that can jar the body. The patient should be instructed to eat a protein and complex carbohydrate snack before exercise to maintain the serum glucose level.
3. When discussing rest and sleep with a pregnant woman, the nurse would discuss which position to use for napping? A) on her stomach with a pillow under her breasts B) on her side with the weight of the uterus on the bed C) on her back with a pillow under her knees and hips D) on her back with a pillow under her head
Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 261 Feedback: Resting on the side prevents pressure from the uterus against the vena cava and, therefore, allows blood to return to the uterus.
9. A pregnant woman enjoys exercising at a local health spa once a week. Which comment would lead the nurse to believe she needs additional health teaching? A) "I limit exercising to low-impact aerobics." B) "Nothing feels nicer than a hot sauna after exercise." C) "I'm learning to play table tennis." D) "The gym gets hot and stuffy by midmorning."
Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 261 Feedback: Hyperthermia may be associated with fetal anomalies and should be avoided during pregnancy. Exercise should be limited to low-impact activities.
34. Which statement would indicate a pregnant nurse needs additional health teaching about avoiding teratogens during pregnancy while at work? A) "I care for about five clients a day." B) "Latex gloves irritate my hands, so I don't use them." C) "I never accompany clients to the X-ray department." D) "I find giving emotional support taxing."
Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 263 Feedback: Teratogens are agents or factors that cause harm to a fetus. To avoid exposure while working, nurses should always wear proper PPE to prevent contact with blood and body fluids. It is recommended to avoid x-ray exposure, except dental, during pregnancy as there is no safe dosage determined. Caring for multiple clients and giving emotional support do not increase exposure to teratogens.
32. A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms? A) Exercise helps reduce the frequency of them. B) If rhythmical, they could indicate preterm labor. C) Lying down for a few hours will help them stop. D) They are false labor and do not need to be reported.
Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 270 Feedback: Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. These sensations are Braxton Hicks contractions and can be similar to a forceful menstrual cramp. These contractions are not usually a sign of beginning labor but should be reported for evaluation. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of preterm labor. Exercise or rest does not reduce the frequency of Braxton Hicks contractions.
2. A client the nurse meets in a prenatal clinic states that she has a vaginal discharge and asks about douching. Which rule is safe regarding douching during pregnancy? A) Only commercial solutions should be used. B) Routine douching is not advised. C) The solution used never should be acid. D) A room-temperature solution should not be used.
Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Remember Page: 260 Feedback: Douching might force fluid into the cervix and infect the uterus and fetus, so it is contraindicated during pregnancy.
14. What advice should the nurse provide to a pregnant client who admits to continuing to drink alcohol 1 to 2 times a week? A) She should avoid alcohol in the first trimester. B) Alcohol should not be consumed during pregnancy. C) The effects of alcohol on the fetus are not fully understood. D) She may have an occasional drink after the first trimester.
Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Understand Page: 274 Feedback: There is no safe amount of alcohol to consume during pregnancy. If the client refuses or has a problem, alert the health care provider for the appropriate referral.
26. A woman who is 4 months pregnant asks what can be done to alleviate frequent heart palpitations and leg cramps. Which nursing diagnosis would be applicable to the patient at this time? A) Pain related to severe complications of pregnancy B) Health-seeking behaviors related to ways to relieve discomforts of pregnancy C) Risk for ineffective breathing pattern related to pressure of the growing uterus D) Impaired urinary elimination related to inability to excrete creatine from the muscles
Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 265 Feedback: The patient is asking for information to reduce the symptoms of heart palpitations and leg cramps caused by pregnancy. This is health-seeking behavior. Heart palpitations and leg cramps are not severe complications of pregnancy. There is no evidence to suggest that the patient is at risk for an ineffective breathing pattern. There is also no evidence to support that the patient is experiencing impaired urinary elimination.
6. A pregnant woman works as a secretary at a large corporation. She states that she wants to take a leave of absence from work for pregnancy but is afraid she will lose seniority standing because of this. You would advise her that A) medically, it is not wise for any woman to work past the seventh month of pregnancy. B) legally, her employer cannot penalize her this way. C) ethically, she has no right to ask for special favors. D) personally, she is selfish to think of herself ahead of the baby this way.
Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Understand Page: 263 Feedback: Pregnancy is not viewed as a condition that is detrimental to career advancement, so women cannot be discriminated against because of pregnancy.
28. A nurse is 5 weeks pregnant and works on a care area where chemotherapy is administered to patients. Which statement indicates that this nurse needs additional health teaching about avoiding teratogens during pregnancy? A) "I care for about five patients a day." B) "I find giving emotional support taxing." C) "Latex gloves irritate my hands, so I don't use them." D) "I never accompany patients to the X-ray department."
Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 263 Feedback: The nurse is not using latex gloves and is exposed to chemotherapeutic agents, which are known teratogens during pregnancy. This nurse needs additional instruction to reduce exposure from the chemotherapy agents. Caring for five patients a day does not necessarily increase the nurse's exposure to teratogens. Emotional support does not increase the nurse's exposure to teratogens. Avoiding X-rays is a positive action to avoid teratogens.
5. A woman is concerned that orgasm will be harmful during pregnancy. Which statement is factual? A) Most women do not experience orgasm during pregnancy. B) Orgasm during pregnancy is potentially harmful. C) Some women experience orgasm intensely during pregnancy. D) Venous congestion in the pelvis makes orgasm painful.
Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 260 Feedback: Because of pelvic congestion, orgasm may be achieved more readily by pregnant women than nonpregnant women.
11. What advice would you give to a woman who is 4 months pregnant and owns a cat? A) Give it away until after delivery. B) Be careful that it doesn't scratch her. C) Ask someone else to change the cat litter. D) Refrain from cleaning the cat's dish.
Ans: C Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 271-272 Feedback: Toxoplasmosis, an infection detrimental to fetal growth, can be spread by cat feces. Women are advised not to change litter boxes during pregnancy.
22. The nurse is reviewing the signs of labor with a patient entering the last phase of the third trimester of pregnancy. What should the nurse include as an indication that the labor is beginning? A) Excessive fatigue and headache B) Sharp, right-sided abdominal pain C) Sudden gush of clear fluid from the vagina D) An increased pulse rate and upper abdominal pain
Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 279 Feedback: Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. Excessive fatigue, headache, abdominal pain, or increased pulse rate are not indications that labor is beginning.
21. A pregnant patient is concerned that she is allergic to something because her hands have been red and itchy since becoming pregnant. What should the nurse explain as the cause of the patient's symptoms? A) Allergy to fetal protein B) Reduced serum protein C) Increased estrogen level D) Chorionic gonadotropin hormone secretion
Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 265 Feedback: Palmar erythema, or palmar pruritus, occurs in early pregnancy and is probably caused by increased estrogen levels. Constant redness or itching of the palms can make a woman believe she has developed an allergy. This type of itching in early pregnancy is normal and is not caused by an allergy to fetal protein, reduced serum protein, or chorionic gonadotropin hormone secretion.
20. A pregnant patient who works as a secretary at a large corporation wants to take a leave of absence from work but is afraid of losing seniority. What should the nurse advise the patient? A) The patient should not ask for special favors. B) The leave of absence should occur after the baby is born. C) The employer cannot penalize the patient for being pregnant. D) It is not wise for any woman to work past the seventh month of pregnancy.
Ans: C Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 263 Feedback: Women who are unable to continue working while pregnant are protected from loss of employment benefits during pregnancy by federal law. According to federal law, an employer cannot deprive women of seniority rights because they take a maternity leave. The patient is not asking for special favors. The maternity leave can occur before the delivery because the Family Medical and Leave Act can be used once the baby is delivered. There is no time limit about how long a pregnant patient can work.
13. A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching? A) "I maintain a high fluid intake." B) "I'll try not to stand for long periods." C) "I dorsiflex my feet and ankles frequently." D) "I wear knee-highs rather than pantyhose."
Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 260-266-267 Feedback: Women with varicosities should not wear knee-high stockings as they put pressure on leg veins and reduce venous return.
10. An adolescent who is pregnant asks the nurse which sport would be safe for her to learn during pregnancy. Which activity would the nurse suggest as safe? A) bicycling B) jogging C) skiing D) swimming
Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 261 Feedback: Sports that require balance (bicycling, skiing) become difficult during pregnancy. Jogging can be difficult because of lax knee cartilage.
27. During the previous prenatal visit, the nurse instructed a pregnant patient on ways to reduce the impact of varicosities. Which patient statement indicates that additional teaching is needed? A) "I drink fluid throughout the day." B) "I'll try not to stand for long periods." C) "I point my toes up and down frequently." D) "I wear knee-highs rather than pantyhose."
Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 267 Feedback: For varicosities, the patient should be instructed to avoid constrictive knee-high hose. Fluid intake, avoiding prolonged positions, and dorsiflexion of the feet are ways to reduce the impact of varicosities and would not require additional teaching.
23. A pregnant patient enjoys exercising at a local health spa once a week. Which patient comment indicates to the nurse that additional health teaching is needed? A) "I'm learning to play table tennis." B) "I limit exercising to low-impact aerobics." C) "The gym gets hot and stuffy by midmorning." D) "Nothing feels nicer than a hot tub soak after exercise."
Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 278 Feedback: Pregnant women should not soak for long periods in extremely hot water or hot tubs because heat exposure for a lengthy time could lead to hyperthermia in the fetus and birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. Playing table tennis, performing low-impact aerobics, and the environment of the gym are not comments that indicate the need for additional teaching.
31. A pregnant patient is planning travel to a foreign country as part of a work assignment and needs immunizations. What should the nurse instruct the patient about immunizations while pregnant? A) Immunizations should be restricted to live viruses only. B) There are no restrictions on immunizations while pregnant. C) The only immunization that should be avoided is for the flu. D) Live virus immunizations are contraindicated while pregnant.
Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 264-265 Feedback: All live virus vaccines are contraindicated during pregnancy and should not be administered unless the risk of the disease outweighs the risk to the pregnancy because live virus vaccines can cross the placenta and infect the fetus. The influenza vaccine is recommended if it is flu season when visiting crowded locations.
25. What advice should the nurse provide to a patient who is 4 months pregnant and owns a cat? A) Give it away until after delivery. B) Refrain from cleaning the cat's dish. C) Be careful that it doesn't scratch the skin. D) Ask someone else to change the cat litter.
Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 271-272 Feedback: Toxoplasmosis, a protozoan infection, may be contracted through handling cat stool in soil or cat litter. Removing a cat from the home during pregnancy as a means of prevention is not necessary as long as the cat is healthy. The pregnant woman should be instructed not to change a cat litter box or garden in soil in an area where cats may defecate to avoid exposure to the disease. Cleaning the cat's dish is acceptable. Scratches do not cause the disease.
4. A pregnant woman experiences frequent leg cramps. Which measure would the nurse include in her teaching plan to provide her with relief? A) elevating her leg on two pillows B) bending her knee and dorsiflexing her foot C) plantar flexing her foot and wiggling her toes D) extending her knee and dorsiflexing her foot
Ans: D Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 266 Feedback: Dorsiflexing the foot with the knee extended is an effective method for relieving cramps in the calf muscle, the most frequently affected muscle.
19. A pregnant patient is concerned that orgasm will be harmful to the developing fetus. What should the nurse include when responding to this patient's concern? A) Orgasm during pregnancy is potentially harmful. B) Venous congestion in the pelvis makes orgasm painful. C) Most women do not experience orgasm during pregnancy. D) Some women experience orgasm intensely during pregnancy.
Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 260 Feedback: Because of increased pelvic congestion from the additional uterine blood supply at midpregnancy, most women notice increased clitoral sensation and may experience orgasm for the first time during pregnancy because of this. Orgasm during pregnancy is not harmful. Pelvic congestion does not make orgasm painful.
24. An adolescent asks which sport would be safe for her to learn during pregnancy. Which activity should the nurse suggest to the patient? A) Skiing B) Jogging C) Bicycling D) Swimming
Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 261 Feedback: Swimming is a good activity for pregnant women and is not contraindicated as long as membranes are intact. It increases muscle tone but may help relieve backache. Pregnancy is not the time to learn to ski or ride a bicycle because the lack of skill could result in many falls. Jogging is questionable because of the strain the extra weight of pregnancy places on the knees.
17. The nurse is emphasizing the importance of adequate rest and sleep with a pregnant patient. Which position should the nurse suggest the patient use? A) On the back with a pillow under the head B) On the stomach with a pillow under her breasts C) On the back with a pillow under the knees and hips D) On the side with the weight of the uterus on the bed
Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 261 Feedback: A good resting or sleeping position for a pregnant patient is a left-sided Sims' position, with the top leg forward. This position puts the weight of the fetus on the bed, not on the woman, and allows good circulation in lower extremities. Lying on the back could cause the weight of the uterus to occlude the inferior vena cava impeding blood flow to the patient and fetus. Stomach lying is not a reasonable option with the size of the uterus.
12. A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her? A) Impaired urinary elimination related to inability to excrete creatine from her muscles B) Risk for ineffective breathing pattern related to pressure of the growing uterus C) Pain related to severe complications of pregnancy D) Health-seeking behaviors related to ways to relieve discomforts of pregnancy
Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 265-268 Feedback: Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.