Chapter 31
The nurse should know that what is the best time to assess a woman's blood pressure during an initial prenatal examination? a. At the end of the examination when she will be the most relaxed b. At the beginning of the interview as a nonthreatening method of gaining rapport c. During the middle of the physical examination when she is the most comfortable d. Before beginning the pelvic examination because her blood pressure will be higher after the pelvic examination
ANS: A Assessing the woman's blood pressure at the end of the examination, when it is hoped that she will be most relaxed, is the best time to assess blood pressure. The other options are not correct.
During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136 beats per minute. How should the nurse proceed? a. Document the results, which are within normal range. b. Have the patient change positions and count the FHTs again. c. Immediately notify the physician for possible fetal distress. d. Take the maternal pulse to verify these findings as the uterine souffle.
ANS: A The normal fetal heart rate is between 110 and 160 beats per minute. The nurse should document the results as within the normal range. The other options are not correct
When performing an examination of a woman who is 34 weeks' pregnant, the nurse notices a midline linear protrusion in the abdomen over the area of the rectus abdominis muscles as the woman raises her head and shoulders off of the bed. Which response by the nurse is correct? a. The presence of diastasis recti should be documented. b. This condition should be discussed with the physician because it will most likely need to be surgically repaired. c. The possibility that the woman has a hernia attributable to the increased pressure within the abdomen from the pregnancy should be suspected. d. The woman should be told that she may have a difficult time with delivery because of the weakness in her abdominal muscles.
ANS: A The separation of the abdominal muscles is called diastasis recti and frequently occurs during pregnancy. The rectus abdominis muscles will return together after pregnancy with abdominal exercise. This condition is not a true hernia.
Which finding is considered normal and expected when the nurse is performing a physical examination on a pregnant woman? a. Palpable, full thyroid b. Edema in one lower leg c. Pale mucous membranes of the mouth d. Significant diffuse enlargement of the thyroid
ANS: A The thyroid may be palpable during pregnancy. It should feel full, but smooth. Significant diffuse enlargement occurs with hyperthyroidism, thyroiditis, and hypothyroidism. Pale mucous membranes may indicate anemia. Bilateral lower extremity edema is common in pregnancy, but edema with pain in only one leg occurs with deep vein thrombosis
When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can be obliterated by pressure with the stethoscope or finger on the thorax just lateral to the murmur. How does the nurse interpret these findings? a. Murmur of aortic stenosis b. Most likely a mammary souffle c. Associated with aortic insufficiency d. Indication of a patent ductus arteriosus
ANS: B Blood flow through the blood vessels, specifically the internal mammary artery, can often be heard over the second, third, and fourth intercostal spaces. This finding is called a mammary souffle, but it may be mistaken for a cardiac murmur. The other options are incorrect.
When examining the face of a woman who is 28 weeks' pregnant, the nurse notices the presence of a butterfly-shaped increase in pigmentation on the face. How should the nurse document this finding? a. Striae b. Chloasma c. Linea nigra d. Mask of pregnancy
ANS: B Chloasma is a butterfly-shaped increase in pigmentation on the face. It is known as the mask of pregnancy, but when documenting, the nurse should use the correct medical term, chloasma. Striae is the term for stretch marks. The linea nigra is a hyperpigmented line that begins at the sternal notch and extends down the abdomen through the umbilicus to the pubis.
A woman at 25 weeks' gestation comes to the clinic for her prenatal visit. The nurse notices that her face and lower extremities are swollen, and her blood pressure is 154/94 mm Hg. The woman states that she has had headaches and blurry vision but thinks it is just because she is tired. What should the nurse suspect? a. Eclampsia b. Preeclampsia c. Preterm labor d. Diabetes type 1
ANS: B Classic symptoms of preeclampsia include elevated blood pressure (greater than 140 mm Hg systolic or 90 mm Hg diastolic in a woman with previously normal blood pressure) and proteinuria. Onset and worsening symptoms may be sudden, and subjective signs include headaches and visual changes. Eclampsia is manifested by generalized tonic-clonic seizures. These symptoms are not indicative of diabetes mellitus (type 1 or 2) or preterm labor.
A patient is being seen at the clinic for her 10-week prenatal visit. She asks when she will be able to hear the baby's heartbeat. How should the nurse reply? a. "The baby's heartbeat is not usually heard until the second trimester." b. "The baby's heartbeat may be heard anywhere from the ninth to the twelfth week." c. "It is often difficult to hear the heartbeat at this point, but we can try." d. "It is normal to hear the heartbeat at 6 weeks. We may be able to hear it today."
ANS: B Fetal heart tones can be heard with the use of the Doppler device between 9 and 12 weeks. The other responses are incorrect.
A patient who is 24 weeks' pregnant asks about wearing a seatbelt while driving. Which response by the nurse is correct? a. "Seatbelts should not be worn during pregnancy." b. "Place the lap belt below the uterus and use the shoulder strap at the same time." c. "Place the lap belt below the uterus but omit the shoulder strap during pregnancy." d. "Place the lap belt at your waist above the uterus and use the shoulder strap at the same time."
ANS: B For maternal and fetal safety, the nurse should instruct the woman to place the lap belt below the uterus and to use the shoulder strap. The other instructions are incorrect.
During the assessment of a woman in her 22nd week of pregnancy, the nurse is unable to hear fetal heart tones with the fetoscope. How should the nurse proceed? a. Wait 10 minutes, and try again. b. Use ultrasound to verify cardiac activity. c. Ask the woman if she has felt the baby move today. d. Immediately notify the physician, then wait 10 minutes and try again.
ANS: B If no fetal heart tones are heard during auscultation with a fetoscope, then the nurse should verify cardiac activity using ultrasonography. An ultrasound should be immediately done and before notifying the physician or causing the woman distress by asking about fetal movement.
When the nurse is assessing the deep tendon reflexes (DTRs) on a woman who is 32 weeks' pregnant, which of these would be considered a normal finding? a. Absent DTRs b. 2+ c. 4+ d. Brisk reflexes with clonus
ANS: B Normally during pregnancy, the DTRs are 1+ to 2+ and bilaterally equal. Brisk or greater than 2+ DTRs and the presence of clonus are abnormal and may be associated with an elevated blood pressure and cerebral edema in the preeclamptic woman.
During a health history interview, a 38-year-old woman shares that she is thinking about having another baby. The nurse knows which statement to be true regarding pregnancy after 35 years of age? a. Fertility does not start to decline until age 40 years. b. Occurrence of Down syndrome is significantly more frequent after the age of 35 years. c. Genetic counseling and prenatal screening are not routine until after age 40 years. d. Women older than 35 years who are pregnant have the same rate of pregnancy-related complications as those who are younger than 35 years.
ANS: B The risk for Down syndrome increases as the woman ages, from approximately 1 in 1250 at age 25 years to 1 in 400 at age 35 years. Fertility declines with advancing maternal age. Women 35 years and older or with a history of a genetic abnormality are offered genetic counseling and the options of prenatal diagnostic screening tests. Because the incidence of chronic diseases increases with age, women older than 35 years who are pregnant more often have medical complications such as diabetes, obesity, and hypertension.
MULTIPLE RESPONSE During a group prenatal teaching session, the nurse teaches Kegel exercises. Which statements would be appropriate for this teaching session? (Select all that apply.) a. "Kegel exercises should be performed twice a day." b. "Kegel exercises should be performed 50 to 100 times a day." c. "Kegel exercises help keep your uterus strong during the pregnancy." d. "To perform Kegel exercises, rapidly perform alternating squeeze-release exercises up to the count of eight." e. "To perform Kegel exercises, slowly squeeze to a peak at the count of eight, and then slowly release to a count of eight."
ANS: B, E Kegel exercises can be performed to prepare for and to recover from birth. The nurse should direct the woman to squeeze slowly to a peak at the count of eight and then to release slowly to the count of eight. The nurse can prescribe this exercise to be performed 50 to 100 times a day.
During the examination of a woman in her second trimester of pregnancy, the nurse notices the presence of a small amount of yellow drainage from the nipples. How does the nurse interpret this finding? a. An indication that the woman's milk is coming in. b. A sign of possible breast cancer in a pregnant woman. c. Most likely colostrum and considered a normal finding at this stage of the pregnancy. d. Too early in the pregnancy for lactation to begin and refers the woman to a specialist.
ANS: C During the second trimester, colostrum, the precursor of milk, may be expressed from the nipples. Colostrum is yellow and contains more minerals and protein but less sugar and fat than mature milk. The other options are incorrect.
The nurse is palpating the fundus of a pregnant woman. Which statement about palpation of the fundus is true? a. The fundus should be hard and slightly tender to palpation during the first trimester. b. Fetal movement may not be felt by the examiner until the end of the second trimester. c. After 20 weeks' gestation, the number of centimeters should approximate the number of weeks' gestation. d. Fundal height is usually less than the number of weeks' gestation, unless an abnormal condition such as excessive amniotic fluid is present.
ANS: C After 20 weeks' gestation, the number of centimeters should approximate the number of weeks' gestation. In addition, at 20 weeks' gestation, the examiner may be able to feel fetal movement and the head can be balloted.
A 25-year-old woman is in the clinic for her first prenatal visit. The nurse will prepare to obtain which laboratory screening test at this time? a. Urine toxicology b. Alpha-fetoprotein c. Complete blood cell count d. Carrier screening for cystic fibrosis
ANS: C At the onset of pregnancy, a routine prenatal panel usually includes a complete blood cell count, serologic testing, rubella antibodies, hepatitis B screening, blood type and Rhesus factor, and antibody screen. A clean-catch urine sample is collected for urinalysis to rule out cystitis. Urine toxicology, although beneficial for women if active substance abuse is suspected or known, is not routinely performed. In the second trimester, maternal serum is analyzed for alpha-fetoprotein. Carrier screening for cystic fibrosis is offered to check whether a person carries the abnormal gene that causes cystic fibrosis but is not part of routine testing.
The nurse auscultates a functional systolic murmur, grade ii/iv, on a woman in week 30 of her pregnancy. The remainder of her physical assessment is within normal limits. How should the nurse proceed? a. Consider this finding abnormal, and refer her for additional consultation. b. Ask the woman to run briefly in place and then assess for an increase in intensity of the murmur. c. Know that this finding is normal and is a result of the increase in blood volume during pregnancy. d. Ask the woman to restrict her activities and return to the clinic in 1 week for re-evaluation.
ANS: C Because of the increase in blood volume, a functional systolic murmur, grade ii/iv or less, can be heard in 95% of pregnant women. The other actions are not appropriate.
A woman who is 8 weeks' pregnant is visiting the clinic for a checkup. Her systolic blood pressure is 30 mm Hg higher than her prepregnancy systolic blood pressure. How should the nurse proceed? a. Consider this a normal finding. b. Expect the blood pressure to decrease as the estrogen levels increase throughout the pregnancy. c. Consider this an abnormal finding because blood pressure is typically lower at this point in the pregnancy. d. Recommend that the patient decreases her salt intake in an attempt to decrease her peripheral vascular resistance.
ANS: C During the seventh gestational week, blood pressure begins to drop as a result of falling peripheral vascular resistance. Early in the first trimester, blood pressure values are similar to those of prepregnancy measurements. In this case, the woman's blood pressure is higher than it should be
A patient who is 20 weeks' pregnant tells the nurse that she feels more shortness of breath as her pregnancy progresses. The nurse recognizes which statement to be true? a. High levels of estrogen cause shortness of breath. b. Feelings of shortness of breath are abnormal during pregnancy. c. Hormones of pregnancy cause an increased respiratory effort. d. The patient should get more exercise in an attempt to increase her respiratory reserve
ANS: C Progesterone and estrogen cause an increase in respiratory effort during pregnancy by increasing tidal volume. Increased tidal volume causes a slight drop in partial pressure of arterial carbon dioxide (PaCO2), causing the woman to have dyspnea occasionally. The other options are not correct
When assessing a woman who is in her third trimester of pregnancy, the nurse looks for the classic symptoms associated with preeclampsia. What symptoms is the nurse looking for that would indicate preeclampsia? a. Edema, headaches, and seizures b. Decreased blood pressure and edema c. Elevated blood pressure and proteinuria d. Elevated liver enzymes and high platelet counts
ANS: C The classic symptoms of preeclampsia are hypertension and proteinuria. Headaches may occur with worsening symptoms, and seizures may occur if preeclampsia is left untreated and leads to eclampsia. A serious variant of preeclampsia, the hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, is an ominous picture. Edema is a common occurrence in pregnancy.
A patient who is in her first trimester of pregnancy tells the nurse that she is experiencing significant nausea and vomiting and asks when it will improve. What is an appropriate response by the nurse? a. "Did your mother have significant nausea and vomiting?" b. "Many women experience nausea and vomiting until the third trimester." c. "Usually, by the beginning of the second trimester, the nausea and vomiting improve." d. "At approximately the time you begin to feel the baby move, the nausea and vomiting will subside."
ANS: C The nausea, vomiting, and fatigue of pregnancy improve by the 12th week. Quickening, when the mother recognizes fetal movement, occurs at approximately 18 to 20 weeks.
A patient's pregnancy test is positive, and she wants to know when the baby is due. The first day of her last menstrual period was June 14, and that period ended June 20. Using the Nägele rule, what is her expected date of delivery? a. March 7 b. March 14 c. March 21 d. March 27
ANS: C To determine the expected date of delivery using the Nägele rule, 7 days are added to the first day of the last menstrual period; then 3 months are subtracted. Therefore, adding 7 days to June 14 would be June 21 and subtracting 3 months would make the expected delivery date March 21.
A female patient has nausea, breast tenderness, fatigue, and amenorrhea. Her last menstrual period was 6 weeks ago. What signs of pregnancy is this patient experiencing? a. Positive b. Possible c. Probable d. Presumptive
ANS: D Presumptive signs of pregnancy are those that the woman experiences and include amenorrhea, breast tenderness, fatigue, nausea, and increased urinary frequency. Probable signs are those that are detected by the examiner, such as an enlarged uterus or changes in the cervix. Positive signs of pregnancy are those that document direct evidence of the fetus such as fetal heart tones or positive cardiac activity on ultrasound.
A woman who is 28 weeks' pregnant has bilateral edema in her lower legs after working 8 hours a day as a cashier at a local grocery store. She is worried about her legs. What is the nurse's best response? a. "You will be at risk for development of varicose veins when your legs are edematous." b. "I would like to listen to your heart sounds. Edema can indicate a problem with your heart." c. "Edema is usually the result of too much salt and fluids in your diet. You may need to cut down on salty foods." d. "As your baby grows, it slows blood return from your legs, causing the swelling. This often occurs with prolonged standing."
ANS: D Edema of the lower extremities occurs because of the enlarging fetus, which impairs venous return. Prolonged standing worsens the edema. Typically, the bilateral, dependent edema experienced with pregnancy is not the result of a cardiac pathologic condition.
The nurse is palpating the abdomen of a woman who is 35 weeks' pregnant and notices that the fetal head is facing downward toward the pelvis. What does this describe? a. Fetal lie b. Fetal variety c. Fetal attitude d. Fetal presentation
ANS: D Fetal presentation describes the part of the fetus that is entering the pelvis first. Fetal lie is orientation of the fetal spine to the maternal spine. Fetal attitude is the position of fetal parts in relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis.
Which of these statements best describes the action of the hormone progesterone during pregnancy? a. Progesterone produces the hormone human chorionic gonadotropin. b. Duct formation in the breast is stimulated by progesterone. c. Progesterone promotes sloughing of the endometrial wall. d. Progesterone maintains the endometrium around the fetus.
ANS: D Rationale: Progesterone prevents the sloughing of the endometrial wall and maintains the endometrium around the fetus. Progesterone increases the alveoli in the breast and keeps the uterus in a quiescent state. The other options are not correct.
A woman in her second trimester of pregnancy complains of heartburn and indigestion. When discussing this with the woman, the nurse considers which explanation for these problems? a. Tone and motility of the gastrointestinal tract increase during the second trimester. b. Sluggish emptying of the gallbladder, from the effects of progesterone, often causes heartburn. c. Lower blood pressure at this time decreases blood flow to the stomach and gastrointestinal tract. d. Enlarging uterus and altered esophageal sphincter tone predispose the woman to have heartburn
ANS: D Stomach displacement from the enlarging uterus plus altered esophageal sphincter and gastric tone as a result of progesterone predispose the woman to heartburn. The tone and motility of the gastrointestinal tract are decreased, not increased, during pregnancy. Emptying of the gallbladder may become more sluggish during pregnancy but is not r/t indigestion. Rather, some women are predisposed to gallstone formation. A lower blood pressure may occur during the second semester, but it does not affect digestion
The nurse is palpating the uterus of a woman who is 8 weeks' pregnant. Which finding would be most consistent with a normal finding at this stage of pregnancy? a. The uterus seems slightly enlarged and softened. b. It reaches the pelvic brim and is approximately the size of a grapefruit. c. The uterus rises above the pelvic brim and is approximately the size of a cantaloupe. d. The uterus is about the size of an avocado, approximately 8 cm across the fundus
ANS: D The 8-week pregnant uterus is approximately the size of an avocado, 7 to 8 cm across the fundus. The 6-week pregnant uterus is slightly enlarged and softened. The 10-week pregnant uterus is approximately the size of a grapefruit and may reach the pelvic brim. The 12-week pregnant uterus will fill the pelvis. At 12 weeks, the uterus is sized from the abdomen.
Which best describes the average length of pregnancy? a. 38 weeks b. 9 lunar months c. 280 days from the last day of the last menstrual period d. 280 days from the first day of the last menstrual period
ANS: D The average length of pregnancy is 280 days from the first day of the last menstrual period, which is equal to 40 weeks, 10 lunar months, or roughly 9 calendar months.
During a woman's 34th week of pregnancy, she is told that she has preeclampsia. The nurse knows which statement concerning preeclampsia is true? a. Preeclampsia has little effect on the fetus. b. Edema is one of the main indications of preeclampsia. c. Eclampsia only occurs before delivery of the baby. d. Untreated preeclampsia may contribute to restriction of fetal growth.
ANS: D Untreated preeclampsia may progress to eclampsia, which is manifested by generalized tonic-clonic seizures. Eclampsia may develop as late as 10 days postpartum. Before the syndrome becomes clinically manifested, it is affecting the placenta through vasospasm and a series of small infarctions. The placenta's capacity to deliver oxygen and nutrients may be seriously diminished, and fetal growth may be restricted. Edema is common in pregnancy and is not an indicator of preeclampsia.
