Chapter 01: Maternity and Women’s Health Care Today Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 1. A nurse educator is teaching a group of nursing students about the
history of family-centered maternity care. Which statement should the nurse include in the teaching session? a. The Sheppard-Towner Act of 1921 promoted family-centered care. b. Changes in pharmacologic management of labor prompted familycentered care. c. Demands by physicians for family involvement in childbirth increased the practice of family-centered care. d. Parental requests that infants be allowed to remain with them rather than in a nursery initiated the practice of familycentered care. ANS: D
As research began to identify the benefits of early, extended parent–infant contact, parents began to insist that the infant remain with them. This gradually developed into the practice of rooming-in and finally to familycentered maternity care. The Sheppard-Towner Act provided funds for state-managed programs for mothers and children but did not promote family-centered care. The changes in pharmacologic management of labor were not a factor in family-centered maternity care. Family-centered care was a request by parents, not physicians. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance 2. Expectant parents ask a prenatal nurse educator, “Which setting for
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childbirth limits the amount of parent–infant interacUtionS?” B.C the nurse provide for these parents in NWhTich answOer should order to assist them in choosing an appropriate birth setting? a. Birth center b. Home birth c. Traditional hospital birth d. Labor, birth, and recovery room ANS: C
In the traditional hospital setting, the mother may see the infant for only short feeding periods, and the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in parent–infant contact. Home births allow the greatest amount of parent–infant contact. The labor, birth, recovery, and postpartum room setting allows for increased parent–infant contact. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance
3. Which statement best describes the advantage of a labor, birth,
recovery, and postpartum (LDRP) room? The family is in a familiar environment. They are less expensive than traditional hospital rooms. The infant is removed to the nursery to allow the mother to rest. The woman’s support system is encouraged to stay until discharge.
a. b. c. d.
ANS: D
Sleeping equipment is provided in a private room. A hospital setting is never a familiar environment to new parents. An LDRP room is not less expensive than a traditional hospital room. The baby remains with the mother at all times and is not removed to the nursery for routine care or testing. The father or other designated members of the mother’s support system are encouraged to stay at all times. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 4. Which nursing intervention is an independent function of the professional
nurse? Administering oral analgesics Requesting diagnostic studies Teaching the patient perineal care Providing wound care to a surgical incision
a. b. c. d.
ANS: C
Nurses are now responsible for various independent functions, including teaching, counseling, and intervening in nonmedical problems. Interventions initiated by the physician and carried out by the nurse are called dependent functions. Administrating oral analgesics is a dependent function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is a dependent function. Providing wound care is a dependent function; however, the physician prescribes the type of wound care through direct orders or protocol. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Safe and Effective Care Environment 5. Which response by the nurse is the most therapeutic when the patient
. states, “I’m so afraid to have a cesarean birth”? a. “Everything will be OK.” b. “Don’t worry about it. It will be over soon.” c. “What concerns you most about a cesarean birth?” d. “The physician will be in later and you can talk to him.” ANS: C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is saying and asks for clarification, which is the most therapeutic response. The response, “Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about it. It will be over soon” will indicate that the patient’s feelings are not important. The response, “The physician will be in later and you can talk to him” does not allow the patient to verbalize her feelings when she wishes to do that. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Psychosocial Integrity 6. In which step of the nursing process does the nurse determine the
appropriate interventions for the identified nursing diagnosis? a. Planning b. Evaluation
c. Assessment d. Intervention ANS: A
The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Safe and Effective Care Environment 7. Which goal is most appropriate for the collaborative problem of wound
infection? The patient will not exhibit further signs of infection. Maintain the patient’s fluid intake at 1000 mL/8 hour. The patient will have a temperature of 98.6F within 2 days. Monitor the patient to detect therapeutic response to antibiotic therapy.
a. b. c. d.
ANS: D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing interventions of monitoring or observing. Monitoring for complications such as further signs of infection is an independent nursing role. Intake and output is an independent nursing role. Monitoring a patient’s temperature is an independent nursing role. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Safe and Effective Care Environment 8. Which nursing intervention is written correctly? a. Force fluids as necessary. b. Observe interaction with the infant. c. Encourage turning, coughing, and deep breathing.
d. Assist to ambulate for 10NmUinRuSteIs NatG8TABM., C2 OPMM,
and 6 PM. ANS: D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is not specific; it does not state how much or how often. Encouraging the patient to turn, cough, and breathe deeply is not detailed or specific. Observing interaction with the infant does not state how often this procedure should be done. Assisting the patient to ambulate for 10 minutes within a certain timeframe is specific. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Safe and Effective Care Environment 9. The patient makes the statement: “I’m afraid to take the baby home
tomorrow.” Which response by the nurse would be the most therapeutic? a. “You’re afraid to take the baby home?” b. “Don’t you have a mother who can come and help?” c. “You should read the literature I gave you before you leave.” d. “I was scared when I took my first baby home, but everything worked out.”
ANS: A
This response uses reflection to show concern and open communication. The other choices are blocks to communication. Asking if the patient has a mother who can come and assist blocks further communication with the patient. Telling the patient to read the literature before leaving does not allow the patient to express her feelings further. Sharing your own birth experience is inappropriate. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Psychosocial Integrity 10. The nurse is writing an expected outcome for the nursing diagnosis—
acute pain related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale of 10. Which expected outcome is correctly stated for this problem? a. Patient will state that pain is a 2 on a scale of 10. b. Patient will have a reduction in pain after administration of the prescribed analgesic. c. Patient will state an absence of pain 1 hour after administration of the prescribed analgesic. d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic. ANS: D
The outcome should be patient-centered, measurable, realistic, and attainable and within a specified timeframe. Patient stating that her pain is now 2 on a scale of 10 lacks a timeframe. Patient having a reduction in pain after administration of the prescribed analgesic lacks a measurement. Patient stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic. DIF: Cognitive Level:
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Applic atUion S N OTB J: N uOrs ing Process Step: Planning MSC: Patient Needs: Physiologic Integrity 11. Which nursing diagnosis should the nurse identify as a priority for a patient
in active labor? a. Risk for anxiety related to upcoming birth b. Risk for imbalanced nutrition related to NPO status c. Risk for altered family processes related to new addition to the family d. Risk for injury (maternal) related to altered sensations and positional or physical changes ANS: D
The nurse should determine which problem needs immediate attention. Risk for injury is the problem that has the priority at this time because it is a safety problem. Risk for anxiety, imbalanced nutrition, and altered family processes are not the priorities at this time. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care Environment 12. Regarding advanced roles of nursing, which statement related to clinical
practice is the most accurate? a. Family nurse practitioners (FNPs) can assist with childbirth
care in the hospital setting. b. Clinical nurse specialists (CNSs) provide primary care to obstetric patients. c. Neonatal nurse practitioners provide emergency care in the postbirth setting to
high-risk infants. d. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse. ANS: C
Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal intensive care unit, as needed. FNPs do not participate in childbirth care; however, they can take care of uncomplicated pregnancies and postbirth care outside of the hospital setting. CNSs work in hospital settings but do not provide primary care services to patients. A CNM is an advanced practice nurse who receives additional certification in the specific area of midwifery. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Management of Care: Legal Rights and Responsibilities 13. Which statement is true regarding the shortage of nurses in the United
States? a. There are a larger proportion of younger nurses in the workforce as compared with older nurses. b. As a result of decreased RN-to-patient ratios, there is a decrease in patient mortality in the clinical setting. c. Nursing programs are turning away qualified applicants. d. There are adequate classroom and clinical facilities for training RNs. ANS: C
According to an Institute of Medicine (IOM) report, by the year 2020, 80% of new RNs should hold baccalaureate degrees. Despite this need, baccalaureate and master’s programs are turning away qualified applicants due to an insufficient number of faculty. There are a larger proportion of older nurses U inSNthe N R T worIkfoGrce Bba.seCd oMn current research by the IOM. Increased nurse-to-patient ratios have resulted in decreased patient mortality in the clinical setting. There are currently numerous limitations of both classroom and clinical facilities necessary to train new nurses adequately. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion: Teaching/Learning 14. A hospital has achieved Magnet status. Which indicators would be
consistent with this type of certification? a. There is stratification of communication in a directed manner between nursing staff and administration. b. There is increased job satisfaction of nurses, with a lower staff turnover rate. c. Physicians are certified in their respective specialty areas. d. All nurses have baccalaureate degrees and certification in their clinical specialty area. ANS: B
Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center) in which hospitals apply based on designated criteria that consider nurse job satisfaction, staff patterns, strength,
quality of nursing staff, and open communication. It is not based on physician status. Also, certification is not required for all nurses at this point. The expectation with Magnet status is that nurses will continue to expand their knowledge by earning additional degrees and certification.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion: Teaching/Learning 15. Which of the following statements highlights the nurse’s role as a
researcher?
a. Reading peer-reviewed journal articles b. Working as a member of the interdisciplinary team to provide patient
care c. Helping patient to obtain home care postdischarge from the hospital d. Delegating tasks to unlicensed personnel to allow for more teaching time with patients ANS: A
A nurse in a researcher role should look to improve her or his knowledge base by reading and reviewing evidence-based practice information as found in peer-reviewed journals. Working as a member of the interdisciplinary team to provide patient care indicates that the nurse is working as a collaborator. Helping the patient to obtain home care postdischarge from the hospital indicates that the nurse is working as a patient advocate. Delegating tasks to unlicensed personnel in order to allow for more teaching time with patients indicates that the nurse is working as a manager. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion: Teaching/Learning 16. Which patient could safely be cared for by a certified nurse-midwife? a. Gravida 3, para 2, with no complications b. Gravida 1, para 0, with mild hypertension c. Gravida 2, para 1, with insulin-dependent diabetes d. Gravida 1, para 0, with bNorUdeRrlSinIe
NpeGlvTicBm.eCasOuMrements
ANS: A
A certified nurse-midwife (CNM) cares for women who are at low risk for complications. The CNM would not care for a woman with hypertension. The CNM would not care for a woman with insulin-dependent diabetes. The CNM would not care for a woman with borderline pelvic measurements. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance 17. A primipara patient asks about possible support options for her during
the labor process. She is apprehensive that her family members will not be prepared to assist her during this time. Which option would be most effective for this patient? a. Reassure the patient that the labor and birth staff consists of highly trained nurses who are well educated to take care of laboring patients so that should be sufficient.
b. Encourage the patient to take prepared childbirth classes with
her husband because that should provide the best support by a family member. c. Provide information to the patient about obtaining a doula during the labor process. d. Tell the patient that this is a normal feeling based on fear of the unknown and that it will subside once she starts the labor process. ANS: C
Providing information about a doula addresses the patient’s concern because the doula’s designated role is to provide support during labor. Although it is true that labor and birth nurses are trained in their specialty, the patient is voicing concern for support so her feelings should not be minimized. Encouraging the patient to take prepared childbirth classes is also important; however, it does not address the patient’s concern for support. Because this patient is a primipara, it is normal to have some anxiety over the unknown process of the labor experience but again this response minimizes the patient’s concern. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychologic Integrity 18. The nurse states to the newly pregnant patient, “Tell me how you feel
about being pregnant.” Which communication technique is the nurse using with this patient? a. Clarifying b. Paraphrasing c. Reflection d. Structuring ANS: A
The nurse is attempting to follow up and check the accuracy of the patient’s message. Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing comprehension of what the patient has said. Structuring takes place when the nurse has set guidelines or set priorities. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance 19. When reviewing a new patienNtU’s RbiSrtIh NplGanT, Bth.e
CnuOrsMe notices that the patient will be bringing a doula to the
hospital during labor. What does the nurse think that this means? a. The patient will have her grandmother as a support person. b. The patient will bring a paid, trained labor support person with her during labor. c. The patient will have a special video she will play during labor to assist with relaxation. d. The patient will have a bag that contains all the approved equipment that may help with the labor process. ANS: B
A doula is a trained labor support person who is employed by the mother to provide labor support. She gives physical support such as massage, helps with relaxation, and provides emotional support and advocacy throughout labor. A doula is usually not a relative of the woman. A doula is a trained labor support person. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE 1. In consideration of the historic evolution of maternity care, which
treatment options were used over the past century? (Select all that apply.) a. During the nineteenth century, women of privilege were delivered by midwives in a hospital setting.
b. Granny midwives received their training through a period of
apprenticeship.
c. The recognition of improved obstetric outcomes was related to
increased usage of hygienic practices. d. A shift to hospital-based births occurred as a result of medical equipment designed to facilitate birth. e. The use of chloroform by midwives led to decreased pain during birth. ANS: B, C, D
Training of granny midwives was done by apprenticeship as opposed to formal medical school training. With the advent of usage of hygienic practices, improved health outcomes were seen with regard to a decrease in sepsis. New equipment such as forceps enabled easier birth. Women of privilege in the nineteenth century delivered at home, attended by a midwife. Chloroform was used by physicians and was not available to midwives. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 2. Many communities now offer the availability of free-standing birth centers
to provide care for low-risk women during pregnancy, birth, and postpartum. When counseling the newly pregnant patient regarding this option, the nurse should be aware that this type of care setting includes which advantages? (Select all that apply.) a. Staffing by lay midwives b. Equipped for obstetric emergencies c. Less expensive than acute care hospitals d. Safe, homelike births in a familiar setting e. Access to follow-up care for 6 weeks postpartum ANS: C, D, E
.
Patients who are at low risk and desire a safe, homelike birth are very satisfied with this type of care setting. The new mother may return to the birth center for postpartum follow-up care, breastfeeding assistance, and family planning information for 6 weeks postpartum. Because birth centers do not incorporate advanced technologies into their services, costs are significantly less than in a hospital setting. The major disadvantage of this care setting is that these facilities are not equipped to handle obstetric emergencies. Should unforeseen difficulties occur, the patient must be transported by ambulance to the nearest hospital. Birth centers are usually staffed by certified nurse-midwives (CNMs). DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Safe and Effective Care Environment 3. The nurse is assessing a patient’s use of complementary and
alternative therapies. Which should the nurse document as an alternative or complementary therapy practice? (Select all that apply.) a. Practicing yoga daily b. Drinking green tea in the morning c. Taking omeprazole (Prilosec) once a day d. Using aromatherapy during a relaxing bath
e. Wearing a lower back brace when lifting heavy objects ANS: A, B, D
Complementary and alternative (CAM) therapies can be defined as those systems, practices, interventions, modalities, professions, therapies, applications, theories, and claims that are currently not an integral part of the conventional medical system in North America. Yoga is considered to be a mind–body alternative therapy. Green tea and aromatherapy are biologically based complementary therapies. Prilosec and the use of a lower back brace would be therapies consistent with those used by conventional medicine. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 4. The nurse is formulating a nursing care plan for a postpartum patient.
Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply.) a. Using a standardized postpartum care plan b. Determining priorities for each diagnosis written c. Writing interventions from a nursing diagnosis book d. Reflecting and suspending judgment when writing the care plan e. Clustering data during the assessment process according to normal versus abnormal ANS: B, D, E
Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes reflective skepticism. Determining priorities, reflecting and suspending judgment, and clustering data are actions that indicate the use of critical thinking. Using a standardized care plan and writing interventions from a nursing diagnosis book do not show that reflection about the patient’s individual care is being done. DIF: Cognitive Level:
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Applic atUion S N OTB J: N uOrs ing Process Step: Planning MSC: Patient Needs: Physiologic Integrity 5. The RN is delegating tasks to the unlicensed assistive personnel (UAP).
Which tasks can the nurse delegate? (Select all that apply.) Teaching the patient about breast care Assessment of a patient’s lochia and perineal area Assisting a patient to the bathroom for the first time after birth Vital signs on a postpartum patient who delivered the night before Assisting a postpartum patient to take a shower on the second postpartum day
a. b. c. d. e.
ANS: D, E
Nurses must be aware that they remain legally responsible for patient assessments and must make the critical judgments necessary to ensure patient safety when delegating tasks to unlicensed personnel. The nurse cannot delegate assessment, teaching, or evaluation. The two tasks that the nurse can delegate are vital signs on a stable postpartum patient and assisting a stable postpartum patient on the second postpartum day to take a shower. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care
Environment
Chapter 02: Social, Ethical, and Legal Issues Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 1. During which phase of the cycle of violence does the batterer
become contrite and remorseful? a. Battering b. Honeymoon c. Tension-building d. Increased drug taking ANS: B
During the honeymoon phase, the battered person wants to believe that the battering will never happen again, and the batterer will promise anything to get back into the home. During the battering phase, violence actually occurs, and the victim feels powerless. During the tensionbuilding phase, the batterer becomes increasingly hostile, swears, threatens, throws things, and pushes the battered person. Often, the batterer increases the use of drugs during the tension-building phase. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Psychosocial Integrity 2. The United States ranks poorly in terms of worldwide infant mortality
rates. Which factor has the greatest impact on decreasing the mortality rate of infants? a. Providing more women’s shelters N R U S GNB.C TM O b. Ensuring early and adequat e pr ena tal c are I and cultural differences c. Resolving all language d. Enrolling pregnant women in the Medicaid program by their eighth month of pregnancy ANS: B
Because preterm infants form the largest category of those needing expensive intensive care, early pregnancy intervention is essential for decreasing infant mortality. The women in shelters have the same difficulties in obtaining health care as other poor people, particularly lack of transportation and inconvenient clinic hours. Language and cultural differences are not infant mortality issues but must be addressed to improve overall health care. Medicaid provides health care for poor pregnant women, but the process may take weeks to take effect. The eighth month is too late to apply and receive benefits for this pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 3. The nurse is planning a teaching session for staff on ethical theories.
Which situation best reflects the Deontologic theory?
a. Approving a physician-assisted suicide b. Supporting the transplantation of fetal tissue and organs c. Using experimental medications for the treatment of AIDS
d. Initiating resuscitative measures on a 90-year-old patient with terminal
cancer
ANS: D
In the Deontologic theory, life must be maintained at all costs, regardless of quality of life. Approving a physician-assisted suicide, supporting the transplantation of fetal tissue and organs, and using experimental medications for the treatment of AIDS are examples of a utilitarian model. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychosocial Integrity 4. Which step of the nursing process is being used when the nurse
decides whether an ethical dilemma exists? Analysis Planning Evaluation Assessment
a. b. c. d.
ANS: A
When a nurse uses the collected data to determine whether an ethical dilemma exists, the data are being analyzed. Planning is done after the data have been analyzed. Evaluation occurs once the outcome has been achieved. Assessment is the data collection phase. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Safe and Effective Care Environment: Coordinated Care 5. The nurse is interviewing a patient who is 6-weeks pregnant. The patient
asks the nurse, “Why is elective abortion considered such an ethical issue?” Which response by the nurse is most appropriate? a. Abortion requires third-pNarUtyRcSonIseNnGt. TB.COM b. The U.S. Supreme Court ruled that life begins at conception. c. Abortion law is unclear about a woman’s constitutional rights. d. There is a conflict between the rights of the woman and the rights of the fetus. ANS: D
Elective abortion is an ethical dilemma because two opposing courses of action are available. Abortion does not require third-party consent. The Supreme Court has not ruled on when life begins. Abortion laws are clear concerning a woman’s constitutional rights. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care Environment 6. At the present time, which agency governs surrogate parenting? a. State law b. Federal law c. Individual court decision d. Protective child services ANS: C
Each surrogacy case is decided individually in a court of law. Surrogate parenting is not governed by either state or federal law. Protective child services do not make decisions related to surrogacy.
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance 7. Which patient will most likely seek prenatal care? a. A 15-year-old patient who tells her friends, “I just don’t
believe that I am pregnant” b. A 28-year-old who is in her second pregnancy and abuses drugs and alcohol c. A 20-year-old who is in her first pregnancy and has access to a free prenatal clinic d. A 30-year-old who is in her fifth pregnancy and delivered her last infant at home with the help of her mother and sister ANS: C
The patient who acknowledges the pregnancy early, has access to health care, and has no reason to avoid health care is most likely to seek prenatal care. Being in denial regarding the pregnancy will prevent a patient from seeking health care. Patients who abuse substances are less likely to seek health care. Some women see pregnancy and birth as a natural occurrence and do not seek health care. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 8. A medical-surgical nurse is asked to float to a women’s health unit to
care for patients who are scheduled for therapeutic abortions. The nurse refuses to accept this assignment and expresses her personal beliefs as being incongruent with this medical practice. The nursing supervisor states that the unit is short-staffed and the nurse is familiar with caring for postoperative patients. In consideration of legal and ethical practices, can the nursing supervisor enforce this assignment? a. The staff nurse has the responsibility of accepting any assignment that is made while working for a healtNh UcaRreSuInNit,GsTo Bth.e CnuOrsMing supervisor is within his or her rights to enforce this assignment. b. Because the unit is short-staffed, the staff nurse should accept the assignment to provide care by benefit of her or his experience to patients who need care. c. The staff nurse has expressed a legitimate concern based on his or her feelings; the nursing supervisor does not have the authority to enforce this assignment. d. The nursing supervisor should emphasize that this assignment requires care of a surgical patient for which the staff nurse is adequately trained and should therefore enforce the assignment. ANS: C
The Nurse Practice Act allows nurses to refuse assignments that involve practices that they have expressed as being opposed to their religious, cultural, ethical, and/or moral values. Although the nursing supervisor has a right to arrange assignments, the supervisor, if made aware of a potential bias or limitation, must act accordingly and accept the nurse’s position. This should be upheld regardless of staffing limitations and independent of persuasive efforts to make the nurse feel guilty for her or his stated beliefs.
DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe Effective Care: Ethical Practice/Assignment, Delegation and Supervision 9. With regard to an obstetric litigation case, a nurse working in labor and
birth is found to be negligent. Which intervention performed by the nurse indicates that a breach of duty has occurred?
a. The nurse did not document fetal heart tones (FHR) during
the second stage of labor.
b. The patient was only provided ice chips during the labor
period, which lasted 8 hours.
c. The nurse allowed the patient to use the bathroom rather than a
bedpan during the first stage of labor. d. The nurse asked family members to leave the room when she prepared to do a pelvic exam on the patient. ANS: A
A breach of duty has occurred when a nurse or health care provider fails to provide treatment relative to the standard of care. In this case, documentation of FHR during the second stage of labor is a recognized standard of care. Providing ice chips to laboring patients is within the standard of care. The time period of 8 hours is not excessive. A patient without any risk factors can use the bathroom and be ambulatory during the first stage of labor. Asking family members to leave during a vaginal exam helps maintain patient privacy. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities 10. A nurse is working with an active labor patient who is in preterm labor
and has been designated as high risk. The patient is very apprehensive and asks the nurse, “Is everything going to be all right?” The nurse replies, “Yes, everything will be okay.” Following delivery via an emergency cesarean birth, the newborn undergoes resuscitation and does not survive. The patient is distraught over the outcome and blames the nurse for telling her that everything would be okay. Which ethical principle did the nurse violate? a. Autonomy . b. Fidelity c. Beneficence d. Accountability ANS: B
In this type of situation, the nurse (and/or health care provider) cannot make statements or promises that cannot be kept. Telling the patient that everything will be okay is not based on the accuracy of medical diagnosis and should not be conveyed to the patient. The other ethical principles of autonomy (self-determination), beneficence (greatest good), and accountability (accepting responsibility) do not apply in this situation. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities 11. A nurse is working in the area of labor and birth. Her assignment is to
take care of a gravida 1 para 0 woman who presents in early labor at term. Vaginal exam reflects the following: 2 cm, cervix posterior, –1 station, and vertex with membranes intact. The patient asks the nurse if she can break her water so that her labor can go faster. The nurse’s response, based on the ethical principle of nonmaleficence, is which of the following?
a. Tell the patient that she will have to wait until she has
progressed further on the vaginal exam and then she will perform an amniotomy. b. Have the patient write down her request and then call the physician for an order to implement the amniotomy. c. Instruct the patient that only a physician or certified midwife can perform this
procedure. d. Give the patient an enema to stimulate labor. ANS: C
The ethical principle of nonmaleficence conveys the concept that one should avoid risk taking or harm to others. The procedure of amniotomy is performed by a physician and/or certified nurse midwife. It is not in the scope of practice of an RN, so option C validates that the nurse is upholding this ethical principle. Options A and B are not within the scope of practice. The use of an enema as a labor stimulant is no longer considered necessary during labor. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities 12. A nurse working in a labor and birth unit is asked to take care of two high-
risk patients in the labor and birth suite: a 34 weeks’ gestation 28-year-old gravida 3, para 2 in preterm labor and a 40-year-old gravida 1, para 0 who is severely preeclamptic. The nurse refuses this assignment telling the charge nurse that based on individual patient acuity, each patient should have one-on-one care. Which ethical principle is the nurse advocating? a. Accountability b. Beneficence c. Justice d. Fidelity ANS: B
In this situation, the patients are each exhibiting significant high-risk conditions and should receive individual nursing care. The nurse is advocating the principle of beneficence in that she is trying to do the “greatest good or the least harm” to improve patient outcomes. The other ethical principles do noNt aUpRplSyIinNtGhiTs sBit.uaCtiOonM. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities 13. A charge nurse is working on a postpartum unit and discovers that one of
the patients did not receive AM care during her shift assessment. The charge nurse questions the nurse assigned to provide care and finds out that the nurse thought “the patient should just do it by herself because she will have to do this at home.” On further questioning of the nurse, it is determined that the rest of her assigned patients were provided AM care. The assigned nurse has violated which ethical principle? a. Justice b. Truth c. Confidentiality d. Autonomy ANS: A
The ethical principle of justice indicates that all patients should be treated equally and fairly. In this case, the charge nurse ascertained that the AM care was not equally applied to all the nurse’s assigned patients. The other ethical principles do not apply to this situation.
DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe Effective Care: Legal Rights and Responsibilities
14. A nurse is entering information on the patient’s electronic health record
(EHR) and is called to assist in an emergency situation with regard to another patient in the labor and birth suite. The nurse rushes to the scene to assist; however, she leaves the chart open on the computer screen. The emergent patient situation is resolved satisfactorily, and the nurse comes back to the computer entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with the nurse and tells her that she is concerned with what happened today on the unit because there was a breach in confidentiality. Which response by the nurse indicates that she understands the nurse manager’s concerns? a. The nurse acknowledges that she should have made sure that her patient was safe before assisting with the emergency. b. The nurse states that she should have logged out of the EHR prior to attending to the emergency. c. The nurse indicates that the unit was understaffed. d. The nurse indicates that the she changed her password following the clinical emergency to maintain confidentiality. ANS: B
With the use of electronic health records, it is necessary to take all steps to maintain confidentiality and limit access to nonhealth care personnel. In an emergent care situation, the nurse should have logged out of the system to maintain confidentiality. Although it is important to make sure that one’s patient is safe, there is no information here to suggest that there were any safety issues applicable to her assigned patient. The staffing of the unit should not affect confidentiality. Changing the password for logging in to a system is an option for clinical practice but does not affect the situation as described. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe EffeNctivRe CaIre: LGegaBl R.iCghtsMand Responsibilities
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15. A nurse is admitting a patient to the labor and birth unit in early labor that
was sent to the facility following a checkup with her health care provider in the office. The patient is a gravida 1, para 0, and is at term. No health issues are discerned from the initial assessment, and the nurse prepares to initiate physician orders based on standard procedures. Which action by the nurse manager is warranted in this situation? a. No action is indicated because the nurse is acting within the scope of practice. b. The nurse manager should intervene and ask the nurse to clarify admission orders directly with the physician. c. The nurse manager should review standard procedures with the nurse to validate that orders are being carried out accurately. d. The nurse manger should review the admission procedure with the nurse. ANS: A
Standard procedures are often used in labor and birth settings because they are based on physician-directed orders that apply to general admissions. The nurse is acting appropriately since the patient was sent directly to the unit, by the health care provider. The nurse manager does
not have to intervene at this point. There is no additional need to review standard procedures or the admission process with the nurse at this time. There is no evidence that the nurse needs additional training and/or does not have the prerequisite knowledge to admit the patient. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance
16. A nurse who works in the emergency department (ED) is assigned to a
patient who is experiencing heavy vaginal bleeding at 12 weeks’ gestation. An ultrasound has confirmed the absence of a fetal heart rate, and the patient is scheduled for a dilation and evacuation of the pregnancy. The nurse refuses to provide any further care for this patient based on moral principles. What is the nurse manager’s initial response to the nurse? a. “I recall you sharing that information in your interview. I will arrange for another nurse to take report on this patient.” b. “Because we are shorthanded today, you have to continue to provide care. There is no one else available to provide care for this patient.” c. “I understand your point of view. You were hired to work here in the ED so you had to know this situation was possible.” d. “Abandonment is a serious issue. I have to advise you to continue to provide care for this patient.” ANS: A
Nurses do not have to provide care if the care is in violation of their moral, ethical, or religious principles. It is the responsibility of the nurse to share these views at the time of the initial interview. Disclosing beliefs that would affect the care of patients at the point of care and refusing to provide care is unethical on behalf of the nurse. The manager cannot force the nurse to provide care if the nurse’s principles were shared at the time of the initial interview. It is the manager’s responsibility to disclose the type of care delivered in the department at the time of the interview. Threats of abandonment are unwarranted at this time. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance
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17. The nurse is providing care to
M
jOus t admitted to the labor and birth unit in active labor at term. The patient informed the nurse, “I have not received any prenatal care because I cannot afford to go to the doctor. And, this is my third baby, so I know what to expect.” What is the nurse’s primary concern when developing the patient’s plan of care? a. Low birth weight b. Oligohydramnios c. Gestational diabetes d. Gestational hypertension ANS: A
Due to adverse living conditions, poor health care, and inadequate nutrition, infants born to low-income women are more likely to begin life with problems such as low birth weight. Oligohydramnios is a condition where there is too little amniotic fluid and is not directly correlated with poverty. While gestational diabetes and gestational hypertension are associated with poverty, they can be seen during any pregnancy. This patient is in active labor and the primary concern at this time is the fetus.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance 18. A nurse is reviewing evidence-based teaching and learning principles.
Which situation is most conducive to learning with patients of other cultures? a. An auditorium is being used as a classroom for 300 students. b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
c. A class is composed of students of various ages and educational
backgrounds.
d. An Asian nurse provides nutritional information to a group of
pregnant Asian women.
ANS: D
A patient’s culture influences the learning process; thus a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the patient’s cultural beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher cannot see nonverbal cues from the students to ensure understanding. The ability to understand the language in which teaching is done determines how much the patient learns. Patients for whom English is not their primary language may not understand idioms, nuances, slang terms, informal usage of words, or medical terms. The teacher should be fluent in the language of the student. Developmental levels and educational levels influence how a person learns best. For the teacher to present the information in the best way, the class should be at the same level. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychosocial Integrity 19. The nurse is teaching a parenting class to new parents. Which
statement should the nurse include in the teaching session about the characteristics of a healthy family? a. Adults agree on the majority of basic parenting principles. b. The parents and children have rigid assignments for all the family tasks. c. Young families assume total responsibility for the parenting tasks, refusing any assistance. d. The family is overwhelmed by the significant changes that occur as a result of childbirth. ANS: A
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Adults in a healthy family communicate with each other, so there is minimal discord in areas such as discipline and sleep schedules. Healthy families remain flexible in their role assignments. Members of a healthy family accept assistance without feeling guilty. Healthy families can tolerate irregular sleep and meal schedules, which are common during the months after childbirth. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 20. A patient who is 6 months pregnant has sought medical attention, saying
she fell down the stairs. Which scenario would cause an emergency department nurse to suspect that the woman has been battered? a. She avoids making eye contact and is hesitant to answer questions. b. The woman and her partner are having an argument that is loud and hostile. c. The woman has injuries on various parts of her body that are in different stages of healing.
d. Examination reveals a fractured arm and fresh bruises. Her
husband asks her about her pain.
ANS: C
The battered woman often has multiple injuries in various stages of healing. It is more normal for the woman to have a flat affect. A loud and hostile argument is not always an indication of battering. Often the batterer will be attentive and refuse to leave the woman’s bedside. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Psychosocial Integrity 21. Which situation is most representative of an extended family? a. It includes adoptive children. b. It is headed by a single-parent. c. It contains children from previous marriages. d. It is composed of children, parents, and grandparents living in the same
house. ANS: D
An extended family is defined as a family having members from three generations living under the same roof. A family with adoptive children is a nuclear family. A single-parent family is headed by a single parent. A blended family is one that contains children from previous marriages. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 22. The nurse is reviewing the principles of family-centered care with a
primiparous patient. Which patient statement will the nurse need to correct? a. “Remaining focused on my family will help benefit me and my baby.” b. “Most of the time, childbirth is uncomplicated and a healthy event for the family.” c. “Because childbirth is normal, after my baby’s birth our family . dynamics will not change.” d. “With correct information, I am able to make decisions regarding my health care while I am pregnant.” ANS: C
The birth of an infant alters family relationships and structures; family dynamics will change with the birth of an infant. Childbirth is usually a normal and healthy event. Given professional support and guidance, the pregnant woman is able to make decisions about her prenatal care. Maintaining a focus on family or other support can benefit a woman as she seeks to maintain her health throughout pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance 23. Which issue is a major concern among members of lower socioeconomic
groups? a. Practicing preventive health care b. Meeting health needs as they occur c. Maintaining an optimistic view of life d. Maintaining group health insurance for their families
ANS: B
Because of their economic uncertainty, lower socioeconomic groups place more emphasis on meeting the needs of the present rather than on future goals. Lower socioeconomic groups may value health care but generally cannot afford preventive health care. They may struggle for basic needs and often do not see a way to improve their situation. It is difficult to maintain optimism. Lower socioeconomic groups usually do not have group health insurance. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 24. While teaching an Asian patient regarding prenatal care, the nurse
notes that the patient refuses to make eye contact. Which is the most likely cause for this behavior? a. A submissive attitude b. Lack of understanding c. Embarrassment about the subject d. Cultural beliefs about eye contact ANS: D
The nurse must understand that making eye contact means different things in different cultures. The nurse should have a basic understanding of normal responses of various cultures within her community. Asians believe that eye contact shows disrespect, not submission. Many Asian women may nod and smile during patient teaching; however, this does not indicate understanding. They are responding that they heard you; therefore validation of information is important. Concerns regarding modesty are more common among Muslim women. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Psychosocial Integrity
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25. The nurse in labor and birth is caring for a Muslim patient during the active
phase of labor. The nurse notes that the patient quickly draws away when touched. Which intervention should the nurse implement? a. Ask the charge nurse to reassign you to another patient. b. Assume that she does not like you and decrease your time with her. c. Continue to touch her as much as you need to while providing care. d. Limit touching to a minimum because physical contact may not be acceptable in her culture. ANS: D
Touching is an important component of communication in various cultures; however, if the patient appears to find it offensive, the nurse should respect her cultural beliefs and limit touching her. Asking the charge nurse to reassign you could be offensive to the patient. A Muslim’s response to touch does not reflect like or dislike. By continuing to touch her, the nurse is showing disrespect for the patient’s cultural beliefs. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Psychosocial Integrity 26. Which patient may require more help and understanding when
integrating the newborn into the family? a. A primipara from an upper income family b. A primipara who comes from a large family
c. A multipara (gravida 2) who has a supportive husband and mother d. A multipara (gravida 6) who has two children younger than 3 years ANS: D
Pregnancy tasks are more complex for the multipara (gravida 6), and she may need special assistance to integrate the infant into the family structure. A primipara from an upper income family has the financial resources to assist her with daily care of the home. This leaves her free to concentrate on the newborn’s needs. The primipara with a large support system has help available to her. The multipara (gravida 2) who has a supportive husband and mother has a support system to assist with integrating the infant into the family structure. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 27.
A patient arrives to the clinic 2 hours late for her prenatal appointment. This is the third time she has been late. What is the nurse’s best action in response to this patient’s tardiness? a. Ask the patient if she has a way to tell the time. b. Ask the patient if she is deliberately being late for her appointments. c. Determine if the patient wants this baby and if this is her way of acting out. d. Determine if the patient arrives after the start time for other types of appointments. ANS: D
Time orientation is viewed differently by other cultures. Native Americans, Middle Easterners, Hispanics, and American Eskimos tend to emphasize the moment rather than the future. This causes conflicts in the health care setting, in which tests or appointments are scheduled at particular times. If a woman does not place the same importance on keeping appointments, she may encounter anger and frustration in the health care setting. Asking if she has a way to tell time does noN U S Nt ge T Rt toItheGpotBen.tiCal roMot of the problem. Asking if she is deliberately late is inconsiderate and nontherapeutic. Although her action may be an acting-out behavior, there are other considerations that must be considered first. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The clinic nurse often cares for patients who are considering an
abortion. Which responsibilities does this nurse have in regard to this issue? (Select all that apply.) a. Informing the patient about pro-life options b. Informing the patient about pro-choice support groups c. Being informed about abortion from a legal standpoint d. Being informed about abortion from an ethical standpoint
e. Recognizing that this issue may result in confusion for the patient ANS: C, D, E
Nurses have several responsibilities while caring for patients who request a termination of pregnancy. First, the nurse must be informed about the complexity of the abortion issue from a legal and an ethical standpoint and know the regulations and laws in their state. Second, the nurse must recognize that for many patients abortion is an ethical dilemma that results in confusion, ambivalence, and personal distress. Informing the patient regarding pro-life options or pro-choice support groups would not be appropriate because it is the patient’s decision and these interventions show bias on the nurse’s part. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance 2. A couple asks the nurse about the procedure for surrogate parenting.
Which correct responses should the nurse provide for this couple? (Select all that apply.) a. Donated embryos can be implanted into the surrogate mother. b. The surrogate mother needs to have carried one previous birth to term. c. You both need to be infertile to be eligible for surrogate parenting. d. Conception can take place outside the surrogate mother’s body and then implanted. e. The surrogate mother can be inseminated artificially with sperm from the intended father. ANS: A, D, E
In surrogate parenting, conception may take place outside the body using ova and sperm from the couple that wishes to become parents. These embryos are then implanted into the surrogate mother, or the surrogate mother may be inseminated artificially with sperm from the intended father. Donated embryos may also be implanted into a surrogate mother. The couple does not need to be infertile. The surrogate parent does not need to have previously carried a pregnancy to term.
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DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 3. Which actions by the nurse indicate compliance with the Health
Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) a. The nurse posts an update about a patient on Facebook. b. The nurse gives the report to the oncoming nurse in a private area. c. The nurse gives information about the patient’s status over the phone to the patient’s friend. d. The nurse logs off any computer screen showing patient data before leaving the computer unattended. e. The nurse puts any documentation with the patient’s information in the shred bin at the hospital before leaving for the day. ANS: B, D, E
HIPAA regulations provide consumers with significant power over their records, including the right to see and correct their records, the application of civil and criminal penalties for violations of privacy standards, and protection against deliberate or inadvertent misuse or disclosure. Discussions about a patient with other professionals should be restricted to those who need to know and should occur in a private location. Nurses must take care to avoid violating patient confidentiality when using electronic patient data formats. For example, nurses must promptly log off terminals when finished so that unauthorized individuals cannot gain access to the system. Shredding documentation with patient identifiers should be done before leaving the hospital. Discussing a patient’s status in any online forum is a violation of HIPAA. Giving information to a patient’s friend over the phone, without the patient’s consent, is a violation of HIPAA. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Safe and Effective Care Environment 4. In some Middle Eastern and African cultures, female genital mutilation
(female cutting) is a prerequisite for marriage. Women who now live in North America need care from nurses who are knowledgeable about the procedure and comfortable with the abnormal appearance of their genitalia. When caring for this patient, the nurse can formulate a diagnosis with the understanding that the patient may be at risk for which of the following? (Select all that apply.) a. Infection b. Laceration c. Hemorrhage d. Obstructed labor e. Increased signs of pain response ANS: A, B, C, D
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The patient is at risk for infection, laceration, hemorrhage, and obstructed labor. Female genital mutilation, cutting, or circumcision involves removal of some or all of the external female genitalia. The labia majora are often stitched together over the vaginal and urethral openings as part of this practice. Enlargement of the vaginal opening may be performed before or during the birth. The woman is unlikely to give any verbal or nonverbal signs of pain. This lack of response does not indicate lack of pain. In fact, pelvic examinations are likely to be very painful because the introitus is so small, and inelastic scar tissue makes the area especially sensitive. A pediatric speculum may be necessary, and the patient should be made as comfortable as possible. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Diagnosis MSC: Patient Needs: Psychosocial Integrity 5. A Vietnamese patient who speaks little English is admitted to the labor
and birth unit in early labor. The nurse plans to use an interpreter during an initial assessment. Which should the nurse plan to implement with regard to using an interpreter? (Select all that apply.) a. Face the interpreter when speaking. b. Listen carefully to what the patient says.
c. Speak slowly and smile when appropriate. d. Plan to use a male interpreter, even if a female interpreter is available. e. Ask the interpreter to explain exactly what is said as much as
possible, instead of paraphrasing.
ANS: B, C, E
The nurse planning to use an interpreter should listen carefully to what the patient says. The nurse should speak slowly and smile when appropriate. Ask the interpreter to explain exactly what is said instead of paraphrasing. It is preferable to use a trained female interpreter when one is available instead of a male interpreter. The nurse should directly face the patient when speaking. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychosocial Integrity
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Chapter 03: Reproductive Anatomy and Physiology Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 1. A postpartum patient who has had a vaginal birth asks the nurse, “I was
wondering if my cervix will return to its previous shape before I had the baby?” Which is the best response by the nurse? a. The cervix will now have a slit-like shape. b. The cervix will be round and smooth after healing occurs. c. The cervix will remain 50% effaced now that you have had a baby. d. The cervix will be slightly dilated to 2 cm for about 6 months. ANS: A
After vaginal birth, the external os has an irregular slit-like shape and may have tags of scar tissue. The external os of a childless woman is round and smooth; however, after a vaginal birth it will be round and smooth. During labor, the cervix effaces (thins) and dilates (opens) to allow passage of the fetus. Once the baby is born, the cervix will close and return to close to 100% effacement. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 2. The school nurse is conducting health education classes for a group of
adolescents. Which statement best describes a secondary sexual characteristic? a. Maturation of ova . b. Production of sperm c. Female breast development d. Secretion of gonadotropin-releasing hormone ANS: C
A secondary sexual characteristic is one not directly related to reproduction, such as development of the characteristic female body form. Maturation of ova is directly related to reproduction and is a primary sexual characteristic. Production of sperm is directly related to reproduction and is a primary sexual characteristic. Secretion of hormones is directly related to reproduction and is a primary sexual characteristic. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 3. Which 16-year-old female patient is most likely to experience secondary
amenorrhea? a. 5 ft 2 in, 130 lb b. 5 ft 9 in, 180 lb c. 5 ft 7 in, 96 lb d. 5 ft 4 in, 125 lb
ANS: C
Due to her height and low body weight, this adolescent is at risk of developing secondary amenorrhea. Secondary amenorrhea occurs in women who are thin and have a low percentage of body fat. Fat is necessary to make the sex hormones that stimulate ovulation and menstruation. The other patients are of sufficient height and weight to promote sex hormone production. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 4. Which characteristic best describes the levator ani? a. Division of the fallopian tube b. Collection of three pairs of muscles c. Imaginary line that divides the true pelvis and false pelvis d. Basin-shaped structure at the lower end of the spine ANS: B
The levator ani is a collection of three pairs of muscles that support internal pelvic structures and resist increases in intraabdominal pressure. The fallopian tube divisions are the interstitial portion, isthmus, ampulla, and infundibulum. The linea terminalis is the imaginary line that divides the false from the true pelvis. The basin-shaped structure at the lower end of the spine is the bony pelvis. DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 5. The nurse is describing the size and shape of the nonpregnant uterus to a
patient. Which is an accurate description? a. The nonpregnant uterus iNs tUheRsSizIeNanGdTsBha.pCe oOfMa pear. b. The nonpregnant uterus is the size and shape of a cantaloupe. c. The nonpregnant uterus is the size and shape of a grapefruit. d. The non-pregnant uterus is the size and shape of a large orange. ANS: A
The nonpregnant uterus is about 7.5 5 2.5 cm, which is close to the size and shape of a pear. A cantaloupe would be too large and is the wrong shape for the uterus. A grapefruit is too large for the nonpregnant uterus; the uterus is larger at the upper end and tapers down. An orange may be the appropriate size, but it is not the appropriate shape. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 6. If a woman’s menstrual cycle began on June 2, on which date should
ovulation mostly likely have occurred? a. June 10 b. June 16 c. June 29 d. July 5 ANS: B
June 16 would be 18 days into the cycle; ovulation should have occurred at this point. June 10 would just be 8 days into the cycle and too early for ovulation. Ovulation occurs about 12 to 14 days after the beginning of the next menstrual period in a 28-day cycle; ovulation normally occurs about 14 days before the beginning of the next period. June 29 is at the end of the cycle. July 5 would be 27 days into the cycle and about time for the next period. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 7. A patient states, “My breasts are so small. I don’t think I will be able to
breastfeed my baby.” Which is the nurse’s best response? a. “It may be difficult but you should try anyway.” b. “You can always supplement with formula.” c. “All women have about the same amount of glandular tissue necessary to secrete milk.” d. “The ability to produce breast milk depends on increased levels of estrogen and progesterone.” ANS: C
All women have 15 to 20 lobes arranged around and behind the nipple and areola. These lobes, not the size of the breast, are responsible for milk production. The size of the breasts does not ensure success or failure in breastfeeding. Supplementation decreases the production of breast milk by decreasing stimulation. Stimulation of the breast, not the size of the breast, brings about milk production. Increased levels of estrogen decrease the production of milk by affecting prolactin. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: PhysiologNicUIRntSegIritNyGTB.COM 8.
The nurse is explaining the function of the male’s cremaster muscle to a group of nursing students. Which statement accurately describes the function of the cremaster muscle? a. Assists with transporting sperm b. Aids in temperature control of the testicles c. Aids in voluntary control of excretion of urine d. Entraps blood in the penis to produce an erection ANS: B
One cremaster muscle is attached to each testicle. Its function is to bring the testicle closer to the body to warm it or allow it to fall away from the body to cool it, thus promoting normal sperm production. Seminal fluid assists with transporting sperm. The urinary meatus aids in controlling the excretion of urine. Entrapment of the blood in the penis is a result of the spongy tissue. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 9. A newly pregnant patient asks the nurse, “What is a false pelvis?”
Which statement by the nurse will best explain this anatomy to the
patient? a. It is the total anterior portion of the pelvis. b. It is considered to be the lower portion of the pelvis. c. It provides support for the internal organs and the upper part of the body.
d. It is the narrowest part of the pelvis through which a fetus will pass
during birth. ANS: C
The linea terminalis, also called the pelvic brim or iliopectineal line, is an imaginary line that divides the upper, or false, pelvis from the lower, or true, pelvis. The false pelvis provides support for the internal organs and upper part of the body. The false pelvis is the upper portion, not the total anterior portion. The lower portion of the pelvis is the true pelvis, which is most important during childbirth because it has the narrowest portion through which the fetus will pass during childbirth. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 10. The clinic nurse is reviewing breastfeeding with a pregnant patient.
Which hormone will the nurse explain is responsible for milk production after the birth of the placenta? a. Pitocin b. Prolactin c. Estrogen d. Progesterone ANS: B
During pregnancy, high levels of estrogen and progesterone produced by the placenta stimulate growth of the alveoli and ductal system to prepare them for lactation. Prolactin secretion by the anterior pituitary gland stimulates milk production during pregnancy; however, this effect is inhibited by estrogen and progesterone produced by the placenta. Inhibiting effects of estrogen and progesterone stop when the placenta is expelled after birth, and active milk production occurs in response to the infant’s suckling while breastfeeding. Pitocin is the hormone that cNauUseRs SthIe NleGt-dToBw.nCreOflMex during breastfeeding. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 11. Which hormonal effect is noted during the menstrual cycle? a. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
secretion rise during the ovulatory phase.
b. A negative feedback mechanism is exhibited by the anterior
pituitary gland and ovaries.
c. The posterior pituitary gland secretes LH. d. Estrogen secretion enhances FSH secretion. ANS: A
Levels of LH and FSH rise dramatically during the ovulatory phase and are known as the LH surge prior to ovulation. A positive feedback mechanism occurs with regard to the menstrual cycle. The anterior pituitary gland secretes LH. Estrogen secretion minimizes FSH secretion. DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential/SystemSpecific Assessments 12. A female patient who has gone through puberty and started
menstruating without any problems has developed cessation of periods after 2 years of normal cycles. Which finding would indicate a possible cause for this occurrence? a. Lag in development of secondary sexual characteristics
b. Overproduction of androgenic hormones c. Negative pregnancy test d. Clinical diagnosis of primary amenorrhea ANS: B
An overproduction of androgenic hormones may cause the development of secondary amenorrhea. This patient has progressed through puberty, which would indicate that there is no problem with the development of secondary sexual characteristics. If the patient had a positive pregnancy test, then menstruation would stop. These signs and symptoms indicate the occurrence of secondary amenorrhea. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 13. On speculum examination of the cervix, it is found to be round and
smooth. These findings suggest that the patient a. is a multipara. b. has had previous vaginal deliveries. c. is nulliparous. d. is a gravida 1, para 0. ANS: C
These findings indicate that the patient has never been pregnant and she would be classified as nulliparous. The other findings indicate that the patient is a multipara, has had vaginal deliveries, or is a gravida 1, para 0. These all refer to a patient with a positive history of pregnancy. DIF: Cognitive Level: ApplicNatioRn I GOBBJ:.CNursMing Process Step: U S N Assessment T Promotion and Maintenance: Techniques of Physical MSC: Patient Needs: Health Assessment 14. Which statement with regard to reproductive anatomy and physiology is
inaccurate? a. Female patients who are past puberty and sexually active can become pregnant even if they have not had a menstrual cycle. b. Puberty symptoms are more prominent in males than females. c. Females enter puberty earlier than their male counterparts. d. Secondary sexual characteristics develop during puberty. ANS: B
Puberty symptoms are less prominent in developing males than females. The other statements are correct. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 15. The nurse is reviewing normal female development with a mother of a 10-
year-old daughter. The mother states, “I noticed that my daughter developed breast buds about a year ago. When do you think she will start her menstrual cycle?” What is the nurse’s best response? a. “In about a year.”
b. “Likely any time now.” c. “Does your daughter know what to expect?” d. “It is impossible to predict when she will start her cycle.”
ANS: A
Menarche occurs about 2 to 2.5 years after breast development. Asking the mother if her daughter knows what to expect is a vague response that does not answer the mother’s question. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 16. The middle school nurse is reviewing the phases of the endometrial
cycle with a group of female students. Which statement by a student will the nurse need to correct? a. “The proliferative phase occurs when the ovum is maturing.” b. “The expulsion phase occurs when the ovum is discharged from the ovary.” c. “The secretory phase occurs during the second half of the menstrual cycle.” d. “The menstrual phase occurs after the levels of estrogen and progesterone fall.” ANS: B
The menstrual cycle has only three phases: proliferative, secretory, and menstrual. Occurrences of each of the three phases have been described. There is no expulsion phase in the menstrual cycle. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A young female patient comes to the health unit at school to discuss her
irregular periods. In providing education regarding the female N R I G reproductive cycle, the nurse describes the regular and recurrent changesB.C related toUthe ovNarieTs and thOe uterine endometrium. Although this is generally referred to as the menstrual cycle, the ovarian cycle includes which phases? (Select all that apply.) a. Follicular b. Ovulatory c. Luteal d. Proliferative e. Secretory ANS: A, B, C
The follicular phase is the period during which the ovum matures. It begins on day 1 and ends around day 14. The ovulatory phase occurs near the middle of the cycle, about 2 days before ovulation. After ovulation and under the influence of the luteinizing hormone, the luteal phase corresponds with the last 12 days of the menstrual cycle. The proliferative and secretory phases are part of the endometrial cycle. The proliferative phase takes place during the first half of the ovarian cycle when the ovum matures. The secretory phase occurs during the second half of the cycle when the uterus is prepared to accept the fertilized ovum. These are
followed by the menstrual phase if fertilization does not occur. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance
2. The school nurse is conducting health education classes for a group of
adolescent girls. Select the actions of the estrogen hormone that the nurse should include in the lessons. (Select all that apply.) a. Stimulates contractions during birth b. Relaxes pelvic ligaments during pregnancy c. Stimulates the endometrium before ovulation d. Stimulates growth of uterus during pregnancy e. Stimulates the let-down reflex during breastfeeding ANS: B, C, D
The hormone estrogen relaxes pelvic ligaments during pregnancy, stimulates the endometrium before ovulation, and stimulates the growth of the uterus during pregnancy. Oxytocin stimulates contractions during pregnancy and stimulates the let-down reflex during breastfeeding. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance COMPLETION 1. Delayed onset of menstruation or primary amenorrhea is considered if
the girl’s periods have not begun by which age in years? Record your answer in a whole number. _ ANS:
16 Delayed onset of menstruatio calIled GprimBa.ryCamMenorrhea NNn isRwithin if the girl’s periods haveUnotSbegun 2 years after the onset of breast development or by age 16, T or if the girl is more than 1 year older than her mother or sisters were when their menarche occurred. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance
Chapter 04: Hereditary and Environmental Influences on Childbearing Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 1. A clinic nurse is planning a teaching session for childbearing-age female
patients. Which information should the nurse include in the teaching session with regard to avoiding exposing a fetus to teratogens? a. Eliminate use of acne medications. b. Immunizations should be updated during the first trimester of pregnancy. c. Use of saunas and hot tubs during pregnancy should be during the winter months only. d. Alcoholic beverages can be consumed in the first and third trimesters of pregnancy. ANS: A
Elimination of nontherapeutic drugs is the best action to avoid teratogen exposure. Acne medication is not essential during pregnancy. Immunizations for diseases such as rubella are contraindicated during pregnancy. Use of saunas and hot tubs are not recommended because maternal hyperthermia is a significant teratogen. Alcohol is an environmental substance known to be teratogenic and should not be consumed during pregnancy. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance 2. The parents of a child with a karyotype of 47,XY,+21 ask the nurse what
N R I G B.C M
this means. Which is the most accurate response by Uthe SnursNe? T
O
a. b. c. d.
This karyotype is for a normal male. This karyotype is for a normal female. This karyotype is for a male with Down syndrome. This karyotype is for a female with Turner’s syndrome.
ANS: C
This child is male because his sex chromosomes are XY. He has one extra copy of chromosome 21 (for a total of 47, instead of 46), resulting in Down syndrome. A normal female would have 46 chromosomes and XX for the sex chromosomes. A normal male would have 46 chromosomes. A female with Turner’s syndrome would have 45 chromosomes; the sex chromosome would have just one X. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Physiologic Integrity 3. People who have two copies of the same abnormal autosomal dominant
gene are generally
a. mildly affected with the disorder. b. infertile and unable to transmit the gene.
c. carriers of the trait but not affected with the disorder. d. more severely affected by the disorder than people with one copy of the
gene.
ANS: D
People who have two copies of an abnormal gene are usually more severely affected by the disorder because they have no normal gene to compensate and maintain normal function. Those mildly affected with the disorder will have only one copy of the abnormal gene. Infertility may or may not be caused by chromosomal defects. A carrier of a trait has one recessive gene. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 4. An infant is born with blood type AB. The father is type A and the
mother is type B. The father asks why the baby has a blood type different from that of the parents. The nurse’s answer should be based on the knowledge that a. both A and B blood types are dominant. b. types A and B are recessive when linked together. c. the baby has a mutation of the parents’ blood types. d. type A is recessive and links more easily with type B. ANS: A
Types A and B are equally dominant, and the baby can thus inherit one from each parent. Both types A and B are dominant, not recessive. The infant has inherited both blood types from the parents and this is not a mutation. Both blood types A and B are equally dominant. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 5. Which statement regarding multifactorial disorders is correct? a. They may not be evident until later in life.
b. They are usually present NanUdRdSeteIcNtaGblTe Bat.bCirtOh.M c. The disorders are characterized by multiple defects. d. Secondary defects are rarely associated with them. ANS: B
Multifactorial disorders result from an interaction between a person’s genetic susceptibility and environmental conditions that favor development of the defect. They are characteristically present and detectable at birth. They are usually single isolated defects, although the primary defect may cause secondary defects. Secondary defects can occur with multifactorial disorders. DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 6. Which information should the nurse include when discussing the prenatal
diagnosis of genetic disorders with an expectant couple? a. The diagnosis may be slow and could be inconclusive. b. A comprehensive evaluation will result in an accurate diagnosis. c. Common disorders can be quickly diagnosed through blood tests. d. Diagnosis can be obtained promptly through most hospital laboratories. ANS: A
Even the best efforts at diagnosis do not always yield the information needed to counsel the patient. The process may require many visits over several weeks. Some tests must be sent to special laboratories, which take additional time. Despite a comprehensive evaluation, a diagnosis may never be established. At this time there are no rapid result blood tests available to diagnose genetic disorders. Some tests must be sent to a special laboratory, which requires a longer waiting period for results. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 7. A patient tells the nurse at a prenatal interview that she has quit
smoking, and only has one glass of wine with dinner. Which response by the nurse will be most helpful in promoting a lifestyle change? a. “Those few things won’t cause any trouble. Good for you.” b. “You need to do a lot better than that. You are still hurting your baby.” c. “Here are some pamphlets for you to study. They will help you to find more ways to improve.” d. “You have made some good progress toward having a healthy baby. Let’s talk about the changes you have made.” ANS: D
Praising her for making positive changes is an effective technique for motivating a patient. She still has risk factors to alter for optimal outcome, and a gentle maneuver to help her see these for herself will be most likely to succeed. Alcohol consumption is still a major risk factor and needs to be addressed in a positive, nonjudgmental manner. The statement, “You need to do a lot better” is belittling to the patient; she will be less likely to N R I G confide in the nurse. The nurse is not acknowledging the efforts that the B.C patient has already accomplished by offering pamphlets; those accoUmplSishmNenTts need Oto be praised to motivate the patient to continue. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 8. A 35-year-old patient has an amniocentesis performed to identify
whether her baby has a chromosomal defect. Which statement indicates that the patient understands the situation? a. “The doctor will tell me if I should have an abortion when the test results come back.” b. “When all the lab results come back, my husband and I will make a decision about the pregnancy.” c. “My mother must not find out about all this testing. If she does, she will think I’m having an abortion.” d. “I know there are support groups for parents who have a baby with birth defects, but we have plenty of insurance to cover what we need.” ANS: B
The final decision about genetic testing and the future of the pregnancy lies with the patient. The patient will involve only those people whom she chooses. An amniocentesis is done to detect chromosomal defects; many women have this done to prepare and educate themselves for the baby’s arrival. The woman should also be assured that her care is confidential. Insurance will help cover expenses; however, a child with birth defects also takes a toll on the emotional, physical, and social aspects of the parents’ lives. Support groups are extremely important for parents of a baby with birth defects. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance 9. Which characteristic is related to Down syndrome? a. Up-slanting eyes b. Abnormal genitalia c. Bleeding tendency d. Edema of extremities ANS: A
Up-slanting eyes, wide short fingers, and low-set ears are often seen in infants with Down syndrome. Bleeding tendency, edema of extremities, and abnormal genitalia are not characteristics of Down syndrome. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 10. Which question posed by the nurse will most likely promote the
sharing of sensitive information during a genetic counseling interview? a. “What kind of defects or NdiUseRasSeIs sNeGemTBto.ruCnOinMthe family?” b. “How many people in your family are mentally retarded or handicapped?” c. “Did you know that you can always have an abortion if the fetus is abnormal?” d. “Are there any members of your family who have learning or developmental problems?” ANS: D
The nurse should probe gently using layperson-oriented terminology, such as learning problems rather than defects or diseases. Some individuals may not be aware of which diseases are genetically linked and may not answer the question accurately. “How many people in your family are mentally retarded or handicapped?” assumes that there are genetic problems that resulted in retardation in the family. Some individuals may find these terms offensive. “Did you know that you can always have an abortion if the fetus is abnormal?” is taking the decision away from the parents. They are seeking counseling to prevent problems, not to find out what to do if there is a problem. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance
11. Testing for the cause of anomalies in a stillborn infant is underway. The
mother angrily asks the nurse how long these tests are going to take. The nurse should understand that this mother is a. exhibiting normal grief behavior. b. trying to place blame on someone.
c. being impatient and unreasonable. d. feeling guilty and blaming herself. ANS: A
Grief after a fetal loss may initially be expressed as anger. The mother is not placing blame; she is in the anger stage of the grieving process. The mother is not being impatient or unreasonable. The mother is expressing anger as an initial stage of grief, not blaming herself or feeling guilty. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Psychosocial Integrity 12. While obtaining a genetic history from a female patient, you note that
there is a family history of a genetic disease on the maternal side; however, no evidence of symptomatology in the patient or the patient’s children, two girls. Which observation can you make related to genetic expression? a. Autosomal dominant expression is observed. b. X-linked dominant trait is observed. c. More information is needed to determine the answer. d. Autosomal recessive expression is observed and both the children will be carriers of the disease process. ANS: C
Because we have no information about the father and/or paternal side, the other stated options do not apply. If an autosomal dominant expression were present in the family history, the patient would be symptomatic. Xlinked recessive traits are more common than X-linked dominant traits and, again, the patient and children are not symptomatic. Although an autosomal recessive expressi U S NNonTmRayIbe GpresBen.t,CweMcannot predict that the children will be carriers. There is a 25% chance of being affected. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Diagnosis MSC: Patient Needs: Physiologic Integrity: Pathophysiology 13. A couple is undergoing genetic counseling and are very concerned
about the possibility of having a child with a birth defect as a result of a strong family history on both sides of the family. Which statement made by the nurse is evidence of therapeutic communication? a. “It is important to ask other members of your family for any information they can provide that will help obtain more insight into the health history.” b. “Given what you have told me, there is little that anyone can do to improve outcomes.” c. “Although you may feel that you have no options, I can’t really discuss these matters as only the physician can provide you with information.” d. “Do you have all your forms filled out correctly? This will make the review easier to accomplish. ” ANS: A
Having as much information as possible will help analyze potential health outcomes. It also shows that the nurse is taking the patients’ concerns seriously. Telling the patients that there is little anyone can do does not provide any comfort or hope and is therefore self-defeating. Although the patients may have limited options based on their genetic and medical history, it is important to provide support and not defer all communication to the physician. The nurse must be able to provide support and counseling to patients. It is important to have completed forms, but asking patients about them does not address their psychological concerns. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Planning MSC: Patient Needs: Psychosocial Integrity: Therapeutic Communication 14. A patient presents with curly hair and blue eyes. These findings are
consistent with phenotype. genotype. dominant alleles. recessive traits.
a. b. c. d.
ANS: A
Curly hair is considered to be a dominant trait, whereas blue eyes are considered to be a recessive trait. Observation of characteristics is noted as phenotype. Genotype identifies the genetic makeup of traits. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential 15. The nurse is working with a patient to obtain information necessary for
genetic counseling. Which tool will be used to obtain this information? . a. Braden scale b. Genogram c. Chorionic villus sampling (CVS) d. Serum protein electrophoresis ANS: B
When obtaining information with regard to genetic counseling, it is important to obtain a family history using a genogram or pedigree as the clinical tool. The use of this diagram provides information for maternal and paternal histories and allows for the interpretation of significance based on findings of age, death, and medical history. A Braden scale is used to assess problems with skin leading to potential breakdown. CVS is a diagnostic procedure used during pregnancy to obtain genetic information about the fetus. Serum protein electrophoresis is a lab test used to determine immunoglobulin levels. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential 16. The nurse receives report on an infant whose analysis indicates 47 total
chromosomes, with the abnormality noted at chromosome 21. Which
additional assessments will the nurse include when evaluating the infant? a. Cleft palate b. Protruding tongue c. Extra fingers or toes (polydactyly) d. Intellectual developmental delay
ANS: B
Trisomy 21 is associated with a number of notable physical characteristics, including wide-set eyes, flat bridge of the nose, protruding tongue, short neck, small chin, poor muscle tone, and space between the great and second toes. An infant with trisomy 21 tends to be short in stature and developmentally delayed, but two characteristics will become more noticeable as the child gets older. Cleft palate and polydactyly are more common with trisomy 13. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 17. The patient indicates to the clinic nurse that she is trying to become
pregnant. The clinic nurse reviews the patient’s chart and notes the following laboratory values: Blood type O, RPR nonreactive, rubella nonimmune, HCT 35%. Which laboratory value is most concerning to the nurse? a. HCT 35% b. Blood type O c. RPR nonreactive d. Rubella non-immune ANS: D
Rubella non-immune indicates that the patient does not have immunity against rubella and is therefore susceptible to the infection. Exposure to rubella, or German measles, in the first trimester is associated with fetal congenital anomalies. The patient requires a rubella immunization and must not become pregnant within the next 28 days. Although a HCT of 35% is low, women of childbearing age may have mild anemia associated with menstruation. A blood type of O indicates that the patient will require Rho GAM; however, it is not of concern in the preconceptionNpUerRioSd.IANnGoTnrBea.cCtivOeMRPR indicates that the patient has not been exposed to syphilis. DIF: Cognitive Level: Synthesis OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The clinic nurse is reviewing charts on prenatal patients. Which patient
histories indicate that a referral to a genetic counselor is warranted? (Select all that apply.) a. A father who is aged 35 b. A patient having a first baby at age 30 c. A family history of unexplained stillbirths d. A patient with a family history of birth defects e. A patient who is a carrier of an X-linked disorder ANS: C, D, E
Reasons for a referral to a genetic counselor include family history of unexplained stillbirths, family history of birth defects, and a woman who
is a carrier of an X-linked disorder. Pregnant women who will be 35 years of age or older when the infant is born and men who father children after age 40 constitute reasons for referral to a genetic counselor. The patient who is 30 and the father who is aged 35 would not warrant a referral to a genetic counselor. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Health Promotion and Maintenance 2. The nurse is teaching prenatal patients about avoiding substances or
conditions that can harm the fetus. Which should the nurse include in the teaching session? (Select all that apply.) a. Elimination of use of alcohol b. Avoidance of supplemental folic acid replacement c. Stabilization of blood glucose levels in a diabetic patient with insulin d. Avoidance of nonurgent radiologic procedures during the pregnancy e. Avoidance of maternal hyperthermia to temperatures of 37.8C (100F) or higher ANS: A, C, D, E
The best action is for the pregnant woman to eliminate use of nontherapeutic drugs and substances such as alcohol. A woman who has diabetes should try to keep her blood glucose levels normal and stable before and during pregnancy for the best possible fetal outcomes. Nonurgent radiologic procedures may be done during the first 2 weeks after the menstrual period begins, before ovulation occurs. Exposure to temperatures of 37.8C (100F) or higher is not advised for the pregnant patient. Folic acid supplements should be taken. All women of childbearing age should take at least 0.4 mg (400 mcg) of folic acid daily before and after conception because this has been found to reduce the incidence of neural tube defects by 50% to 70%. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 3. The nurse is explaining genetics to a group of nursing students. Which
are autosomal recessive disorders that the nurse should discuss during the teaching session? (Select all that apply.) . a. Hemophilia b. Cystic fibrosis c. Sickle cell disease d. Turner’s syndrome e. Phenylketonuria (PKU) disease ANS: B, C, E
Cystic fibrosis, sickle cell disease, and PKU disease are autosomal recessive disorders. Hemophilia and Turner’s syndrome are X-linked genetic disorders. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance COMPLETION 1. Two healthy parents who carry the same abnormal autosomal recessive
gene have what percentage chance of having a child affected with the disorder caused by this gene? Record your answer as a whole number. %
ANS:
25
Two healthy parents who carry the same abnormal autosomal recessive gene have a 25% chance of having a child affected with the disorder caused by this gene. Unaffected parents are carriers of the abnormal autosomal recessive trait. Children of carriers have a 25% (1 in 4) chance of receiving both copies of the defective gene and thus having the disorder. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health Promotion and Maintenance
.
Chapter 05: Conception and Prenatal Development Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 1. An expectant father asks the nurse, “Which part of the mature
sperm contains the male chromosome?” What is the correct response by the nurse? a. X-bearing sperm b. The tail of the sperm c. The head of the sperm d. The middle portion of the sperm ANS: C
The head of the sperm contains the male chromosomes that will join the chromosomes of the ovum. If an X-bearing sperm fertilizes the ovum, the baby will be female. The tail of the sperm helps propel the sperm toward the ovum. The middle portion of the sperm supplies energy for the tail’s whip-like action. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 2. One of the assessments performed in the birth room is checking the
umbilical cord for blood vessels. Which finding is considered to be within normal limits? a. One artery and one vein b. Two veins and one artery c. Two arteries and one vein N veins RSINGTB.C d. Two arteries and two U ANS: C
MO
The umbilical cord contains two arteries and one vein to transport blood between the fetus and the placenta. Any option other than two arteries and one vein is considered abnormal and requires further assessment. Two veins and one artery is abnormal and may indicate an anomaly. Two arteries instead is a normal finding; this infant would require further assessment for anomalies due to the finding of two veins. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 3. What is the purpose of the ovum’s zona pellucida? a. Prevents multiple sperm from fertilizing the ovum b. Stimulates the ovum to begin mitotic cell division c. Allows the 46 chromosomes from each gamete to merge d. Makes a pathway for more than one sperm to reach the ovum ANS: A
Fertilization causes the zona pellucida to change its chemical composition so that multiple sperm cannot fertilize the ovum. Mitotic cell division
begins when the nuclei of the sperm and ovum unite. Each gamete (sperm and ovum) has only 23 chromosomes; there will be 46 chromosomes when they merge. Once sperm has entered the ovum, the zona pellucida changes to prevent other sperm from entering.
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 4. The nurse is explaining the process of cell division during the
preembryonic period to a group of nursing students. Which statement best describes the characteristics of the morula? a. Fertilized ovum before mitosis begins b. Double layer of cells that becomes the placenta c. Flattened, disk-shaped layer of cells within a fluid-filled sphere d. Solid ball composed of the first cells formed after fertilization ANS: D
The morula is so named because it resembles a mulberry. It is a solid ball of 12 to 16 cells that develops after fertilization. The fertilized ovum is called the zygote. The placenta is formed from two layers of cells—the trophoblast, which is the other portion of the fertilized ovum, and the decidua, which is the portion of the uterus where implantation occurs. The flattened, disk-shaped layer of cells is the embryonic disk; it will develop into the body. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 5. The upper uterus is the best place for the fertilized ovum to implant due
to which anatomical adaptation? a. Maternal blood flow is lower. b. Placenta attaches most firmly. c. Uterine endometrium is softer. d. Developing baby is best nourished. ANS: D
.
The uterine fundus is richly supplied with blood and has the thickest endometrium, both of which promote optimum nourishment of the fetus. The blood supply is rich in the fundus, which allows for optimal nourishment of the fetus. If the placenta attaches too deeply, it does not easily detach. Softness is not a concern with implantation; attachment and nourishment are the major concerns. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 6. Some of the embryo’s intestines remain within the umbilical cord
during the embryonic period because the a. intestines need this time to grow until week 15. b. nutrient content of the blood is higher in this location. c. abdomen is too small to contain all the organs while they are developing. d. umbilical cord is much larger at this time than it will be at the end of pregnancy. ANS: C
The abdominal contents grow more rapidly than the abdominal cavity, so part of their development takes place in the umbilical cord. By 10 weeks, the abdomen is large enough to contain them. The intestines remain within the umbilical cord only until about week 10. Blood supply is adequate in all areas; intestines stay in the umbilical cord for about 10 weeks because they are growing faster than the abdomen. Intestines begin their development within the umbilical cord, but only because the liver and kidneys occupy most of the abdominal cavity, not because of the size of the umbilical cord. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 7. A patient who is 16 weeks pregnant with her first baby asks how long it
will be before she feels the baby move. Which is the nurse’s best answer? a. “You should have felt the baby move by now.” b. “The baby is moving, but you can’t feel it yet.” c. “Some babies are quiet and you don’t feel them move.” d. “Within the next month you should start to feel fluttering sensations.” ANS: D
Maternal perception of fetal movement (quickening) usually begins between 17 and 20 weeks after conception. Because this is her first pregnancy, movement is felt toward the later part of the 17 to 20 weeks. “The baby is moving, but you can’t feel it yet” may be alarming to the woman. “Some babies are quiet and you don’t feel them move” is a true statement; the fetus’ movements are not strong enough to be felt until 17 to 20 weeks; however, this statement does not answer the woman’s concern. Fetal movement should be felt between 17 and 20 weeks; if movement is not perceptible by the end of that time, further assessment will be necessary.
N
R I G
B . C
M
DIF: Cognitive Level: Applic atUion S N OTB J: N uOrs ing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 8. Which statement best describes the changes that occur during the fetal
period of development? Maturation of organ systems Development of basic organ systems Resistance of organs to damage from external agents Development of placental oxygen–carbon dioxide exchange
a. b. c. d.
ANS: A
During the fetal period, the body systems grow in size and mature in function to allow independent existence after birth. Basic organ systems are developed during the embryonic period. The organs are always at risk for damage from external sources; however, the older the fetus, the more resistant will be the organs. The greatest risk is when the organs are developing. The placental system is complete by week 12, but that is not the best description of the fetal period. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and
Maintenance 9. An expectant mother says to the nurse, “When my sister’s baby was born,
it was covered in a cheese-like coating. What is the purpose of this coating?” The correct response by the nurse is to explain that the purpose of vernix caseosa is to a. regulate fetal temperature.
b. protect the fetal skin from amniotic fluid. c. promote normal peripheral nervous system development. d. allow the transport of oxygen and nutrients across the amnion. ANS: B
Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the skin without the protection of the vernix caseosa. The amniotic fluid aids in maintaining fetal temperature. Normal peripheral nervous system development is dependent on the nutritional intake of the mother. The amnion is the inner membrane that surrounds the fetus. It is not involved in the oxygen and nutrient exchange. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 10. An expectant mother, diagnosed with oligohydramnios, asks the nurse
what this condition means for the baby. Which statement should the nurse provide for the patient? a. Oligohydramnios can cause poor fetal lung development. b. Oligohydramnios means that the fetus is excreting excessive urine. c. Oligohydramnios could mean that the fetus has a gastrointestinal blockage. d. Oligohydramnios is associated with fetal central nervous system abnormalities. ANS: A
Because an abnormally small amount of amniotic fluid restricts normal lung development, the fetus may have poor fetal lung development. Oligohydramnios may be caused by a decrease in urine secretion. Excessive amniotic fluid production may occur when the gastrointestinal tract prevents normal ingestion of amniotic fluid. Excessive amniotic fluid production may occur when the fetus has a central nervous system abnormality.
N G B.C U RS I N T M O
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 11. The nurse is conducting a staff in-service on multifetal pregnancy. Which
statement regarding dizygotic twin development should the nurse include in the teaching session? a. Dizygotic twins arise from two fertilized ova and are the same sex. b. Dizygotic twins arise from a single fertilized ovum and are always of the same sex. c. Dizygotic twins arise from two fertilized ova and may be the same sex or different sexes. d. Dizygotic twins arise from a single fertilized ovum and may be the same sex or different sexes. ANS: C
Dizygotic twins arise from two ova that are fertilized by different sperm. They may be the same or different gender, and they may not have similar physical traits. Monozygotic twins are always the same sex. A single fertilized ovum that produces twins is called monozygotic. Dizygotic twins are from two fertilized ova and may or may not be the same sex.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 12. An infant is diagnosed with fetal anemia. Which information would
support this clinical diagnosis?
a. Presence of excess maternal hormones
b. Maternal blood type O-negative, Rh-negative, and infant blood type O-
negative, Rh-negative c. Passive immunity d. Rh-negative mother and Rh-positive baby ANS: C
Passive immunity provides temporary protection to the baby based on the transfer of maternal antibodies. Maternal hormones would not lead to a clinical diagnosis of fetal anemia. These blood types and Rh factors are the same; therefore, no antibodies will be created. In this situation, an Rhnegative mother and Rh-positive baby will result in stimulation of antibodies that will stimulate a reaction leading to hemolysis. DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity/Reduction of Risk Potential 13. The nurse is explaining the function of the placenta to a pregnant
patient. Which statement indicates to the nurse that further clarification is necessary? a. “My baby gets oxygen from the placenta.” b. “The placenta functions to help excrete waste products.” c. “The nourishment that I take in passes through the placenta.” d. “The placenta helps maintain a stable temperature for my baby.” ANS: D
Amniotic fluid and not the placenta helps with thermoregulation. The remaining statements are correct regarding placental function. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Evaluation MSC: Patient Needs: Health PrNom
UoRtiSonIaNndGMTaBin.teCnaOncMe
14. The nurse is assessing a newborn immediately after birth. After assigning
the first Apgar score of 9, the nurse notes two vessels in the umbilical cord. What is the nurse’s next action? a. Assess for other abnormalities of the infant. b. Note the assessment finding in the infant’s chart. c. Notify the health care provider of the assessment finding. d. Call for the neonatal resuscitation team to attend the infant immediately. ANS: A
The normal finding in the umbilical cord is two arteries and one vein. Two vessels may indicate other fetal anomalies. Notation of the finding is the appropriate next step when the finding is expected. The health care provider will need to be notified; however, the infant is the nurse’s primary concern and must be assessed for abnormalities first. The initial Apgar score is 9, indicating no signs of distress or need of resuscitation. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance 15. A pregnant patient asks the nurse how her baby gets oxygen to
breathe. What is the nurse’s best response? a. “Oxygen-rich blood is delivered through the umbilical vein to the baby.” b. “Take lots of deep breaths because the baby gets all of its oxygen from you.” c. “You don’t need to be concerned about your baby getting enough oxygen.” d. “The baby’s lungs are not mature enough to actually breathe, so don’t worry.”
Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
ANS: A
Oxygen-rich blood travels from the mother’s circulatory system to the placenta and from the placenta to the umbilical vein (veins carry blood to the heart). From the vein, most of the oxygenated blood travels to the fetal liver or the inferior vena cava. Taking deep breaths can temporarily increase oxygenation but can also lead to increased carbon dioxide retention and dizziness. The patient is asking a normal fetal developmental question often asked by pregnant women. Fetal lungs reach maturity by 37 weeks of gestation, but fetal breathing movements are common. Oxygen transport across lung tissue occurs with the first breath. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which physical characteristics decrease as the fetus nears term? (Select all
that apply.) Vernix caseosa Lanugo Port wine stain Brown fat Eyebrows or head hair
a. b. c. d. e.
ANS: A, B
Both vernix caseosa and lanugo decrease as the fetus reaches term. Port wine stain is a birthmark and, if present, will be exhibited at or shortly after birth. Brown fat in the fetus will be maintained in order to maintain core temperature. Eyebrows and head hair increase as the fetus nears term.
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DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 2. Along with gas exchange and nutrient transfer, the placenta produces
many hormones necessary for normal pregnancy, including which of the following? (Select all that apply.) a. Insulin b. Estrogen c. Progesterone d. Testosterone e. Human chorionic gonadotropin (hCG) ANS: B, C, E
HCG causes the corpus luteum to persist and produce the necessary estrogens and progesterone for the first 6 to 8 weeks. Estrogens cause enlargement of the woman’s uterus and breasts and growth of the ductal system in the breasts and, as term approaches, plays a role in the initiation of labor. Progesterone causes the endometrium to change, providing early nourishment. Progesterone also protects against spontaneous abortion by suppressing maternal reactions to fetal antigens
and reduces unnecessary uterine contractions. Other hormones produced by the placenta include hCT, hCA, and a number of growth factors. Insulin and testosterone are not secreted by the placenta. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Health Promotion and Maintenance
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Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
3. The nurse is planning a prenatal class on fetal development. Which
characteristics of prenatal development should the nurse include for a fetus of 24 weeks, based on fertilization age? (Select all that apply.) a. Ear cartilage firm b. Skin wrinkled and red c. Testes descending toward the inguinal rings d. Surfactant production nears mature levels e. Fetal movement becoming progressively more noticeable ANS: B, C, E
A fetus of 24 weeks, based on fertilization age, will have wrinkled and red skin, testes descending toward inguinal rings, and the fetal movement becoming progressively more noticeable. Surfactant production nearing the mature levels does not occur until 32 weeks and ear cartilage is not firm until 38 weeks. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning MSC: Patient Needs: Health Promotion and Maintenance 4. The nurse is explaining fetal circulation to a group of nursing students.
Which information should be included in the teaching session? (Select all that apply.) a. After birth the ductus venosus remains open, but the other shunts close. b. The foramen ovale shunts blood from the right atrium to the left atrium. c. The ductus venosus shunts blood from the liver to the inferior vena cava. d. The ductus arteriosus shunts blood from the right ventricle to the left ventricle. ANS: B, C
The foramen ovale shunts U ox S NNygeTRnateId bGloodBf.roCm tMhe right atrium to the left atrium, bypassing the lungs. The ductus venosus shunts oxygenated blood from the liver to the inferior vena cava. All shunts close after birth. The ductus arteriosus shunts blood from the right ventricle to the aorta. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance 5. A nurse is conducting prenatal education classes for a group of
expectant parents. Which information should the nurse include in her discussion of the purpose of amniotic fluid? (Select all that apply.) a. Cushions the fetus b. Protects the skin of the fetus c. Provides nourishment for the fetus d. Allows for buoyancy for fetal movement e. Maintains a stable temperature for the fetus ANS: A, D, E
The amniotic fluid provides cushioning for the fetus against impacts to the maternal abdomen. It provides a stable temperature and allows room and buoyancy for fetal movement. Vernix caseosa, the cheeselike coating on the fetus, provides skin protection. The placenta provides nourishment for the fetus.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation MSC: Patient Needs: Health Promotion and Maintenance
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Chapter 06: Maternal Adaptations to Pregnancy Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 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 2. A pregnant woman has come to the emergency department with
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complaints of nasal congestion and epistaxis. WhicUh isStheNcorTrect B.C inteOrpretation 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
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 4. What is the physiologic reason for vascular volume increasing by
40% to 60% during pregnancy? Prevents maternal and fetal dehydration Eliminates metabolic wastes of the mother Provides adequate perfusion of the placenta Compensates for decreased renal plasma flow
a. b. c. d.
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 thNeUinRcSreIasNedGvTaBsc.ulCarOvMolume. Renal plasma flow increases during pregnancy. DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment MSC: Patient Needs: Physiologic Integrity 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
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 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: PhysiologNic
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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 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 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.
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d. Contact the physician and
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 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 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.
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constipation during the pregnancy? Increased emptying time in the intestines Abdominal distention and bloating Decreased absorption of water Decreased motility in the intestines
a. b. c. d.
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 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 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: PhysiologNic
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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
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 18. Which comment made by a patient in her first trimester indicates
ambivalent feelings? “My body is changing so quickly.” “I haven’t felt well since this pregnancy began.” “I’m concerned about the amount of weight I’ve gained.” “I wanted to become pregnant, but I’m scared about being a mother.”
a. b. c. d.
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. TNheUwRoSmIaNn GisTtrByi.ngCtOo Mconfirm 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 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
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? Fantasy Grief work Role playing Looking for a fit
a. b. c. d.
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 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
Rst trIimeGsterBan.dCproMgressing to Developing a strong tie in U the SN NfirT 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 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 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:
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Unders taUnd inSg N OTB J: N uOrs ing Process Step: Assessment 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
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 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 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 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
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1. The nurse is assessing a patient in her 38th 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
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, U and S NNChTRadwIickG’s sBig.n Care Mpresumptive 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 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
Chapter 07: Antepartum Assessment, Care, and Education Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition MULTIPLE CHOICE 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. What is the rationale for a woman in her first trimester of pregnancy
to expect to visit her health care provider every 4 weeks? Problems can be eliminated. She develops trust in the health care team. Her questions about labor can be answered. The conditions of the exp ecta nt m oth er an d fetu s can be N R I G B . C M monitored.
a. b. c. d.
ANS: D
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O
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. 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
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 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 umbilicus at 20 weeks, so 3 cm below the umbilicus is an inappropriate height and needs further assessment. This is lower U tha S NNn ex T RpecItedGat thBi.s dCateM. 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 6. Which complaint made by a patient at 35 weeks of gestation requires
additional assessment? Abdominal pain Ankle edema in the afternoon Backache with prolonged standing Shortness of breath when climbing stairs
a. b. c. d.
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 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 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 wNoUmReSn.INGTB.COM DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment 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 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 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? Multigravida Multipara Nullipara Primigravida
a. b. c. d.
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 moNrUe.
RASpIriNmGipTarBa .haCs OdeMlivered 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 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
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. G5 T1 P2 A2 L 2 b. G5 T1 P1 A1 L2 c. G5 T0 P2 A2 L2 d. G5 T1 P1 A2 L2 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 14. Use Nägele’s rule to determine the EDD (estimated day of birth) for a
patient whose last menstrual period started on April 12. February 19 January 19 January 21 February 7
a. b. c. d.
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 answNeUr iRs SJaInuNaGryT1B9.oCf tOheMfollowing calendar year. DIF: Cognitive Level: Application OBJ: Nursing Process Step: Analysis MSC: Patient Needs: Health Promotion and Maintenance 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
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 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 occNuUrsR. SINGTB.COM DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning MSC: Patient Needs: Physiologic Integrity: Reduction of Risk Potential 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 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 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 U S NNareRdisIcussGed Bin.aCchiMldbirth preparation class. The phases and stages of labor are usually covered in a T Cesarean birth preparation classes discuss childbirth preparation class. 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 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
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 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 planUshou S N N ldTRbe eIducGatedBt.haCt fleMxibility 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 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
25. Which technique would provide the best pain relief for a pregnant
woman with an occiput posterior position? Neuromuscular disassociation Effleurage Psychoprophylaxis Sacral pressure
a. b. c. d.
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 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 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 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 U viruSNsNvaT RccinIes sGuchBa.s CMMMR, 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 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
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