Maternity/OB HESI Practice #2

67. Which of the following anticoagulants would the nurse expect to administer when caring for a primigravid client at 12 weeks' gestation who has class II cardiac disease due to mitral valve stenosis? 1. Heparin. 2. Warfarin. 3. Enoxaparin. 4. Ardeparin.

67. 1. Although there is no completely safe anticoagulant therapy during pregnancy, heparin is typically the drug of choice. Warfarin, a pregnancy category D drug, can cause fetal malformations. Enoxaparin is sometimes used, but clients are typically switched to heparin near labor because enoxaparin used along with spinal or epidural anesthesia presents an increased risk of bleeding in the epidural or spinal space. Ardeparin also can cause fetal malformations. CN: Pharmacological and parenteral therapies; CL: Apply

78. The primary health care provider prescribes 1,000 mL of Ringer's Lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute? ___________________________________ gtts/min.

78. 25 gtts/min CN: Pharmacological and parenteral therapies; CL: Apply The Client with a Gestational Trophoblastic Disease

80. A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which of the following? 1. Pregnancy-induced hypertension. 2. Gestational diabetes. 3. Hypothyroidism. 4. Polycythemia

80. 1. Hydatidiform mole is suspected when the following are present: pregnancyinduced hypertension before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from cardiac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies. CN: Reduction of risk potential; CL: Analyze

85. When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? 1. External genitalia. 2. Myelinization of nerves. 3. Brown fat stores. 4. Air ducts and alveoli.

85. 1. Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of fetal development. Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approximately 21 to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks. CN: Health promotion and maintenance; CL: Apply

93. After instructing participants in a childbirth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which of the following? 1. Biofeedback. 2. Effleurage. 3. Guided imagery. 4. Pelvic tilt exercises.

93. 4. Pelvic tilt exercises are useful to alleviate backache during pregnancy and labor but are not useful for the pain from contractions. Biofeedback (a conscious effort to control the response to pain), effleurage (light uterine massage), and guided imagery (focusing on a pleasant scene) are appropriate pain relief techniques to practice before labor begins. Various breathing exercises also can help to alleviate the discomfort from contraction pain. CN: Health promotion and maintenance; CL: Evaluate

96. A multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following? 1. Placental blood. 2. Amniotic fluid. 3. Fetal blood. 4. Maternal blood.

96. 4. For the Rh-negative client who may be pregnant with an Rh-positive fetus, an indirect Coombs test measures antibodies in the maternal blood. Titers should be performed monthly during the first and second trimesters and biweekly during the third trimester and the week before the due date. CN: Health promotion and maintenance; CL: Apply

98. A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which of the following? Select all that apply. 1. Hepatitis B immune globulin at birth. 2. Series of three hepatitis B vaccinations per recommended schedule. 3. Hepatitis B screening when born. 4. Isolation of infant during hospitalization. 5. Universal precautions for mother and infant. 6. Contraindication for breast-feeding.

98.1,2,5. The test result indicates that the mother has an active hepatitis infection and is a carrier. Hepatitis B immune globulin at birth provides the infant with passive immunity against hepatitis B and serves as a prophylactic treatment. Additionally, the infant will be started on the vaccine series of three injections. The infant should not be screened or isolated because the infant is already hepatitis B positive. As with all clients, universal precautions should be used and are sufficient to prevent transmission of the virus. Women who are positive for hepatitis B surface antigen are able to breastfeed. CN: Management of care; CL: Create

87. During a 2-hour childbirth preparation class focusing on the labor and birth process for primigravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is the presenting part. In which order do these maneuvers occur? 1. Engagement 2. Flexion 3. Descent 4. Internal rotation

1. Engagement 3. Descent 2. Flexion 4. Internal rotation Engagement refers to the fetus' entering the true pelvis and occurs before descent in primiparas and concurrently in multiparous women. If the head is the presenting part, the normal maneuvers during labor and birth are (in order): descent, flexion, internal rotation, extension, external rotation, and expulsion. These maneuvers are called the cardinal movements. They occur as the fetal head passes through the maternal pelvis during the normal labor process. CN: Health promotion and maintenance; CL: Apply

64. After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching? 1. "I should avoid being near people who have a cold." 2. "I may be given antibiotics during my pregnancy." 3. "I should reduce my intake of protein in my diet." 4. "I should limit my salt intake at meals."

The Pregnant Client with Heart Disease 64. 3. The client needs a diet that is adequate in protein and calories to prevent anemia, which can place additional strain on the cardiac system, further compromising the client's cardiac status. The client should avoid contact with people who have infections because of the increased risk for developing endocarditis. The client may need antibiotics during the pregnancy to prevent endocarditis. Limiting sodium intake can help to prevent excessive expansion of blood volume and decrease cardiac workload. CN: Reduction of risk potential; CL: Evaluate

84. When preparing a prenatal class about endocrine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? 1. Human placental lactogen maintains the corpus luteum. 2. Progesterone is responsible for hyperpigmentation and vascular skin changes. 3. Estrogen relaxes smooth muscle in the respiratory tract. 4. The thyroid enlarges with an increase in basal metabolic rate.

84. 4. Thyroid enlargement and increased basal body metabolism are common occurrences during pregnancy. Human placental lactogen enhances milk production. Estrogen is responsible for hyperpigmentation and vascular skin changes. Progesterone relaxes smooth muscle in the respiratory tract. CN: Health promotion and maintenance; CL: Create

88. A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated birth. The nurse should tell the woman: 1. "The maximum blood loss considered within normal limits is 500 mL." 2. "The minimum blood loss considered within normal limits is 1,000 mL." 3. "Blood loss during childbirth is rarely estimated unless there is a hemorrhage." 4. "It would be very unusual if you lost more than 100 mL of blood during childbirth."

88. 1. In a normal birth and for the first 24 hours postpartum, a total blood loss not exceeding 500 mL is considered normal. Blood loss during childbirth is almost always estimated because it provides a valuable indicator for possible hemorrhage. A blood loss of 1,000 mL is considered hemorrhage. CN: Health promotion and maintenance; CL: Apply

100. A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client? 1. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. 2. Refer the client to her health care provider for evaluation and treatment of the pain. 3. Discuss nutritional strategies to decrease the possibility of heartburn. 4. Support the client's use of acetaminophen (Tylenol) to relieve pain.

100. 2. The nurse seeing this client should refer her to a health care provider for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Tylenol is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems. CN: Management of care; CL: Synthesize

61. At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean birth. The nurse explains to the client that childbirth helps to prevent which of the following? 1. Neonatal hyperbilirubinemia. 2. Congenital anomalies. 3. Perinatal asphyxia. 4. Stillbirth.

61. 4. Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean section is necessary. Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia. CN: Reduction of risk potential; CL: Apply

62. A primigravid client with diabetes at 39 weeks' gestation is seen in the highrisk clinic. The primary health care provider estimates that the fetus weighs at least 4,500 g (10 lb). The client asks, "What causes the baby to be so large?" The nurse's response is based on the understanding that fetal macrosomia is usually related to which of the following? 1. Family history of large infants. 2. Fetal anomalies. 3. Maternal hyperglycemia. 4. Maternal hypertension.

62. 3. Maternal hyperglycemia and poor control of the mother's diabetes mellitus have been implicated in fetal macrosomia. When the mother is hyperglycemic, large amounts of amino acids, free fatty acids, and glucose are transferred to the fetus. Although maternal insulin does not cross the placenta, the fetal pancreas responds by hypertrophy of the islet cells of the pancreas. The islet cells produce large amounts of insulin, which acts as a growth hormone. A family history of large infants usually is not the reason for large-for-gestational-age fetuses in diabetic mothers. Maternal hypertension is associated with small-for-gestational-age fetuses because of vasoconstriction of the maternal and placental blood vessels. CN: Physiological adaptation; CL: Apply

63. With plans to breast-feed her neonate, a pregnant client with insulin-dependent diabetes asks the nurse about insulin needs during the postpartum period. Which of the following statements about postpartal insulin requirements for breast-feeding mothers should the nurse include in the explanation? 1. They fall significantly in the immediate postpartum period. 2. They remain the same as during the labor process. 3. They usually increase in the immediate postpartum period. 4. They need constant adjustment during the first 24 hours.

63. 1. Insulin needs fall significantly for the first 24 hours postpartum because the client has usually been on nothing-by-mouth status for a period of time during labor and the labor process has used maternal glycogen stores. If the client breast-feeds, lower blood glucose levels decrease the insulin requirements. With insulin resistance gone, the client commonly needs little or no insulin during the immediate postpartum period. Although the need for insulin decreases during the intrapartum period, the insulin requirements fall further during the first 24 hours postpartum. After the first 24 hours postpartum, insulin requirements may fluctuate markedly, needing adjustment during the next few days as the mother's body returns to a nonpregnant state. CN: Pharmacological and parenteral therapies; CL: Create

65. While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her primary health care provider immediately if the client experiences which of the following? 1. Mild ankle edema. 2. Emotional stress on the job. 3. Weight gain of 1 lb (0.45 kg) in 1 week. 4. Increased dyspnea at rest.

65. 4. Increased dyspnea at rest must be reported immediately because it may be indicative of increasing congestive heart failure. Mild ankle edema in the third trimester is a common finding. However, generalized or pitting edema, suggesting increasing congestive heart failure, must be reported immediately. Emotional stress on the job increases cardiac demand. However, it needs to be reported only if the client experiences symptoms, such as palpitations or irregular heart rate, indicating heart failure related to the increased stress. Weight gain of 1 lb (0.45 kg) per week is a normal finding during the third trimester. CN: Reduction of risk potential; CL: Apply

66. When developing the collaborative plan of care with the health care provider for a multigravid client at 10 weeks' gestation with a history of cardiac disease who was being treated with digitalis therapy before this pregnancy, the nurse should instruct the client about which of the following regarding the client's drug therapy regimen? 1. Need for an increased dosage. 2. Continuation of the same dosage. 3. Switching to a different medication. 4. Addition of a diuretic to the regimen.

66. 2. Unless the client has cardiac decompensation during the pregnancy, she will most likely be able to continue taking the same dose of medication. The client may be prescribed prophylactic antibiotics, particularly if she has had rheumatic fever. The medication would be switched only if digitalis toxicity occurs. A diuretic is added only if congestive heart failure is not controlled by sodium and activity restrictions. CN: Management of care; CL: Apply

68. A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-cal diet. Which of the following instructions should the nurse give the client? 1. Avoid folic acid supplements to prevent megaloblastic anemia. 2. Severely restrict sodium intake throughout the pregnancy. 3. Take iron supplements with milk to enhance absorption. 4. Increase caloric intake to 2,200 cal daily to promote fetal growth. The Client with an Ectopic Pregnancy

68. 4. The client can continue a low-sodium diet but should increase the caloric intake to 2,200 cal daily to provide adequate nutrients to support fetal growth and development. Folic acid supplements, a standard component of care, are used to prevent folic acid deficiency, which is associated with megaloblastic anemia during pregnancy. Severe restriction of sodium intake is not recommended because sodium is necessary to maintain fluid volume. Iron supplements should be taken with acidic foods and fluids (eg, citrus juices) for maximum absorption. Milk decreases the absorption of iron. CN: Reduction of risk potential; CL: Apply

70. The nurse is assessing a multigravid client at 12 weeks' gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which of the following should the nurse obtain about the client's history? Select all that apply. 1. History of sexually transmitted infections. 2. Number of sexual partners. 3. Last menstrual period. 4. Cesarean section. 5. Contraceptive use.

70. 1,2,3,5. The client may be experiencing an ectopic pregnancy. Contributing factors to an ectopic pregnancy include a prior history of sexually transmitted infection that can scar the fallopian tubes. Multiple sex partners increase the risk of sexually transmitted infections. Knowledge of the client's last menstrual period and contraceptive use may support or rule out the possibility of an ectopic pregnancy. The client's history of cesarean sections would not contribute information valuable to the client's current situation or potential diagnosis of ectopic pregnancy. CN: Reduction of risk potential; CL: Analyze

71. Before surgery to remove an ectopic pregnancy and the fallopian tube, which of the following would alert the nurse to the possibility of tubal rupture? 1. Amount of vaginal bleeding and discharge. 2. Falling hematocrit and hemoglobin levels. 3. Slow, bounding pulse rate of 80 bpm. 4. Marked abdominal edema.

71. 2. Falling hematocrit and hemoglobin levels indicate shock, which occurs if the tube ruptures. Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain and referred shoulder pain. The amount of vaginal bleeding that is evident is a poor estimate of actual blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse. Abdominal edema is a late sign of a tubal rupture in ectopic pregnancy. CN: Reduction of risk potential; CL: Analyze

72. A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess? 1. Uterine cramping. 2. Abdominal distention. 3. Hemoglobin and hematocrit. 4. Pulse rate.

72. 4. Fallopian tube rupture is an emergency situation because of extensive bleeding into the peritoneal cavity. Shock soon develops if precautionary measures are not taken. The nurse readying a client for surgery should be especially careful to monitor blood pressure and pulse rate for signs of impending shock. The nurse should be prepared to administer fluids, blood, or plasma expanders as necessary through an intravenous line that should already be in place. Because the fertilized ovum has implanted outside the uterus, uterine cramping is unlikely. However, abdominal tenderness or knife-like pain may occur. Abdominal fullness may be present, but abdominal distention is rare unless peritonitis has developed. Although the hemoglobin and hematocrit may be checked routinely before surgery, the laboratory results may not truly reflect the presence or degree of acute hemorrhage. CN: Reduction of risk potential; CL: Analyze

73. A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic pregnancy. When obtaining the client's history, which of the following would be most important to identify as a predisposing factor? 1. Urinary tract infection. 2. Marijuana use during pregnancy. 3. Episodes of pelvic inflammatory disease. 4. Use of estrogen-progestin contraceptives.

73. 3. Anything that causes a narrowing or constriction in the fallopian tubes so that a fertilized ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy. Pelvic inflammatory disease is the most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic pregnancy is not related to urinary tract infections. Use of marijuana during pregnancy is not associated with ectopic pregnancy, but its use can result in cognitive reduction if the mother's use during pregnancy is extensive. Progestin-only contraceptives and intrauterine devices have been associated with ectopic pregnancy. CN: Physiological adaptation; CL: Analyze

74. A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which of the following may be prescribed? 1. Progestin contraceptives. 2. Medroxyprogesterone. 3. Methotrexate. 4. Dyphylline.

74. 3. Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by leucovorin. This chemotherapeutic agent attacks the fast-growing zygote and trophoblast cells. RU-486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine whether the tube is still patent. Progestinonly contraceptives and medroxyprogesterone are ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used. CN: Pharmacological and parenteral therapies; CL: Analyze The Pregnant Client with Hyperemesis Gravidarum

75. After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which of the following client statements indicates the need for additional teaching? 1. "I'll eat dry crackers or toast before arising in the morning." 2. "I'll drink adequate fluids separate from my meals or snacks." 3. "I'll eat two large meals daily with frequent protein snacks." 4. "I'll snack on a small amount of carbohydrates throughout the day."

75. 3. The client needs further instructions when she says she should eat two meals a day with frequent protein snacks to decrease nausea and vomiting. The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting. Eating dry crackers or toast before arising, consuming fluids separately from meals, and avoiding greasy or spicy foods may also help to decrease nausea and vomiting. CN: Basic care and comfort; CL: Evaluate

76. A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which of the following? 1. Hypercalcemia. 2. Hypobilirubinemia. 3. Hypokalemia. 4. Hyperglycemia

76. 3. Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased metabolism of nutrients, and excessive vomiting. CN: Reduction of risk potential; CL: Analyze

77. A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which of the following hormones? 1. Progesterone. 2. Estrogen. 3. Somatotropin. 4. Aldosterone.

77. 2. Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotropin production. Hyperemesis is also associated with infectious conditions, such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole. Progesterone is a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone. CN: Physiological adaptation; CL: Apply

The Client with a Gestational Trophoblastic Disease 79. A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should prepare to do which of the following? 1. Transfer the client to the antenatal unit. 2. Keep the client NPO for 24 hours. 3. Administer magnesium sulfate. 4. Obtain an ultrasound.

79. 4. The nurse should prepare the client for an ultrasound to determine the cause of the symptoms. Elevated blood pressure at this point in the pregnancy could indicate chronic hypertension as well as hydatidiform mole. The fundal height of 19 cm is higher than is typically found at 15 weeks' gestation and is indicative of a molar pregnancy (hydatidiform mole). The dark brown vaginal bleeding in isolation could indicate an abortion but when placed in context of the other symptoms is likely related to a hydatidiform mole. The continuous nausea and vomiting is abnormal at this point in the pregnancy and can be a result of the high levels of progesterone from a molar pregnancy. There is no fetus involved; the blood pressure elevation and the continuous nausea and vomiting will resolve with evacuation of the mole, negating the need for magnesium sulfate therapy and placing the client on NPO status. CN: Reduction of risk potential; CL: Synthesize

81. Which of the following client statements indicates a need for additional teaching about self-care during pregnancy? 1. "I should use nonskid pads when I take a shower or bath." 2. "I should avoid using soap on my nipples to prevent drying." 3. "I should sit in a hot tub for 20 minutes to relax after working." 4. "I should avoid douching even if my vaginal secretions increase."

81. 3. The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the first trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk of infection. CN: Health promotion and maintenance; CL: Evaluate

82. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. 1. Differentiating the fetus from the self. 2. Ambivalence concerning pregnancy. 3. Experimenting with mothering roles. 4. Realignment of roles and tasks. 5. Trying various caregiver roles. 6. Concern about labor and birth.

82.3,4,5,6. During the third trimester of pregnancy, the woman experiments with maternal and caregiver roles and may make plans for changes in employment, managing household tasks, and/or childcare. The woman is also concerned about safety and passage through labor and birth. Other psychological tasks include preparation of the nursery, being tired of the pregnancy, and being introspective. A woman will begin to see herself as someone different from the fetus in the second trimester. Additionally, the mother may fantasize about the infant during the second trimester and be concerned about her changing body image. She may experience ambivalence about pregnancy in the first trimester.

83. A new antenatal G 6, P 4, Ab 1 client attends her first prenatal visit with her partner. The nurse is assessing this couple's psychological response to the pregnancy. Which of the following requires the most immediate follow-up? 1. The couple is concerned with financial changes this pregnancy causes. 2. The couple expresses ambivalence about the current pregnancy. 3. The father of the baby states that the pregnancy has changed the mother's focus. 4. The father of the baby is irritated that the mother is not like she was before pregnancy.

83. 4. Pregnancy creates changes in the mother and father. Being considerate, accepting changes, and being supportive of the current situation are considered acceptable responses by the father, rather than feeling irritation about these changes. Expressing concern with the financial changes pregnancy and an expanded family include is normal. The first trimester involves the client and family feeling ambivalent about pregnancy and moving toward acceptance of the changes associated with pregnancy. Maternal acceptance of the pregnancy and a subsequent change in her focus are normal occurrences. CN: Health promotion and maintenance; CL: Analyze

86. A primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? 1. Monozygotic twins result from fertilization of two ova by different sperm. 2. Monozygotic twins occur by chance regardless of race or heredity. 3. Dizygotic twins are usually of the same sex. 4. Dizygotic twins occur more often in primigravid than in multigravid clients.

86. 2. Monozygotic twinning is independent of race, age, parity, or heredity. Monozygotic twins result from the fertilization of one ovum by two different sperm. Dizygotic twinning occurs with the fertilization of more than one ovum during conception. Dizygotic twins may be of the same sex or different sexes. Dizygotic twinning is correlated with increased parity, becoming pregnant within 1 month after stopping oral contraception, and infertility treatments. A primigravid client is less likely to conceive dizygotic twins. CN: Health promotion and maintenance; CL: Apply

89. Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? 1. "The amniotic fluid helps to dilate the cervix once labor begins." 2. "Fetal nutrients are provided by the amniotic fluid." 3. "Amniotic fluid provides a cushion against impact of the maternal abdomen." 4. "The fetus is kept at a stable temperature by the amniotic fluid and sac."

89. 2. Although the amniotic fluid promotes normal prenatal development by allowing symmetric development, it does not provide the fetus with nutrients. Rather, nutrients are provided by the placenta. The amniotic fluid does help dilate the cervix once labor begins by pressure and gravity forces. The amniotic fluid helps to protect the fetus from injury by cushioning against impact of the maternal abdomen and allows room and buoyancy for fetal movement. The amniotic fluid and sac keep the fetus at a stable temperature by maintaining a neutral thermal environment. CN: Health promotion and maintenance; CL: Evaluate

90. During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which of the following exercises suggested by the nurse would be most helpful? 1. Pelvic rocking. 2. Deep breathing. 3. Tailor sitting. 4. Squatting.

90. 1. Pelvic rocking helps to relieve backache during pregnancy and early labor by making the spine more flexible. Deep breathing exercises assist with relaxation and pain relief during labor. Tailor sitting and squatting help stretch the perineal muscles in preparation for labor. CN: Health promotion and maintenance; CL: Analyze

91. A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. 1. Walk in the hospital room. 2. Use slow chest breathing. 3. Request pain medication on a regular basis. 4. Lightly massage her abdomen. 5. Sip ice water.

91.1,2,4. Pain during the first stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching of the lower uterine segment, dilatation of the cervix and perineum, and pressure on adjacent structures. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles. Slow chest breathing is appropriate during the first stage of labor to promote increased oxygenation as well as relaxation. The woman or her coach can lightly massage the abdomen (effleurage) while using slow chest breathing. Chest breathing and massaging increase oxygenation and relaxation of uterine muscles. Pain medication is not used during the first stage of labor because most medications will slow labor; anesthesia may be considered during the second stage of labor. Sipping ice water, while helpful for maintaining hydration, will not be useful as a pain management strategy. CN: Health promotion and maintenance; CL: Synthesize

92. During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" The nurse should tell the participant which of the following about true labor contractions? 1. "Walking around helps to decrease true contractions." 2. "True labor contractions may disappear with ambulation, rest, or sleep." 3. "The duration and frequency of true labor contractions remain the same." 4. "True labor contractions are felt first in the lower back, then the abdomen."

92. 4. With true labor, the contractions are felt first in the lower back and then the abdomen. They gradually increase in frequency and duration and do not disappear with ambulation, rest, or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase true contractions. False labor contractions disappear with ambulation, rest, or sleep. False labor contractions commonly remain the same in duration and frequency. Clients who are experiencing false labor may have pain, even though the contractions are not very effective. CN: Health promotion and maintenance; CL: Apply

94. After a preparation for parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse's best action is to advise the client to do which of the following? 1. Use an over-the-counter cream for yeast infections. 2. Schedule an appointment at the clinic for an examination. 3. Administer a vinegar douche under low pressure. 4. Prepare for preterm labor and birth.

94. 2. Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge with local itching is associated with infection (e.g., Trichomonas vaginalis). The client's symptoms must be further assessed by a health professional because the client needs treatment for this condition. T. vaginalis infection is commonly treated with metronidazole (Flagyl). However, this drug is not used in the first trimester. In the first trimester, the typical treatment is topical clotrimazole. Although a yeast infection is associated with vaginal itching, the vaginal discharge is cheese-like. Furthermore, because the client may have a serious vaginal infection, over-the-counter medications are not advised until the client has been evaluated. Douching is not recommended during pregnancy because it would predispose the client to an ascending infection. The client is not exhibiting signs and symptoms of preterm labor, such as contractions or leaking fluid. And although the client's problems are suggestive of a T. vaginalis infection, which can lead to preterm labor and premature rupture of the membranes, further evaluation is needed to confirm the cause of the infection. CN: Health promotion and maintenance; CL: Synthesize

95. The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan? 1. Decreased plasma volume. 2. Increased risk for urinary tract infections. 3. Increased peripheral vascular resistance. 4. Increased hemoglobin levels.

95. 2. During pregnancy, urinary tract infections are more common because of urinary stasis. Clients need instructions about increasing fluid volume intake. Plasma volume increases during pregnancy. The increase in plasma volume is more pronounced and occurs earlier than the increase in red blood cell mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable blood pressure. Hemoglobin levels decrease during pregnancy even though there is an increase in blood volume. CN: Health promotion and maintenance; CL: Apply The Pregnant Client with Risk Factors

97. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She has dyspnea with exertion and is very tired. Her vital signs are 98, 80, 20, BP 116/72. She has +2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac functional classification? 1. Class I. 2. Class II. 3. Class III. 4. Class IV.

97. 2. According to both the New York Heart Association and the Canadian Cardiovascular Society, this client would fit under Class II because she is symptomatic with increased activity (dyspnea with exertion). Class II clients have cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits. CN: Management of care; CL: Analyze

99. A woman with asthma controlled through the consistent use of medication is now pregnant for the first time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction? 1. "I need to continue taking my asthma medication as prescribed." 2. "It is my goal to prevent or limit asthma attacks." 3. "During an asthma attack, oxygen needs continue to be high for mother and fetus." 4. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

99. 4. Asthma medications and bronchodilators should be continued during pregnancy as prescribed before the pregnancy began. The medications do not cause harm to the mother or fetus. Regular use of asthma medication will usually prevent asthma attacks. Prevention and limitation of an asthma attack is the goal of care for a client who is or is not pregnant and is the appropriate care strategy. During an asthma attack, oxygen needs continue as with any pregnant client but the airways are edematous, decreasing perfusion. Asthma exacerbations during pregnancy may occur as a result of infrequent use of medication rather than as a result of the pregnancy. CN: Pharmacological and parenteral therapies; CL: Evaluate

69. On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the primary health care provider immediately because of the possibility of: 1. Ectopic pregnancy. 2. Abruptio placentae. 3. Gestational trophoblastic disease. 4. Complete abortion.

The Client with an Ectopic Pregnancy 69. 1. The client's signs and symptoms indicate a probable ectopic pregnancy, which can be confirmed by ultrasound examination or by culdocentesis. The primary health care provider is notified immediately because hypovolemic shock may develop without external bleeding. Once the fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae would be manifested by a board-like uterus in the third trimester. Gestational trophoblastic disease would be suspected if the client exhibited no fetal heart rate and symptoms of pregnancy-induced hypertension before 20 weeks' gestation. A client with a complete abortion would exhibit a normal pulse and blood pressure with scant vaginal bleeding. CN: Physiological adaptation; CL: Analyze