TEST BANK. Maternity Newborn and Women’s Health Nursing A Case-Based Approach 1st Edition O’Meara. C by QuentinAxel

Maternity Newborn and Women’s Health Nursing A Case-Based Approach 1st Edition Maternity Newborn and Women’s Health Nursing A Case-Based Approach 1st Edition O’Meara Test Bank O’Meara Test Bank Chapter 1 Immediate Postpartum Hemorrhage

MULTIPLE CHOICE 1. A pregnant woman is being discharged from the hospital after the placement of a cervical cerclage because of a history of recurrent pregnancy loss, secondary to an incompetent cervix. Which information regarding postprocedural care should the nurse emphasize in the discharge teaching? a. Any vaginal discharge should be immediately reported to her health care provider. b.

The presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should

The client will need to make arrangements for care at home, because her activity level will be restric

The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by mea hormone that your body produces during pregnancy. If you were to get pregnant, then it would mak this cancer more difficult. If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy improve your chance of a successful pregnancy, not getting pregnant at this time is best.

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d. The client will be scheduled for a cesarean birth. ANS: B Nursing care should stress the importance of monitoring for the signs and symptoms of preterm labor. Vaginal bleeding needs to be reported to her primary health care provider. Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, which allows her the freedom to see her physician. Home uterine activity monitoring may be used to limit the womans need for visits and to monitor her status safely at home. The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean birth can be planned. DIF: Cognitive Level: Apply REF: dm. 675 TOP: Nursing Process: Planning | Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. A perinatal nurse is giving discharge instructions to a woman, status postsuction, and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. What is the bestresponse by the nurse? If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if y a. pregnancy, it would be better for you to use the most reliable method of contraception available.

d. Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregn ANS: B Betahuman chorionic gonadotropin (beta-hCG) hormone levels are drawn for 1 year to ensure that the mole is completely gone. The chance of developing choriocarcinoma after the development of a hydatidiform mole is increased. Therefore, the goal is to achieve a zero human chorionic gonadotropin (hCG) level. If the woman were to become pregnant, then it may obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy

for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device (IUD) is acceptable. DIF: Cognitive Level: Apply REF: dm. 679 TOP: Nursing Process: Planning | Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 3. The nurse is preparing to administer methotrexate to the client. This hazardous drug is most often used for which obstetric complication? a. Complete hydatidiform mole Missed abortion

Unruptured ectopic pregnancy

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d. Abruptio placentae ANS: C Methotrexate is an effective nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and measures less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole, for a missed abortion, or for abruptio placentae. DIF: Cognitive Level: Apply REF: dm. 677 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 4. A 26-year-old pregnant woman, gravida 2, para 1-0-0-1, is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, which diagnostic procedure will the client most likely have performed? a. Amniocentesis for fetal lung maturity Transvaginal ultrasound for placental location

Contraction stress test (CST)

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d. Internal fetal monitoring ANS: B The presence of painless bleeding should always alert the health care team to the possibility of placenta previa, which can be confirmed through ultrasonography. Amniocentesis is not performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus is presumed to have immature lungs at this gestational age, and the mother is given corticosteroids to aid in fetal lung maturity. A CST is not performed at a preterm gestational age. Furthermore, bleeding is a contraindication to a CST. Internal fetal monitoring is also contraindicated in the presence of bleeding. DIF: Cognitive Level: Apply REF: dm. 680 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. A laboring woman with no known risk factors suddenly experiences spontaneous ROM. The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. No change in uterine resting tone has occurred. The fetal heart rate (FHR) begins to decline rapidly after the ROM. The nurse should suspect the possibility of what condition? a. Placenta previa b.

Vasa previa

Severe abruptio placentae

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d. Disseminated intravascular coagulation (DIC) ANS: B Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. The umbilical blood vessels thus are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the FHR without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and is considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity typically is tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as the hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome. This woman did not have any prior risk factors. DIF: Cognitive Level: Analyze REF: dm. 684 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 6. A woman arrives for evaluation of signs and symptoms that include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination, the nurse notices an ecchymotic blueness around the womans umbilicus. What does this finding indicate? a. Normal integumentary changes associated with pregnancy Turner sign associated with appendicitis

Cullen sign associated with a ruptured ectopic pregnancy

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d. Chadwick sign associated with early pregnancy ANS: C Cullen sign, the blue ecchymosis observed in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy and exhibits a brown pigmented, vertical line on the lower abdomen. Turner sign is ecchymosis in the flank area, often associated with pancreatitis. A Chadwick sign is a blue-purple cervix that may be seen during or around the eighth week of pregnancy. DIF: Cognitive Level: Analyze REF: dm. 676 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 7. The nurse who elects to practice in the area of womens health must have a thorough understanding of miscarriage. Which statement regarding this condition is most accurate? a. A miscarriage is a natural pregnancy loss before labor begins. b.

It occurs in fewer than 5% of all clinically recognized pregnancies.

Careless maternal behavior, such as poor nutrition or excessive exercise, can be a factor in causing a

If a miscarriage occurs before the 12th week of pregnancy, then it may be observed only as moderat blood loss.

d. ANS: D Before the sixth week, the only evidence might be a heavy menstrual flow. After the 12th week, more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but it

occurs, by definition, before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriages can be caused by a number of disorders or illnesses outside the mothers control or knowledge. DIF: Cognitive Level: Understand REF: dm. 670 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 8. A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which differential diagnosis would not be applicable for this client? a. Placenta previa Abruptio placentae

Spontaneous abortion

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d. Cord insertion ANS: C Spontaneous abortion is another name for miscarriage; it occurs, by definition, early in pregnancy. Placenta previa is a well-known reason for bleeding late in pregnancy. The premature separation of the placenta (abruptio placentae) is a bleeding disorder that can occur late in pregnancy. Cord insertion may cause a bleeding disorder that can also occur late in pregnancy. DIF: Cognitive Level: Understand REF: dm. 669 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity, Physiologic Adaptation 9. With regard to hemorrhagic complications that may occur during pregnancy, what information is most accurate? a. An incompetent cervix is usually not diagnosed until the woman has lost one or two pregnancies. Incidences of ectopic pregnancy are declining as a result of improved diagnostic techniques.

One ectopic pregnancy does not affect a womans fertility or her likelihood of having a normal pregn

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d. Gestational trophoblastic neoplasia (GTN) is one of the persistently incurable gynecologic malignan ANS: A Short labors and recurring losses of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence. Because diagnostic technology is improving, more ectopic pregnancies are being diagnosed. One ectopic pregnancy places the woman at increased risk for another one. Ectopic pregnancy is a leading cause of infertility. Once invariably fatal, GTN now is the most curable gynecologic malignancy. DIF: Cognitive Level: Understand REF: dm. 675 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 10. The management of the pregnant client who has experienced a pregnancy loss depends on the type of miscarriage and the signs and symptoms. While planning care for a client who desires outpatient management after a first-trimester loss, what would the nurse expect the plan to include? a. Dilation and curettage (D&C) b.

Dilation and evacuation (D&E)

Misoprostol

d. ANS: C

Ergot products

Presence of fibrin split products

Thrombocytopenia

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Outpatient management of a first-trimester loss is safely accomplished by the intravaginal use of misoprostol for up to 2 days. If the bleeding is uncontrollable, vital signs are unstable, or signs of infection are present, then a surgical evacuation should be performed. D&C is a surgical procedure that requires dilation of the cervix and scraping of the uterine walls to remove the contents of pregnancy. This procedure is commonly performed to treat inevitable or incomplete abortion and should be performed in a hospital. D&E is usually performed after 16 weeks of pregnancy. The cervix is widely dilated, followed by removal of the contents of the uterus. Ergot products such as Methergine or Hemabate may be administered for excessive bleeding after miscarriage. DIF: Cognitive Level: Apply REF: dm. 672 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 11. Which laboratory marker is indicative of DIC? a. Bleeding time of 10 minutes

6 to 8

23 to 24

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d. Hypofibrinogenemia ANS: B Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys vasculature. Bleeding time in DIC is normal. Low platelets may occur but are not indicative of DIC because they may be the result from other coagulopathies. Hypofibrinogenemia occurs with DIC. DIF: Cognitive Level: Remember REF: dm. 684 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 12. When is a prophylactic cerclage for an incompetent cervix usually placed (in weeks of gestation)? a. 12 to 14

d. After 24 ANS: A A prophylactic cerclage is usually placed at 12 to 14 weeks of gestation. The cerclage is electively removed when the woman reaches 37 weeks of gestation or when her labor begins. Six to 8 weeks of gestation is too early to place the cerclage. Cerclage placement is offered if the cervical length falls to less than 20 to 25 mm before 23 to 24 weeks. Although no consensus has been reached, 24 weeks is used as the upper gestational age limit for cerclage placement. DIF: Cognitive Level: Apply REF: dm. 674 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 13. In caring for an immediate postpartum client, the nurse notes petechiae and oozing from her intravenous (IV) site. The client would be closely monitored for which clotting disorder? a. DIC b.

Amniotic fluid embolism (AFE)

Hemorrhage

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d. HELLP syndrome ANS: A The diagnosis of DIC is made according to clinical findings and laboratory markers. A physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the womans arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the postpartum client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP syndrome is not a clotting disorder, but it may contribute to the clotting disorder DIC. DIF: Cognitive Level: Understand REF: dm. 685 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 14. In caring for the woman with DIC, which order should the nurse anticipate? a. Administration of blood b.

Preparation of the client for invasive hemodynamic monitoring

Restriction of intravascular fluids

Inevitable

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d. Administration of steroids ANS: A Primary medical management in all cases of DIC involves a correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be initially ordered in a client with DIC because it could contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC. DIF: Cognitive Level: Apply REF: pp. 685-686 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 15. A woman arrives at the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion? a. Incomplete c.

Threatened

d. Septic ANS: C A woman with a threatened abortion has spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would have heavy bleeding, mild-to-severe cramping, and cervical dilation. An inevitable abortion demonstrates the same symptoms as an incomplete abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic abortion has malodorous bleeding and typically a dilated cervix. DIF: Cognitive Level: Understand REF: dm. 670 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

16. In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio placentae? a. Bleeding b.

Intense abdominal pain

Uterine activity

Complete placenta previa

Ectopic pregnancy

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d. Cramping ANS: B Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions. DIF: Cognitive Level: Understand REF: dm. 683 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 17. Which maternal condition always necessitates delivery by cesarean birth? a. Marginal placenta previa

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d. Eclampsia ANS: B In complete placenta previa, the placenta completely covers the cervical os. A cesarean birth is the acceptable method of delivery. The risk of fetal death occurring is due to preterm birth. If the previa is marginal (i.e., 2 cm or greater away from the cervical os), then labor can be attempted. A cesarean birth is not indicated for an ectopic pregnancy. Labor can be safely induced if the eclampsia is under control. DIF: Cognitive Level: Understand REF: dm. 681 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 18. What is the correct definition of a spontaneous termination of a pregnancy (abortion)? a. Pregnancy is less than 20 weeks. Fetus weighs less than 1000 g.

Products of conception are passed intact.

d. No evidence exists of intrauterine infection. ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete and may be caused by many problems, one being intrauterine infection. DIF: Cognitive Level: Remember REF: dm. 669 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 19. What is the correct terminology for an abortion in which the fetus dies but is retained within the uterus? a. Inevitable abortion b.

Missed abortion

Incomplete abortion

Bradycardia

Hard, boardlike abdomen

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d. Threatened abortion ANS: B Missed abortion refers to the retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion, the woman has cramping and bleeding but no cervical dilation. DIF: Cognitive Level: Remember REF: dm. 670 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 20. What condition indicates concealed hemorrhage when the client experiences abruptio placentae? a. Decrease in abdominal pain

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d. Decrease in fundal height ANS: C Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. Abdominal pain may increase. The client will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height increases. DIF: Cognitive Level: Analyze REF: dm. 683 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 21. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy? a. Assessing FHR and maternal vital signs Performing a venipuncture for hemoglobin and hematocrit levels

Placing clean disposable pads to collect any drainage

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d. Monitoring uterine contractions ANS: A Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check the well-being of both the mother and the fetus. The blood levels can be obtained later. Assessing future bleeding is important; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not a top priority. DIF: Cognitive Level: Apply REF: dm. 681 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 22. Which order should the nurse expect for a client admitted with a threatened abortion? a. Bed rest b.

Administration of ritodrine IV

Nothing by mouth (nil per os [NPO])

Narcotic analgesia every 3 hours, as needed

Blood pressure of 120/80 mm Hg

Fundal height measurement of 18 cm

ANS: A Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. Having the woman placed on NPO is unnecessary. At times, dehydration may produce contractions; therefore, hydration is important. Narcotic analgesia will not decrease the contractions and may mask the severity of the contractions. DIF: Cognitive Level: Understand REF: pp. 671-672 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 23. Which finding on a prenatal visit at 10 weeks of gestation might suggest a hydatidiform mole? a. Complaint of frequent mild nausea

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d. History of bright red spotting for 1 day, weeks ago ANS: C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the clients history, bleeding is normally described as brownish. DIF: Cognitive Level: Analyze REF: dm. 678 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Which information assists the nurse in developing the plan of care? a. Bed rest and analgesics are the recommended treatment. She will be unable to conceive in the future.

A D&C will be performed to remove the products of conception.

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d. Hemorrhage is the primary concern. ANS: D Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture to prevent hemorrhaging. If the tube must be removed, then the womans fertility will decrease; however, she will not be infertile. A D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes. DIF: Cognitive Level: Apply REF: dm. 676 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 1. A client who has undergone a D&C for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that her vital signs are stable, that bleeding has been controlled, and that the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, what information should discharge teaching include? (Select all that apply.) a. Iron supplementation b.

Resumption of intercourse at 6 weeks postprocedure

Referral to a support group, if necessary

Expectation of heavy bleeding for at least 2 weeks

Infections

Endocrine imbalance

Systemic disorders

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e. Emphasizing the need for rest ANS: A, C, E The woman should be advised to consume a diet high in iron and protein. For many women, iron supplementation also is necessary. The nurse should acknowledge that the client has experienced a loss, however early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure, including tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her health care provider. DIF: Cognitive Level: Apply REF: dm. 672 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 2. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.) a. Chromosomal abnormalities

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e. Varicella ANS: A, C, D, E Infections are not a common cause of early miscarriage. At least 50% of pregnancy losses result from chromosomal abnormalities. Endocrine imbalances such as hypothyroidism or diabetes are also possible causes for early pregnancy loss. Other systemic disorders that may contribute to pregnancy loss include lupus and genetic conditions. Although infections are not a common cause of early miscarriage, varicella infection in the first trimester has been associated with pregnancy loss. DIF: Cognitive Level: Remember REF: dm. 669 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. The reported incidence of ectopic pregnancy has steadily risen over the past 2 decades. Causes include the increase in sexually transmitted infections (STIs) accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse suspects that a client has early signs of ectopic pregnancy. The nurse should be observing the client for which signs or symptoms? (Select all that apply.) a. Pelvic pain b.

Abdominal pain

Unanticipated heavy bleeding

Vaginal spotting or light bleeding

e. Missed period ANS: A, B, D, E

A missed period or spotting can be easily mistaken by the client as an early sign of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage, which may progress to hypovolemic shock with minimal or even no external bleeding. In approximately one half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage. Chapter 2 Later Postpartum Hemorrhage

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1. What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output ANS: B Tachycardia is usually the first sign of inadequate blood volume. 2. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location. ANS: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm.

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3. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis ANS: A The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient. 5. Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage? a. My discharge would change to red after it has been pink or white. b. If I have a postpartum hemorrhage, I will have severe abdominal pain. c. I should be alert for an increase in bright red blood. d. I would pass a large clot that was retained from the placenta. ANS: A When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage.

6. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage ANS: B, C, D, E Hypertension is not a cause for postpartum shock; all the other options can cause shock.

Chapter 3 Gestational Diabetes, Deep Vein Thrombosis, and Postpartum Pulmonary Embolism

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MULTIPLE CHOICE 1. Preconception counseling is critical in the safe management of diabetic pregnancies. Which complication is commonly associated with poor glycemic control before and during early pregnancy? a. Frequent episodes of maternal hypoglycemia b.

Congenital anomalies in the fetus

Hydramnios

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d. Hyperemesis gravidarum ANS: B Preconception counseling is particularly important since strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risk of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormonal changes and the effects on insulin production and use. Hydramnios occurs approximately 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically, it is observed in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia. DIF: Cognitive Level: Understand REF: dm. 687 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 2. During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? a. I will need to eat 600 more calories per day because I am pregnant. b.

I can continue with the same diet as before pregnancy as long as it is well balanced.

Diet and insulin needs change during pregnancy.

d. I will plan my diet based on the results of urine glucose testing. ANS: C Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs may double or even quadruple. The diet is

Congenital anomalies of the central nervous system

Preterm birth

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individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Energy needs are usually calculated on the basis of 30 to 35 calories per kilogram of ideal body weight. Dietary management during a diabetic pregnancy must be based on blood, not urine, glucose changes. DIF: Cognitive Level: Analyze REF: dm. 689 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 3. Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the client mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. This fetus is at the greatest risk for which condition? a. Macrosomia

Imbalanced nutrition: less than body requirements

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d. Low birth weight ANS: A Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this fetus. DIF: Cognitive Level: Understand REF: dm. 690 TOP: Nursing Process: Planning | Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 4. A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. Which nursing diagnosis is most appropriate for the client at this time? a. Deficient fluid volume Imbalanced nutrition: more than body requirements

d. Disturbed sleep pattern ANS: B This clients clinical cues include weight loss, which supports a nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support a nursing diagnosis of deficient fluid volume. This client reports weight loss, not weight gain. Although the client reports nervousness, the most appropriate nursing diagnosis, based on the clients other clinical symptoms, is Imbalanced nutrition: less than body requirements. DIF: Cognitive Level: Analyze REF: dm. 706 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

5. A client with maternal phenylketonuria (PKU) has come to the obstetrical clinic to begin prenatal care. Why would this preexisting condition result in the need for closer monitoring during pregnancy? a. PKU is a recognized cause of preterm labor. b.

The fetus may develop neurologic problems.

A pregnant woman is more likely to die without strict dietary control.

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d. Women with PKU are usually mentally handicapped and should not reproduce. ANS: B Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of an uncertain cause, or who have given birth to microcephalic infants. DIF: Cognitive Level: Understand REF: dm. 707 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 6. The nurse who is caring for a woman hospitalized for hyperemesis gravidarum would expect the initial treatment to involve what? a. Corticosteroids to reduce inflammation Intravenous (IV) therapy to correct fluid and electrolyte imbalances

Antiemetic medication, such as pyridoxine, to control nausea and vomiting

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d. Enteral nutrition to correct nutritional deficits ANS: B Initially, the woman who is unable to down clear liquids by mouth requires IV therapy to correct fluid and electrolyte imbalances. Corticosteroids have been successfully used to treat refractory hyperemesis gravidarum, but they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic medication. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation but is not the initial treatment for this client. DIF: Cognitive Level: Apply REF: dm. 705 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 7. In terms of the incidence and classification of diabetes, which information should the nurse keep in mind when evaluating clients during their ongoing prenatal appointments? a. Type 1 diabetes is most common. b.

Type 2 diabetes often goes undiagnosed.

GDM means that the woman will receive insulin treatment until 6 weeks after birth.

d. Type 1 diabetes may become type 2 during pregnancy. ANS: B Type 2 diabetes often goes undiagnosed because hyperglycemia gradually develops and is often not severe. Type 2, sometimes called adult-onset diabetes, is the most common type of diabetes.

GDM refers to any degree of glucose intolerance first recognized during pregnancy; insulin may or may not be needed. People do not go back and forth between type 1 and type 2 diabetes. DIF: Cognitive Level: Apply REF: dm. 688 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 8. A number of metabolic changes occur throughout pregnancy. Which physiologic adaptation of pregnancy will influence the nurses plan of care? a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its o

Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester becau consuming more sugar.

During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abund glucose for the fetus.

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d. Maternal insulin requirements steadily decline during pregnancy. ANS: C Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own around the 10th week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy. DIF: Cognitive Level: Understand REF: MSC: Client Needs: Physiologic Integrity 9. Which statement concerning the complication of maternal diabetes is the most accurate? a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.

Hydramnios occurs approximately twice as often in diabetic pregnancies than in nondiabetic pregna

Infections occur about as often and are considered about as serious in both diabetic and nondiabetic

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d. Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being. ANS: A Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being. DIF: Cognitive Level: Understand REF: dm. 691 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 10. Which statement regarding the laboratory test for glycosylated hemoglobin Alc is correct? The laboratory test for glycosylated hemoglobin Alc is performed for all pregnant women, not only a. to have diabetes. b.

This laboratory test is a snapshot of glucose control at the moment.

This laboratory test measures the levels of hemoglobin Alc, which should remain at less than 7%.

d. This laboratory test is performed on the womans urine, not her blood. ANS: C Hemoglobin Alc levels greater than 7% indicate an elevated glucose level during the previous 4 to 6 weeks. This extra laboratory test is for diabetic women and defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are performed on the blood.

DIF: Cognitive Level: Understand REF: dm. 692 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 11. A new mother with a thyroid disorder has come for a lactation follow-up appointment. Which thyroid disorder is a contraindication for breastfeeding? a. Hyperthyroidism b.

PKU

Hypothyroidism

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d. Thyroid storm ANS: B PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine and therefore should elect not to breastfeed. A woman with either hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism and is not a contraindication to breastfeeding. DIF: Cognitive Level: Understand REF: dm. 708 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 12. An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to assist in planning adequate care. What is the most appropriate diagnosis at this time? a. Risk for injury, to the fetus related to birth trauma b.

Deficient knowledge, related to diabetic pregnancy management

Deficient knowledge, related to insulin administration

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d. Risk for injury, to the mother related to hypoglycemia or hyperglycemia ANS: B Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears more concerned about changes to her social life than adopting a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come later in the pregnancy. At this time, the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made and may not participate in the plan of care until understanding takes place. DIF: Cognitive Level: Analyze REF: dm. 693 TOP: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity 13. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates? a. 75 mg/dl before lunch. This is low; better eat now. b.

115 mg/dl 1 hour after lunch. This is a little high; maybe eat a little less next time.

115 mg/dl 2 hours after lunch. This is too high; it is time for insulin.

Hypercalcemia

Hypobilirubinemia

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d. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep. ANS: D 50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl. DIF: Cognitive Level: Apply REF: dm. 693 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 14. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia

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d. Hypoinsulinemia ANS: A The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth, and large amounts of bilirubin are released into the neonates circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, hyperinsulinemia develops in the neonate. DIF: Cognitive Level: Apply REF: dm. 698 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 15. Which preexisting factor is known to increase the risk of GDM? a. Underweight before pregnancy Maternal age younger than 25 years

Previous birth of large infant

d. Previous diagnosis of type 2 diabetes mellitus ANS: C A previous birth of a large infant suggests GDM. Obesity (body mass index [BMI] of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years is not generally at risk for GDM. The person with type 2 diabetes mellitus already has diabetes and thus will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy. DIF: Cognitive Level: Understand REF: dm. 699 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. Which physiologic alteration of pregnancy most significantly affects glucose metabolism? a. Pancreatic function in the islets of Langerhans is affected by pregnancy. b.

Pregnant women use glucose at a more rapid rate than nonpregnant women.

Pregnant women significantly increase their dietary intake.

Reduce the carbohydrates in her diet.

Eat her meals and snacks on a fixed schedule.

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d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance. ANS: D Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin is also broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day. DIF: Cognitive Level: Understand REF: dm. 699 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 17. To manage her diabetes appropriately and to ensure a good fetal outcome, how would the pregnant woman with diabetes alter her diet? a. Eat six small equal meals per day.

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d. Increase her consumption of protein. ANS: C Having a fixed meal schedule will provide the woman and the fetus with a steady blood sugar level, provide a good balance with insulin administration, and help prevent complications. Having a fixed meal schedule is more important than the equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates. DIF: Cognitive Level: Understand REF: dm. 693 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A serious but uncommon complication of undiagnosed or partially treated hyperthyroidism is a thyroid storm, which may occur in response to stress such as infection, birth, or surgery. What are the signs and symptoms of this emergency disorder? (Select all that apply.) a. Fever Hypothermia

Restlessness

Bradycardia

e. Hypertension ANS: A, C Fever, restlessness, tachycardia, vomiting, hypotension, and stupor are symptoms of a thyroid storm. Fever, not hypothermia; tachycardia, not bradycardia; and hypotension, not hypertension, are symptoms of thyroid storm. DIF: Cognitive Level: Analyze REF: dm. 706 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 2. Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Because severe hypothyroidism is associated with infertility and miscarriage, it is not often seen in pregnancy. Regardless of this fact, the nurse should be aware of the characteristic symptoms of hypothyroidism. Which do they include? (Select all that apply.) a. Hot flashes

Weight loss

Lethargy

Decrease in exercise capacity

Retinopathy

Intrauterine fetal death (IUFD)

Nephropathy

Neuropathy

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e. Cold intolerance ANS: C, D, E Symptoms include weight gain, lethargy, decrease in exercise capacity, and intolerance to cold. Other presentations might include constipation, hoarseness, hair loss, and dry skin. Thyroid supplements are used to treat hyperthyroidism in pregnancy. DIF: Cognitive Level: Understand REF: dm. 707 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 3. Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. What do these complications include? (Select all that apply.) a. Atherosclerosis

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f. Autonomic neuropathy ANS: A, B, D, E These structural changes will most likely affect a variety of systems, including the heart, eyes, kidneys, and nerves. IUFD (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication. DIF: Cognitive Level: Understand REF: dm. 688 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity COMPLETION 1. Achieving and maintaining euglycemia are the primary goals of medical therapy for the pregnant woman with diabetes. These goals are achieved through a combination of diet, insulin, exercise, and blood glucose monitoring. The target blood glucose levels 1 hour after a meal should be _____________. ANS: 110 to 129 mg/dl Target levels of blood glucose during pregnancy are lower than nonpregnant values. Accepted fasting levels are between 60 and 99 mg/dl, and 1-hour postmeal levels should be between 110 to 129 mg/dl. Two-hour postmeal levels should be 120 mg/dl or less. DIF: Cognitive Level: Apply REF: dm. 693 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance MATCHING The nurse is preparing to teach an antepartum client with GDM the correct method of administering an intermediate-acting insulin, such as neutral protamine Hagedorn (NPH), with a

short-acting insulin (regular). In the correct order from 1 through 6, match the step number with the action needed to teach the client self-administration of this combination of insulin. a. Without adding air, withdraw the correct dose of NPH insulin. b.

Gently rotate the insulin to mix it, and wipe the stopper.

Inject air equal to the dose of NPH insulin into the vial, and remove the syringe.

Inject air equal to the dose of regular insulin into the vial, and withdraw the medication.

Check the insulin bottles for the expiration date.

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f. Wash hands. 1. Step 1 2. Step 2 3. Step 3 4. Step 4 5. Step 5 6. Step 6 1. ANS: F DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type. 2. ANS: E DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type. 3. ANS: B DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type. 4. ANS: C DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type. 5. ANS: D DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type. 6. ANS: A DIF: Cognitive Level: Apply REF: dm. 694 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment NOT: Regular insulin is always drawn up first when combining insulin. Other steps include ensuring that the insulin syringe corresponds to the concentration of insulin that is being used. The bottle should be checked before withdrawing the medication to be certain that it is the appropriate type.

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Chapter 4 Preeclampsia

1. Indications for a primary cesarean birth are often nonrecurring. Therefore, a woman who has had a cesarean birth with a low transverse scar may be a candidate for vaginal birth after cesarean (VBAC). Which clients would beless likely to have a successful VBAC? (Select all that apply.) a. Lengthy interpregnancy interval African-American race

Delivery at a rural hospital

Estimated fetal weight <4000 g

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e. Maternal obesity (BMI >30) ANS: B, C, E Indications for a low success rate for a VBAC delivery include a short interpregnancy interval, non-Caucasian race, gestational age longer than 40 weeks, maternal obesity, preeclampsia, fetal weight greater than 4000 g, and delivery at a rural or private hospital. Chapter 5 Cord Prolapse and Nonreassuring Fetal Status

1. The obstetric provider has informed the nurse that she will be performing an amniotomy on the client to induce labor. What is the nurses highest priority intervention after the amniotomy is performed? a. Applying clean linens under the woman b.

Taking the clients vital signs

Performing a vaginal examination

d. Assessing the fetal heart rate (FHR) ANS: D The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse. Providing comfort measures, such as clean linens, for the client is important but not the priority immediately after an amniotomy. The womans temperature should be checked every 2 hours after the rupture of membranes but not the priority

immediately after an amniotomy. The woman would have had a vaginal examination during the procedure. Unless cord prolapse is suspected, another vaginal examination is not warranted. Additionally, FHR assessment provides clinical cues to a prolapsed cord.

2. A pregnant womans amniotic membranes have ruptured. A prolapsed umbilical cord is suspected. What intervention would be the nurses highest priority? a. Placing the woman in the knee-chest position Covering the cord in sterile gauze soaked in saline

Preparing the woman for a cesarean birth

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d. Starting oxygen by face mask ANS: A The woman is assisted into a modified Sims position, Trendelenburg position, or the knee-chest position in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression. Chapter 6 Placental Abruption and Fetal Loss

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1. A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a. Refers to the two live infants as twins Asks about the dead triplets current status

Brings in play clothes for all three infants

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d. Refers to the dead infant in the past tense ANS: D Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets. DIF: Cognitive Level: Understand REF: dm. 927 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their sons prognosis. When the father sees his son, he says, He looks just fine to me. I cant understand what all this is about. What is the most appropriate response or reaction by the nurse at this time? a. Didnt the physician tell you about your sons problems?

This must be a difficult time for you. Tell me how youre doing.

Quietly stand beside the infants father.

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d. Youll have to face up to the fact that he is going to die sooner or later. ANS: B The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse. DIF: Cognitive Level: Apply REF: dm. 911 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 3. During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurses role at this time? a. To take over as much as possible to relieve the pressure b.

To encourage the grandparents to take over

To ensure that the parents, themselves, approve the final decisions

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d. To leave them alone to work things out ANS: C The nurse is always the clients advocate. Nurses can offer support and guidance and yet leave room for the same from grandparents. In the end, however, nurses should let the parents make the final decisions. For the nurse to be able to present options regarding burial and autopsy, among other issues, in a sensitive and respectful manner is essential. The nurse should assist the parents in any way possible; however, taking over all arrangements is not the nurses role. Grandparents are often called on to help make the difficult decisions regarding funeral arrangements or the disposition of the body because they have more life experiences with taking care of these painful, yet required arrangements. Some well-meaning relatives may try to take over all decision-making responsibilities. The nurse must remember that the parents, themselves, should approve all of the final decisions. During this time of acute distress, the nurse should be present to provide quiet support, answer questions, obtain information, and act as a client advocate. DIF: Cognitive Level: Understand REF: dm. 921 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 4. A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt? a. Siblings b.

Mother

Father

d. ANS: D

Grandparents

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Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that they are alive and their grandchild is not. The siblings of the expired infant may also experience a profound loss. A young child will respond to the reactions of the parents and may act out. Older children have a more complete understanding of the loss. School-age children are likely to be frightened, whereas teenagers are at a loss on how to react. The mother of the infant is experiencing intense grief at this time. She may be dealing with questions such as, Why me? or Why my baby? and is unlikely to be experiencing survival guilt. Realizing that fathers can be experiencing deep pain beneath their calm and quiet appearance and may need help acknowledging these feelings is important. This need, however, is not the same as survivor guilt. DIF: Cognitive Level: Understand REF: dm. 916 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 5. When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful? a. Using the words lost or gone rather than dead or died b.

Making sure the family understands that naming the baby is important

Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby

Autopsies must be performed within a few hours after the infants death.

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d. Setting a firm time for ending the visit with the baby so that the parents know when to let go ANS: C Presenting the baby as nicely as possible stimulates the parents senses and provides pleasant memories of their baby. Baby lotion or powder can be applied, and the baby should be wrapped in a soft blanket, clothed, and have a cap placed on his or her head. Nurses must use the words dead and died to assist the bereaved in accepting the reality. Although naming the baby can be helpful, creating the sense that the parents have to name the baby is not important. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different times with their baby to say good-bye. Nurses need to be careful not to rush the process. DIF: Cognitive Level: Apply REF: dm. 919 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 6. Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information? a. Autopsies are usually covered by insurance. c.

In the current litigious society, more autopsies are performed than in the past.

d. Some religions prohibit autopsy. ANS: D Some religions prohibit autopsies or limit the choice to the times when it may help prevent further loss. The cost of the autopsy must be considered; it is not covered by insurance and can be very expensive. There is no rush to perform an autopsy unless evidence of a contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of a fear by medical facilities that errors by the staff might be revealed, resulting in litigation. DIF: Cognitive Level: Understand REF: dm. 921 TOP: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment 7. Parents have asked the nurse about organ donation after that infants death. Which information regarding organ donation is important for the nurse to understand? Federal law requires the medical staff to ask the parents about organ donation and then to contact th a. procurement organization (OPO) to handle the procedure if the parents agree. b.

Organ donation can aid grieving by giving the family an opportunity to see something positive abou

Most common donation is the infants kidneys.

You have an angel in heaven.

I know how you feel.

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d. Corneas can be donated if the infant was either stillborn or alive as long as the pregnancy went full t ANS: B Evidence indicates that organ donation can promote healing among the surviving family members. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation, the infant must have been born alive at 36 weeks of gestation or later. DIF: Cognitive Level: Understand REF: dm. 921 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 8. Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a. This happened for the best.

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d. What can I do for you? ANS: D Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parent would find the statement This has happened for the best to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use clichs. Unless the nurse has lost a child, he or she does not understand how the parents feel. DIF: Cognitive Level: Apply REF: dm. 922 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. After giving birth to a stillborn infant, the woman turns to the nurse and says, I just finished painting the babys room. Do you think that caused my baby to die? What is the nurses most appropriate response? a. Thats an old wives tale; lots of women are around paint during pregnancy, and this doesnt happen to b.

Thats not likely. Paint is associated with elevated pediatric lead levels.

Silence.

d. I can understand your need to find an answer to what caused this. What else are you thinking about? ANS: D The statement I can understand your need to find an answer to what caused this. What else are you thinking about? is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichs in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist

or trying to squelch their guilt feeling does not help the process of grieving. Silence would probably increase the mothers feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and then listening with care. The nurse should encourage the mother to express her thoughts. DIF: Cognitive Level: Apply REF: dm. 922 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 10. Which options for saying good-bye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse should not discuss any options at this time; plenty of time will be available after the baby Would you like a picture taken of your baby after birth?

When your baby is born, would you like to see and hold her?

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d. What funeral home do you want notified after the baby is born? ANS: C Mothers and fathers may find it helpful to see their infant after delivery. The parents wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents wishes concerning seeing or holding their dead infant. Although information about funeral home notification may be relevant, this information is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born. DIF: Cognitive Level: Apply REF: dm. 919 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 11. During a follow-up home visit, the nurse plans to evaluate whether parents have progressed to the second stage of grieving (phase of intense grief). Which behavior would the nurse not anticipate finding? a. Guilt, particularly in the mother Numbness or lack of response

Bitterness or irritability

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d. Fear and anxiety, especially about getting pregnant again ANS: B The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, which indicates that the parents are still in denial or shock. DIF: Cognitive Level: Analyze REF: dm. 914 TOP: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity 12. Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving? a. The parents say that they feel no pain. b.

The parents are discussing sex and a future pregnancy, even if they have not yet sorted out their feel

The parents have abandoned those moments of bittersweet grief.

d. ANS: B

The parents questions have progressed from Why? to Why us?

Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly beyond the first year when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, such as anniversary dates. Most couples never abandon these reminders. Recovery is ongoing. Typically, a couples search for meaning progresses from Why? in the acute phase to Why me? in the intense phase to What does this loss mean to my life? in the reorganizational phase. DIF: Cognitive Level: Understand REF: dm. 914 TOP: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity 13. Which statement most accurately describes complicated grief? a. Occurs when, in multiple births, one child dies and the other or others live Is a state during which the parents are ambivalent, as with an abortion

Is an extremely intense grief reaction that persists for a long time

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d. Is felt by the family of adolescent mothers who lose their babies ANS: C Parents showing signs of complicated grief should be referred for counseling. Multiple births, in which not all of the babies survive, create a complicated parenting situation but not complicated bereavement. Abortion can generate complicated emotional responses, but these responses do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but these issues are not complicated bereavement. DIF: Cognitive Level: Understand REF: dm. 927 TOP: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity 14. A client is diagnosed with having a stillborn infant. At first, she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What is the proper term for the phase of bereavement that this client is experiencing? a. Anticipatory grief Acute distress

Intense grief

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d. Reorganization ANS: B The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, a lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infants possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

15. Which classification of placental separation is not recognized as an abnormal adherence pattern? a. Placenta accreta b.

Placenta increta

Placenta percreta

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d. Placenta abruptio ANS: D Placenta abruptio is premature separation of the placenta as opposed to partial or complete adherence. This classification occurs between the 20th week of gestation and delivery in the area of the decidua basalis. Symptoms include localized pain and bleeding. Placenta accreta is a recognized degree of attachment. With placenta accreta, the trophoblast slightly penetrates into the myometrium. Placenta increta is a recognized degree of attachment that results in deep penetration of the myometrium. Placenta percreta is the most severe degree of placental penetration that results in deep penetration of the myometrium. Bleeding with complete placental attachment occurs only when separation of the placenta is attempted after delivery. Treatment includes blood component therapy and, in extreme cases, hysterectomy may be necessary.

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16. The induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? (Select all that apply?) a. Rupture of membranes at or near term Convenience of the woman or her physician

Chorioamnionitis (inflammation of the amniotic sac)

Postterm pregnancy

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e. Fetal death ANS: A, C, D, E The conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks of completed gestation.

Chapter 7 Chorioamnionitis and Neonatal Sepsis 1. How do you diagnose chorioamnionitis? Clinical: 1. maternal temp of 38ºC (100.4ºF) 2. maternal or fetal tachycardia 3. uterine tenderness

4. foul-smelling amniotic fluid 5. maternal leukocytosis (> 15K) Exclude other sources of infection. Histology confirms the dx of clinical chorio in only 62% of cases. 2. What are the mechanisms of chorioamnionitis? 1. Ascending bacteria from the lower genital tract into the uterus 2. Bloodborne (eg. listeria) 3. Through intact membranes (eg. ureaplasma)

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3.Predisposing factors PROM Prolonged labor Multiple vaginal exams 4.Incidence of chorioamnionitis At term: 1-4% Preterm: much higher

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5.Treatment of chorioamnionitis Choices include: 1. Ampicillin and Gentamicin (+ Clinda/Flagyl if CD) Amp 2g IV q6h Gent 1.5 mg/kg IV q8h Clinda 900 mg IV q8h Metronidazole 500 mg IV q12h

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2. Unasyn

Usually requires oxytocin for augmentation. Reserve CD for ob indications.

PP tx should be individualized. Usually you stop the abc after afebrile for 24h or after the first postpartum dose. 6. Complications of chorioamnionitis Maternal: 1. dysfunctional labor 2. PPH 3. higher risk for CD 4. higher rates of PP endomyometritis and wound infection Neonatal: 1. sepsis

2. pneumonia 3. depression at birth 4. IVH 5. death 6. cerebral palsy 7. developmental dela Chapter 8 Preterm Premature Rupture of Membranes and Neonatal Respiratory Distress Syndrome

MULTIPLE CHOICE 1. Which pelvic shape is most conducive to vaginal labor and birth? Android

Gynecoid

Platypelloid

Anthropoid

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ANS: B

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The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch. The prognosis for a vaginal birth is good. Only 30% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. PTS: 1 DIF: Cognitive Level: Understanding REF: 574

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which action by the nurse prevents infection in the labor and birth area? a.

Using clean techniques for all procedures

Keeping underpads and linens as dry as possible

Cleaning secretions from the vaginal area by using a back to front motion

Performing vaginal examinations every hour while the client is in active labor

ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. PTS: 1 DIF: Cognitive Level: Application REF: 576 OBJ:Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment 3. A pregnant client with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicate a potential infection? Fetal heart rate, 150 beats/min

Maternal temperature, 99 F

Cloudy amniotic fluid, with strong odor

Lowered maternal pulse and decreased respiratory rates

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ANS: C

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Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/min is often the first sign of intrauterine infection. A temperature of 100.4 F or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation. PTS: 1 DIF: Cognitive Level: Analysis REF: 576

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

4. A client in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will be prescribed for at-home continuation of the tocolytic effect? a.

Buccal oxytocin (Pitocin)

Terbutaline sulfate (Brethine)

Calcium gluconate (Calgonate)

Magnesium sulfate

ANS: B

PTS: 1 DIF: Cognitive Level: Application REF: 585

The client receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. Pitocin increases the strength of contractions and is used to augment or stimulate labor. Buccal Pitocin dosing is uncontrollable. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.

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OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

5. A client with polyhydramnios was admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless, but the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? Perform Leopold maneuvers.

Perform a vaginal examination.

Apply warm saline soaks to the vagina.

Place the client in a high Fowler position.

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ANS: B

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A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation. PTS: 1 DIF: Cognitive Level: Application REF: 591 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity 6. Which technique is least effective for the client with persistent occiput posterior position? a.

Squatting

Lying supine and relaxing

Sitting or kneeling, leaning forward with support

Rocking the pelvis back and forth while on hands and knees

ANS: B

OBJ:Nursing Process Step: Implementation

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PTS: 1 DIF: Cognitive Level: Application REF: 572

Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

MSC: Client Needs: Health Promotion and Maintenance

7. Birth for the nulliparous client with a fetus in a breech presentation is usually: cesarean section.

vaginal birth.

vacuumed extraction.

ANS: A

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forceps-assisted birth.

Birth for the nulliparous client with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required. PTS: 1 DIF: Cognitive Level: Understanding REF: 572 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?

A primigravida who is 17 years old

A 22-year-old multiparous client with ruptured membranes

A primigravida who has requested no analgesia during her labor

A multiparous client at 39 weeks of gestation who is expecting twins

ANS: D

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Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this clients uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus. PTS: 1 DIF: Cognitive Level: Analysis REF: 569

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 9. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? Incomplete uterine relaxation

Maternal fatigue and exhaustion

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Administration of tocolytic drugs

Maternal sedation with narcotics

ANS: A

A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow. PTS: 1 DIF: Cognitive Level: Understanding REF: 573 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

palpate the infants clavicles.

encourage the parents to hold the infant.

perform a complete newborn assessment.

give supplemental oxygen with a small face mask.

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ANS: A

10. After a birth complicated by a shoulder dystocia, the infants Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:

Because of the shoulder dystocia, the infants clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed. PTS: 1 DIF: Cognitive Level: Understanding REF: 570, 571

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. A laboring client in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?

Let me take off the monitor belts and help you get into a more comfortable position.

You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain.

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You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger.

I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.

ANS: D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the client cope with the situation, no matter at what stage. It is important to get her into a more comfortable position, but fetal monitoring should continue. Breathing will not decrease the pain.

PTS: 1 DIF: Cognitive Level: Application REF: 570 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. Which nursing action should be initiated first when there is evidence of prolapsed cord? Notify the health care provider.

Apply a scalp electrode.

Prepare the mother for an emergency cesarean birth.

Reposition the mother with her hips higher than her head.

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ANS: D

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The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. PTS: 1 DIF: Cognitive Level: Application REF: 591

OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity

Observe for abnormally high uterine resting tone.

Notify the health care provider promptly.

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13. A client who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurses priority action?

Decrease the rate of nonadditive intravenous fluid.

Reposition the client with her hips slightly elevated.

ANS: A Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones

put the client at high risk for uterine rupture. The client is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the client with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties. PTS: 1 DIF: Cognitive Level: Application REF: 592 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity

Oligohydramnios

Pregnancy at 38 weeks of gestation

Presenting part at a station of 3

Meconium-stained amniotic fluid

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14. Which factor should alert the nurse to the potential for a prolapsed umbilical cord?

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ANS: C

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Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the client at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the client at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord. PTS: 1 DIF: Cognitive Level: Understanding REF: 590 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

the buttocks are much larger than the head.

15. The fetus in a breech presentation is often born by cesarean birth because:

compression of the umbilical cord is more likely.

internal rotation cannot occur if the fetus is breech.

postpartum hemorrhage is more likely if the client delivers vaginally.

ANS: B

After the fetal legs and trunk emerge from the clients vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage. PTS: 1 DIF: Cognitive Level: Understanding REF: 590 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

16. A client who is 32 weeks pregnant telephones the nurse at her obstetricians office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is: You should come into the office and let the doctor check you.

Acetaminophen is acceptable during pregnancy. You should not take aspirin, however.

Back pain is common at this time during pregnancy because you tend to stand with a sway back.

Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.

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ANS: A

A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The client needs to be assessed for preterm labor before providing pain relief.

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PTS: 1 DIF: Cognitive Level: Application REF: 580 OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity

17. Which is (are) the priority nursing assessment(s) for the client having tocolytic therapy with terbutaline (Brethine)? a.

Intake and output

Maternal blood glucose level

Internal temperature and odor of amniotic fluid

Fetal heart rate, maternal pulse, and blood pressure

ANS: D All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured, but these are not relevant to the medication. PTS: 1 DIF: Cognitive Level: Application REF: 576

18. Which assessment finding indicates uterine rupture? Fetal tachycardia occurs.

The client becomes dyspneic.

Labor progresses unusually quickly.

Contractions abruptly stop during labor.

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OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

ANS: D

A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 582 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

19. Which intervention should be incorporated in a plan of care for a labor client who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam3 cm, 80% effaced, and 0 station presenting part vertex. a.

Augmentation of labor with oxytocin (Pitocin)

AROM

Performing a vaginal exam to denote progress

Preparing the client for epidural administration as ordered by the physician

ANS: D The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore, augmentation would not be advised as this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided. PTS: 1 DIF: Cognitive Level: Analysis REF: 570

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

OBJ:Nursing Process Step: Implementation

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20. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken by the nurse in response to this request? Put pressure on the fundus.

Ask the physician if he or she would like you to prepare for a surgical method of birth.

Tell the client not to push until you prepare vacuum extraction device for physician.

Reposition the client to facilitate birth.

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ANS: B

In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it can cause additional problems. Vacuum extraction will not help solve this birth issue and may lead to further complications. Repositioning of the client may not be effective to relieve this condition and facilitate birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 570, 571 OBJ:Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities 21. A pregnant client who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered an fFN (fetal fibronectin) test. Which instructions should be given to the client related to this clinical test? a.

Client must be NPO prior to testing.

Blood work will be drawn every week to help confirm the start of preterm labor.

Client should refrain from sexual activity prior to testing.

A urine specimen will be collected for testing.

ANS: C

OBJ:Nursing Process Step: Planning

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PTS: 1 DIF: Cognitive Level: Application REF: 581

Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

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22. An obstetric client has been identified as being high risk and so has had activities restrictions (placed on bed rest) placed on her until the end of the pregnancy. Currently, she is at 32 weeks gestation and has two other children at home, ages 3 and 6. The clients husband works at home. A nursing diagnosis of Impaired home maintenance is noted. Which statement potentially identifies a long-term goal?

The client and husband will hire a nanny to act as an additional caregiver for the next month.

The client will continue to take care of her children at home, taking frequent rest periods.

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The client and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.

The client and husband will be able to adapt their schedules accordingly to meet activities of daily livin until the clients next scheduled antepartum visit the following week.

ANS: D A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified time frame. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the client to take care of her children at home with rest period because the client will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications. PTS: 1 DIF: Cognitive Level: Analysis REF: 580

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 23. A labor client has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, what birth method is available? Vaginal birth with vacuum extraction

Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractio

Cesarean section

Insertion of Foley catheter into empty bladder to provide more room for fetal descent

ANS: C

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The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the client should be prepped for a cesarean section. PTS: 1 DIF: Cognitive Level: Analysis REF: 570

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OBJ:Nursing Process Step: Evaluation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency

Initiation of CPR and other life support measures Respiratory treatments with nebulizers

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Normal amniotic fluid

24. A client is diagnosed with anaphylactoid syndrome. Which therapeutic intervention does the nurse suspect will be included in the plan of care?

Internal fetal monitoring

ANS: B Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 593 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency 25. A 20-year-old gravida 1, para 0, is determined to be at 42 weeks gestation on admission to the labor and birth unit. The client is not in labor at the current time but has been sent over by her physician to be admitted for the induction of labor. The client indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the clients request?

Inform the client that there are a number of serious concerns related to a postdate pregnancy and that sh would be better off to be monitored in a clinical setting.

Tell the client that an assessment will be done and if there are no findings indicating that an induction o labor would be favorable, the client will be sent home.

Tell the client that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physicians directions.

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There is no way to tell if any complications would arise. Because the client is not presenting with any problems, the nurse should call the health care provider and inform her or him of the clients decision to go home and wait.

ANS: B

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The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the client wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore, it is best for the client to remain in a supervised clinical setting. Indicating that the client could possibly go home would place the client at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks. PTS: 1 DIF: Cognitive Level: Analysis REF: 590 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency 26. Which presentation is least likely to occur with a hypotonic labor pattern? a.

Prolonged labor duration

Fetal distress

Maternal comfort during labor

Irregular labor contraction pattern

ANS: B

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A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and clients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure. PTS: 1 DIF: Cognitive Level: Application REF: 569

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Pathophysiologic Integrity

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27. Which finding by the nurse on a vaginal exam would be a concern if a spontaneous rupture of the membranes occurred? Cephalic presentation

Left occiput position

Dilation 2 cm

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ANS: D

Presenting part at 3 station

If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings. PTS: 1 DIF: Cognitive Level: Analysis REF: 590 OBJ:Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment/Management of Care 28. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes?

Apply oxygen at 8 to 10 L/min.

Stop the Pitocin infusion.

Position the client in the knee-chest position.

Increase the main line infusion to 150 mL/hr.

ANS: C

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A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression. PTS: 1 DIF: Cognitive Level: Application REF: 591 OBJ:Nursing Process Step: Analysis

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MSC: Client Needs: Safe and Effective Care Environment/Management of Care 29. When increasing the IV infusion rate of terbutaline (Brethine) 0.01 mg/min every 30 minutes, the nurse knows to stop increasing the rate when the:

systolic blood pressure falls below 110 mm Hg. contractions are less than two in a 10-minute period. maternal heart rate remains over 120 beats/min.

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maximum dose of 0.1 mg/min is reached.

ANS: D The infusion rate is not increased or may be decreased if the maternal pulse rate remains over 120 beats/min (bpm). A maximum dose of 0.1 mg is above the recommended maximum rate, systolic blood pressure below 110 mm Hg may be a normal finding for this client, and the medication should continue to be increased until the maximum level is reached or contractions stop. PTS: 1 DIF: Cognitive Level: Application REF: 584

OBJ:Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

Fetal heart rate (FHR) of 134 bpm

Heart rate of 122 bpm

Two episodes of diarrhea

Fasting blood glucose level of 100 mg/dL

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30. Which finding would indicate an adverse response to terbutaline (Brethine)?

ANS: B

Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 584 OBJ:Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

2:30 PM on March 12. 8:30 PM on March 12.

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31. A dose of dexamethasone 12 mg was administered to a client in preterm labor at 8:30 AM on March 12. The nurse knows that the next dose must be scheduled for:

8:30 AM on March 13.

2:30 PM on March 13.

ANS: C The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 2:30 PM on March 12, 8:30 PM on March 12, and 2:30 PM on March 13 do not fall within this recommendation. PTS: 1 DIF: Cognitive Level: Application REF: 586

OBJ:Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies 32. When reviewing the prenatal record of a client at 42 weeks gestation, the nurse recognizes that induction of labor is indicated based on the finding of: reduced amniotic fluid volume.

cervix 2 cm at last prenatal visit.

fundal height measured at the xyphoid process.

1-pound weight gain at each of the last two weekly visits.

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ANS: A

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Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-pound weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation. PTS: 1 DIF: Cognitive Level: Analysis REF: 589

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

Urine output >30 mL/hr

Blood pressure of 100/60 mm Hg

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33. Which assessment finding in the postpartum client following a uterine inversion indicates normovolemia?

Rebound skin turgor <5 seconds

Pulse rate <120 beats/min

ANS: B In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hr; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/min may be indications of hypovolemia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 593 OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation 34. Which assessment finding indicates a complication in the client attempting a vaginal birth after cesarean (VBAC)? Complaint of pain between the scapulae

Change in fetal baseline from 128 to 132 bpm

Contractions every 3 minutes lasting 70 seconds

Pain level of 6 on scale of 0 to 10 during acme of contraction

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ANS: A

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A client attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 592

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OBJ:Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

35. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurses next action? a.

Palpate the patients bladder for fullness.

Contact the health care provider for a prescription to augment the labor.

Obtain an order for an internal pressure catheter.

Reassure the patient that she is making adequate progress.

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

PTS: 1 DIF: Cognitive Level: Synthesis REF: 575 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

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MULTIPLE RESPONSE 36. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) Administration of oxygen via face mask at 8 to 10 L/min

Maternal change of position to knee-chest

Administration of tocolytic agent

Administration of oxytocin (Pitocin)

Vaginal elevation

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Insertion of cord back into vaginal area

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ANS: A, B, C, E

Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated. PTS: 1 DIF: Cognitive Level: Analysis REF: 591 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency

Increased risk for placenta previa

Painful uterine contractions

Increased resting tone

Uterine vasodilation

Increased uterine pressure

Effective uterine contraction

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37. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.)

ANS: B, C, E

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Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus, there is an increased risk for placental abruption as compared with placenta previa, which is based on malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor.

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Chapter 9 Gestational Diabetes, Macrosomia, and Neonatal Cephalhematoma

1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia. Answer: 1 Explanation: 1. IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum). 2) The nurse is caring for a prenatal client. Reviewing the clients pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The mothers low socioeconomic status 2. Maternal age of 26 3. Mothers exposure to toxic chemicals 4. More than three previous deliveries

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5. Maternal hypertension Answer: 1, 3, 4, 5 Explanation: 1. Low socioeconomic status is associated with at-risk newborns. 3. Exposure to environmental dangers, such as toxic chemicals is associated with at-risk newborns. 4. Maternal factors such as multiparity are associated with at-risk newborns. 5. Preexisting maternal conditions, such as heart disease, diabetes, hypertension, hyperthyroidism, and renal disease are associated with at-risk newborns. 3) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory 2. 23-year-old of low socioeconomic status, unmarried 3. 16-year-old who began prenatal care at 30 weeks 4. 28-year-old with a history of gestational diabetes Answer: 1 Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.

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Chapter 10 Advanced Maternal Age, HELLP Syndrome, and Neonatal Necrotizing Enterocolitis

I will be sure to avoid getting pregnant for at least 1 year.

My intake of iron will have to be closely monitored for 6 months.

My blood pressure will continue to be increased for about 6 more months.

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After teaching a woman who has had an evacuation for a hydatidiform mole (molar pregnancy. about her condition, which of the following statements indicates that the nurses teaching was successful?

I wont use my birth control pills for at least a year or two.

Which of the following findings on a prenatal visit at 10 weeks might lead the nurse to suspect a hydatidiform mole?

Complaint of frequent mild nausea

Blood pressure of 120/84 mm Hg

History of bright red spotting 6 weeks ago

Fundal height measurement of 18 cm

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

Urinary output of 20 mL per hour

Respiratory rate of 10 breaths/minute

Deep tendons reflexes 2+

Difficulty in arousing

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which of the following responses by the nurse would be most appropriate?

Why are you crying?

Will a pill help your pain?

Im sorry you lost your baby.

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A baby still wasnt formed in your uterus.

Which of the following data on a clients health history would the nurse identify as contributing to the clients risk for an ectopic pregnancy?

Use of oral contraceptives for 5 years

Ovarian cyst 2 years ago

Recurrent pelvic infections

Heavy, irregular menses

In a woman who is suspected of having a ruptured ectopic pregnancy, the nurse would expect to assess for which of the following as a priority?

Hemorrhage

Jaundice

Edema

Infection

Which of the following findings would the nurse interpret as suggesting a diagnosis of gestational trophoblastic disease?

Elevated hCG levels, enlarged abdomen, quickening

Vaginal bleeding, absence of FHR, decreased hPL levels

Visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen

Gestational hypertension, hyperemesis gravidarum, absence of FHR

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It is determined that a clients blood Rh is negative and her partners is positive. To help prevent Rh isoimmunization, the nurse anticipates that the client will receive RhoGAM at which time?

At 34 weeks gestation and immediately before discharge

24 hours before delivery and 24 hours after delivery

In the first trimester and within 2 hours of delivery

At 28 weeks gestation and again within 72 hours after delivery

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the womans increased risk?

Oligohydramnios

Preeclampsia

Post-term labor

Chorioamnionitis

10.

A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which of the following would the lead the nurse to suspect that the client is having an adverse effect associated with this drug?

Gastrointestinal bleeding

Blurred vision

Tachycardia

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Sweating

11.

After reviewing a clients history, which factor would the nurse identify as placing her at risk for gestational hypertension?

Mother had gestational hypertension during pregnancy.

Client has a twin sister.

Sister-in-law had gestational hypertension.

This is the clients second pregnancy.

12.

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. Which of the following would the nurse expect to include in the clients plan of care?

Clear liquid diet

Total parenteral nutrition

Nothing by mouth

Administration of labetalol

13.

The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome?

Hyperglycemia

Elevated platelet count

Leukocytosis

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Elevated liver enzymes

14.

Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?

Calcium gluconate

Potassium chloride

Ferrous sulfate

Calcium carbonate

15.

Which assessment finding would lead the nurse to suspect infection as the cause of a clients PROM?

Yellow-green fluid

Blue color on Nitrazine testing

Ferning

Foul odor

16.

While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios based on which of the following? (Select all that apply.)

History of diabetes

Complaints of shortness of breath

Identifiable fetal parts on abdominal palpation

Difficulty obtaining fetal heart rate

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Fundal height below that for expected gestataional age

17.

After teaching a group of nursing students about the possible causes of spontaneous abortion, the instructor determines that the teaching was successful when the students identify which of the following as the most common cause of first trimester abortions?

Maternal disease

Cervical insufficiency

Fetal genetic abnormalities

Uterine fibroids

18.

A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which of the following would lead the nurse to suspect that the woman is developing an infection? (Select all that apply.)

Fetal bradycardia

Abdominal tenderness

Elevated maternal pulse rate

Decreased C-reactive protein levels

Cloudy malodorous fluid

19.

A nurse is teaching a pregnant woman with preterm premature rupture of membranes who is about to be discharged home about caring for herself. Which statement by the woman indicates a need for additional teaching?

I need to keep a close eye on how active my baby is each day.

I need to call my doctor if my temperature increases.

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Its okay for my husband and me to have sexual intercourse.

I can shower but I shouldnt take a tub bath.

20.

A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia?

Urine protein 300 mg/24 hours

Blood pressure 150/96 mm Hg

Mild facial edema

Hyperreflexia

21.

A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment of which of the following? (Select all that apply.)

Dark red vaginal bleeding

Insidious onset

Absence of pain

Rigid uterus

Absent fetal heart tones

22.

The health care provider orders PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which of the following would be most important for the nurse to do?

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Use clean technique to administer the drug.

Keep the gel cool until ready to use.

Maintain the client for hour after administration.

Administer intramuscularly into the deltoid area.

High body mass index

Urinary tract infection

Low socioeconomic status

Single gestations

Smoking

24.

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?

My mother lives next door and can drive me here if necessary.

I have a toddler and preschooler at home who need my attention.

I know to call my health care provider right away if I start to bleed again.

I realize the importance of following the instructions for my care.

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23.

A nursing student is reviewing an article about preterm premature rupture of membranes. Which of the following would the student expect to find as factor placing a woman at high risk for this condition? (Select all that apply.)

25.

A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make?

Make sure that anything around your waist is quite snug.

Try to eat three large meals a day with less snacking.

Drink fluids in between meals rather than with meals.

Lie down for about an hour after you eat

26.

A woman with gestational hypertension experiences a seizure. Which of the following would be the priority?

Fluid replacement

Oxygenation

Control of hypertension

Delivery of the fetus

27.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the womans serum magnesium levels. Which level would the nurse identify as therapeutic?

3.3 mEq/L

6.1 mEq/L

8.4 mEq/L

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10.8 mEq/L

Answer Key 1.

10.

11.

12.

13.

D A, B, D

16.

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14. 15.

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17.

18.

B, C, E

19.

20.

A, D, E

22.

23.

B, C, E

24.

25.

26.

27.

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Chapter 11 Migraine With Aura, Shoulder Dystocia, and Brachial Plexus Palsy

Most common on right side

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1.Incidence of brachial plexus palsy reported to affect 1 per 1000 live births (Bar et al 2001) Mechanical injury related to how the baby was delivered

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most common delivery presentation is left occiput anterior vertex

Associated with: pre and gestational diabetes older maternal age high birth weight or LGA

2. What is Dystocia? difficult birth, typically caused by a large or awkwardly positioned fetus, by smallness of the maternal pelvis, or by failure of the uterus and cervix to contract and expand normally 3. What are Both Shoulder dystocia? ( obstructed labor where the delivery of the head and anterior shoulder cannot pass below or require significant manipulation) and brachial plexus palsy are more common in LGA babies and Infants of diabetic mothers 4. Brachial plexus comprised of :

comprised of a group of nerves arising form the nerve roots C5-T1

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5. What are some previously used terms for Migraine With Aura? Classic or classical migraine, Ophthalmic Migraine, Hemiparaesthetic Migraine, Hemiplegic Migraine, Aphasic Migraine, Migraine Accompagnée, Complicated Migraine 6. What type of disorder is Migraine with Aura? Migraine with Aura is a "recurrent" primary headache disorder 7. What neurological symptoms does Migraine with Aura have? Migraine with Aura is manifested in "attacks of reversible focal neurological symptoms". 8. How long does it take for the reversible focal neurological symptoms, the aura, of Migraine with Aura to develop? The neurological symptoms of Migraine with Aura usually develop gradually over "5-20 minutes" 9. How long do Migraine with Aura reversible focal neurological symptoms usually last? The Migraine with Aura neurological symptoms usually last for "less than 60 minutes". 10. What usually follows the aura in Migraine with Aura? Headache with the features of "Migraine Without Aura" usually follow the aura symptoms.

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Chapter 12 Intimate Partner Violence, Formula Feeding, and Postpartum Depression

MULTIPLE CHOICE 1. The breastfeeding client should be taught a safe method to remove her breast from the babys mouth. Which suggestion by the nurse is most appropriate? a. Break the suction by inserting your finger into the corner of the infants mouth. A popping sound occurs when the breast is correctly removed from the infants mouth.

Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed.

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Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the d. baby cries. ANS: A Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple, making it sore. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended. PTS: 1 DIF: Cognitive Level: Application REF: 446 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. Which woman is most likely to continue breastfeeding beyond 6 months?

A woman who avoids using bottles

A woman who uses formula for every other feeding

A woman who offers water or formula after breastfeeding

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d. A woman whose infant is satisfied for 4 hours after the feeding ANS: A Women who avoid using bottles and formula are more likely to continue breastfeeding. Use of formula decreases breastfeeding time and decreases the production of prolactin and, ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The new breastfeeding mother needs to nurse often to stimulate milk production. PTS: 1 DIF: Cognitive Level: Analysis REF: 453 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. In which condition is breastfeeding contraindicated? a. Triplet birth b.

Flat or inverted nipples

Human immunodeficiency virus infection

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d. Inactive, previously treated tuberculosis ANS: C Human immunodeficiency virus is a serious illness that can be transmitted to the infant via body fluids. Because the amount of milk being produced depends on the amount of suckling of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin to be treated during pregnancy but may begin after birth. Many methods help flat or inverted nipples to become more erect. Only active tuberculosis patients would be cautioned not to breastfeed. PTS: 1 DIF: Cognitive Level: Understanding REF: 454 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment 4. Which type of formula should not be diluted before being administered to an infant? a. Powdered Concentrated

Ready to use

d. Modified cows milk ANS: C Ready to use formula can be poured directly from the can into the babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted. PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day?

50 to 75

100 to 110

120 to 140

40 to 60

60 to 100

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d. 150 to 200 ANS: B The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional needs each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are too much. PTS: 1 DIF: Cognitive Level: Understanding REF: 436 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. How many milliliters per kilogram (mL/kg) of fluids does a newborn need daily for the first 3 to 5 days of life? a. 20 to 30

Prolactin

Progesterone

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d. 120 to 150 ANS: C The newborn needs 60 to 100 mL/kg of fluids daily for the first 3 to 5 days of life. 20 to 30 mL/kg and 40 to 60 mL/kg are too small an amount for the newborn. 120 to 150 mL/kg is too large an amount for the newborn. PTS: 1 DIF: Cognitive Level: Understanding REF: 436, 437 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. Which is the hormone necessary for milk production? a. Estrogen

d. Lactogen ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. PTS: 1 DIF: Cognitive Level: Understanding REF: 441 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which recommendation should the nurse make to a client to initiate the milk ejection reflex? a. Wear a well-fitting firm bra. b.

Drink plenty of fluids.

Place the infant to the breast.

Apply cool packs to the breast.

ANS: C Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast but will not initiate the let-down reflex. Drinking plenty of fluids is necessary for adequate milk production but will not initiate the let-down reflex. Cool packs to the breast will decrease the let-down reflex. PTS: 1 DIF: Cognitive Level: Application REF: 441 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. Which is the first step in assisting the breastfeeding mother? a. Assess the womans knowledge of breastfeeding. Provide instruction on the composition of breast milk.

Discuss the hormonal changes that trigger the milk ejection reflex.

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d. Help her obtain a comfortable position and place the infant to the breast. ANS: A The nurse should first assess the womans knowledge and skill in breastfeeding to determine her teaching needs. Assessment should occur before instruction. Discussing the hormonal changes and helping her obtain a comfortable position may be part of the instructional plan, but assessment should occur first to determine what instruction is needed. PTS: 1 DIF: Cognitive Level: Application REF: 443, 444 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Which is an important consideration in positioning a newborn for breastfeeding? a. Placing the infant at nipple level facing the breast Keeping the infants head slightly lower than the body

Using the forefinger and middle finger to support the breast

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d. Limiting the amount of areola the infant takes into the mouth ANS: A Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. Keeping the infants head slightly lower will pull the nipple down and cause trauma. The forefinger and middle finger can be used to support the breast, but this is not an important consideration in positioning the newborn. The infant should take in as much areola as possible to prevent trauma to the nipples. PTS: 1 DIF: Cognitive Level: Analysis REF: 444 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 11. The client should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following? a. Unwrap and gently arouse the infant. b.

Wait an hour and attempt to feed again.

Try offering a bottle at the next feeding.

d. Put the infant in the crib and try again later. ANS: A

Limit her intake of fluids for the first few days.

Apply cold packs to the breast prior to feeding.

The infant who falls asleep during feeding may not have fed adequately and should be gently aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast milk production will decrease. The infant should be aroused and feeding continued. PTS: 1 DIF: Cognitive Level: Application REF: 449 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. To prevent breast engorgement, what should the new breastfeeding mother be instructed to do? a. Feed her infant no more than every 4 hours.

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d. Breast-feed frequently and for adequate lengths of time. ANS: D Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, so waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before feedings. PTS: 1 DIF: Cognitive Level: Application REF: 453 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 13. What is the difference between the aseptic and terminal methods of sterilization? a. The aseptic method requires a longer preparation time. The aseptic method does not require boiling of the bottles.

The terminal method requires boiling water to be added to the formula.

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The terminal method sterilizes the prepared formula at the same time it sterilizes the d. equipment. ANS: D In the terminal sterilization method, the formula is prepared in the bottles, which are loosely capped, and then the bottles are placed in the sterilizer, where they are boiled for 25 minutes. The terminal method takes 25 minutes to boil; the aseptic method takes 5 minutes to boil. With the aseptic method, the bottles are boiled separate from the formula. With the terminal method, the formula is prepared, placed in bottles, and everything is boiled at one time. PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment 14. How many ounces will an infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? a. 1 b.

1.5

3.5

d. 5 ANS: C The newborn requires approximately 12 to 24 oz of formula each day (6 feedings/24-hour period). 1 and 1.5 ounces are too small to meet calorie needs; 5 ounces with every feeding would be overfeeding the infant. PTS: 1 DIF: Cognitive Level: Analysis REF: 459 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 15. A new mother is concerned because her 1-day-old newborn is taking only 1 oz at each feeding. What should the nurse explain? a. The infant is probably having difficulty adjusting to the formula. An infant does not require as much formula in the first few days of life.

The infants stomach capacity is small at birth but will expand within a few days.

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d. The infant tires easily during the first few days but will gradually take more formula. ANS: C The infants stomach capacity at birth is 10 to 20 mL and increases to 30 to 90 mL by the end of the first week. There are other symptoms if there is a formula intolerance. The infants requirements are the same, but the stomach capacity needs to increase before taking in adequate amounts. The infants sleep patterns do change, but the infant should be awake enough to feed. PTS: 1 DIF: Cognitive Level: Application REF: 446 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 16. As the nurse assists a new mother with breastfeeding, the mother asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The nurses best response is that it contains: a. more calcium. more calories.

essential amino acids.

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d. important immunoglobulins. ANS: D Breast milk contains immunoglobulins that protect the newborn against infection. Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly. The calorie counts of formula and breast milk are about the same. All the essential amino acids are in formula and breast milk. The concentrations may differ. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. What should the nurse explain when responding to the question, Will I produce enough milk for my baby as she grows and needs more milk at each feeding? a. Early addition of baby food will meet the infants needs. b.

The breast milk will gradually become richer to supply additional calories.

As the infant requires more milk, feedings can be supplemented with cows milk.

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d. The mothers milk supply will increase as the infant demands more at each feeding. ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Solids should not be added until about 4 to 6 months, when the infants immune system is more mature. This will decrease the chance of allergy formations. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. PTS: 1 DIF: Cognitive Level: Application REF: 441 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 18. Which should the nurse recommend to the postpartum client to prevent nipple trauma? a. Assess the nipples before each feeding. b.

Limit the feeding time to less than 5 minutes.

Wash the nipples daily with mild soap and water.

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d. Position the infant so the nipple is far back in the mouth. ANS: D If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for trauma is important, but it will not prevent sore nipples. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. Soap can be drying to the nipples and should be avoided during breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 458 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 19. A breastfeeding client who was discharged yesterday calls to ask about a tender hard area on her right breast. What should be the nurses first response? a. This is a normal response in breastfeeding mothers. Notify your doctor so he can start you on antibiotics.

Stop breastfeeding because you probably have an infection.

d. Try massaging the area and apply heat; it is probably a plugged duct. ANS: D A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation. PTS: 1 DIF: Cognitive Level: Application REF: 451 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 20. Which is an important consideration about the storage of breast milk?

Can be thawed and refrozen

Can be frozen for up to 2 months

Should be stored only in glass bottles

Aspiration

Dental caries

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d. Can be kept refrigerated for 48 hours ANS: D If used within 48 hours after being refrigerated, breast milk will maintain its full nutritional value. It should not be refrozen. Frozen milk should be kept for 1 month only. Antibodies in the milk will adhere to glass bottles. Only rigid polypropylene plastic containers should be used. PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment 21. What is the most serious consequence of propping an infants bottle? a. Colic

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d. Ear infections ANS: B Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. Colic can occur but is not the most serious consequence. Dental caries becomes a problem when milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs. However, this is not the most serious consequence. PTS: 1 DIF: Cognitive Level: Understanding REF: 459 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 22. A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurses best response? a. Formula may turn sour after it is opened. Bacteria can grow rapidly in warm milk.

Formula loses some nutritional value once it is opened.

d. This makes it easier to keep track of how much the baby is taking. ANS: B Formula should not be saved from one feeding to the next because of the danger of rapid growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This will cause problems in a newborn with an immature immune system. The loss of some nutritional value after the formula is opened is not the reason for using fresh bottles with each feeding. The danger of bacterial growth is the main concern. PTS: 1 DIF: Cognitive Level: Application REF: 459 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 23. A new mother asks whether she should feed her newborn colostrum because it is not real milk. The nurses best answer includes which information?

Colostrum is unnecessary for newborns.

Colostrum is high in antibodies, protein, vitamins, and minerals.

Colostrum is lower in calories than milk and should be supplemented by formula.

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Giving colostrum is important in helping the mother learn how to breast-feed before she d. goes home. ANS: B Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Colostrum provides immunity and enzymes necessary to clean the gastrointestinal system, among other things. Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge, but the importance of the colostrum to the infant is top priority. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 24. A newborn infant weighs 7 pounds, 2 ounces, on the fifth day of life. How much water should be given to the newborn based on required fluid needs? Fluid replacement should be based on weight and calculated in the range of 60 to 100 a. mL/kg. Offer additional water to tolerance in between infant feedings to maintain hydration.

Give 12 ounces of fluid per feeding.

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d. No water is needed because formula and breast milk are adequate to maintain hydration. ANS: A There is an expected weight loss of up to 10% postdelivery, so fluid replacement should be calculated to improve health outcomes and maintain adequate hydration.12 ounces of fluid per feeding is excessive and may cause overdistention. Offering water between feedings to tolerance may not provide enough fluid replacement. Newborn infants require additional water to supplement feedings and support hydration. PTS: 1 DIF: Cognitive Level: Analysis REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 25. A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The best nursing response would be to: a. tell the client to wear a bra at all times to provide more support to breast tissue. b.

have the client put the infant to her breast more frequently.

place ice packs on breast tissue after infant feeding.

d. ANS: B

explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.

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The client may be experiencing signs of engorgement. Intervention methods such as placing the infant to feed more frequently may help prevent physical complaints of tenderness to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but can provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement issues. Warm water compresses are more likely to provide comfort. Engorgement is not a normal finding but is a common presentation in nursing mothers. These symptoms will not dissipate with continuation of breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 442, 451 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 26. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, the nurse would designate a score of: a. 10 and document findings in the chart. b.

6 and further teach and assist the mother in feeding activities.

5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.

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d. 8 and no further assistance is needed for feeding. ANS: B The LATCH assessment tool is used to identify whether mothers need additional instruction in the area of breastfeeding. The LATCH categories are latch, audible communication/swallowing, type of nipple, comfort of breasts, and holding position of infant. The assessment data reveal a score of 6 (0 + 2 + 1 + 2 + 1) so the mother needs additional assistance during breastfeeding at this time. PTS: 1 DIF: Cognitive Level: Analysis REF: 443 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 27. A mother conveys concern over the fact that she is not sure if her newborn child is getting enough nutrients from breastfeeding. This is the babys first clinic visit after birth. What information can you provide that will help alleviate her fears about nutrient status for her newborn? Monitor the infants output; as long as at least six or more diapers are changed in a 24a. hour period, that should be sufficient. b.

Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy.

Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition.

Provide nutrition information in the form of pamphlets for the mother to take home with her so that she uses them as a point of reference.

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ANS: A The presence of wet diapers confirms that the infant is receiving enough milk. Recording weight and seeing an increase in weight is also an objective finding that can be used to note nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although breast milk is potentially the perfect food for the newborn, not everyones breast milk has nutrient quality, so recording of weight gain and output measurements (wet diapers and stool production) confirm nutritional status. Providing the mother with educational pamphlets may be advisable but does not address the immediate problem. PTS: 1 DIF: Cognitive Level: Application REF: 448 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 28. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurses best response? a. Are you concerned about your ability to adequately nurse your baby? b.

Do you eat a well-balanced diet, high in protein and carbohydrates?

Breast milk is low in vitamin D and supplementation with 400 IU is recommended.

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d. Your breast milk has all the vitamins and will adequately meet your babys needs. ANS: C Generally, nutrients provided in breast milk are present in amounts and proportions needed by the infant. However, recent studies have shown that the vitamin D content of breast milk is low, and daily supplementation with 400 IU of vitamin D is recommended within the first few days of life. Breastfeeding infants who are not exposed to the sun and those with dark skin are particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart of vitamin Dfortified milk per day should also be supplemented. Although the fatty acid content of breast milk is influenced by the mothers diet, malnourished mothers milk has about the same proportions of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk are affected by the mothers intake and stores. It is important for breastfeeding women to eat a well-balanced diet to maintain their own health and energy levels. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 29. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding? I should encourage my baby to consume the entire amount of formula prepared for each a. feeding. b.

I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.

I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby.

I will generally feed my baby every 3 to 4 hours or more as signs of hunger are displayed.

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ANS: A Infants will stop suckling when they are full. Encouraging them to overeat may lead to problems with regurgitation and possible aspiration. The mother can prepare a single bottle or a 24-hour supply if adequate refrigeration is available. Show the parents how to position the infant in a semiupright position, such as the cradle hold. This allows them to hold the infant close in a faceto-face position. The bottle is held with the nipple kept full of formula to prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but avoid rigid scheduling and take cues from the infant. PTS: 1 DIF: Cognitive Level: Analysis REF: 458 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 30. A client who is receiving a pitocin (Oxytocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority? a. Increase the rate of pitocin infusion to help spread out the contraction pattern. b.

Place oxygen on the client at 8 to 10 L/min via face mask and turn the client to her left side.

Stop the pitocin infusion.

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d. Call the physician to obtain an order for the initiation of magnesium sulfate. ANS: C The client is exhibiting uterine tachysystole (uterine tetany). The priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be contacted for additional orders. 31. What data in the clients history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression? a. Teenage depression episode b.

Unexpected operative birth

Ambivalence during the first trimester

d. Second pregnancy in a 3-year period ANS: A A personal history of depression is a risk factor for postpartum depression. An operative birth, ambivalence during the first trimester, and two pregnancies in 3 years are not risk factors for postpartum depression. Chapter 13 Gestational Trophoblastic Disease (Molar Pregnancy) and Advanced Maternal Age

After teaching a woman who has had an evacuation for a hydatidiform mole (molar pregnancy. about her condition, which of the following statements indicates that the nurses teaching was successful?

I will be sure to avoid getting pregnant for at least 1 year.

My intake of iron will have to be closely monitored for 6 months.

My blood pressure will continue to be increased for about 6 more months.

I wont use my birth control pills for at least a year or two.

Which of the following findings on a prenatal visit at 10 weeks might lead the nurse to suspect a hydatidiform mole?

Complaint of frequent mild nausea

Blood pressure of 120/84 mm Hg

History of bright red spotting 6 weeks ago

Fundal height measurement of 18 cm

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

Urinary output of 20 mL per hour

Respiratory rate of 10 breaths/minute

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Deep tendons reflexes 2+

Difficulty in arousing

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which of the following responses by the nurse would be most appropriate?

Why are you crying?

Will a pill help your pain?

Im sorry you lost your baby.

A baby still wasnt formed in your uterus.

Which of the following data on a clients health history would the nurse identify as contributing to the clients risk for an ectopic pregnancy?

Use of oral contraceptives for 5 years

Ovarian cyst 2 years ago

Recurrent pelvic infections

Heavy, irregular menses

In a woman who is suspected of having a ruptured ectopic pregnancy, the nurse would expect to assess for which of the following as a priority?

Hemorrhage

Jaundice

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Edema

Infection

Which of the following findings would the nurse interpret as suggesting a diagnosis of gestational trophoblastic disease?

Elevated hCG levels, enlarged abdomen, quickening

Vaginal bleeding, absence of FHR, decreased hPL levels

Visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen

Gestational hypertension, hyperemesis gravidarum, absence of FHR

It is determined that a clients blood Rh is negative and her partners is positive. To help prevent Rh isoimmunization, the nurse anticipates that the client will receive RhoGAM at which time?

At 34 weeks gestation and immediately before discharge

24 hours before delivery and 24 hours after delivery

In the first trimester and within 2 hours of delivery

At 28 weeks gestation and again within 72 hours after delivery

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the womans increased risk?

Oligohydramnios

Preeclampsia

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Post-term labor

Chorioamnionitis

10.

Gastrointestinal bleeding

Blurred vision

Tachycardia

Sweating

11.

After reviewing a clients history, which factor would the nurse identify as placing her at risk for gestational hypertension?

Mother had gestational hypertension during pregnancy.

Client has a twin sister.

Sister-in-law had gestational hypertension.

This is the clients second pregnancy.

12.

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. Which of the following would the nurse expect to include in the clients plan of care?

Clear liquid diet

Total parenteral nutrition

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Nothing by mouth

Administration of labetalol

13.

The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome?

Hyperglycemia

Elevated platelet count

Leukocytosis

Elevated liver enzymes

14.

Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?

Calcium gluconate

Potassium chloride

Ferrous sulfate

Calcium carbonate

15.

Which assessment finding would lead the nurse to suspect infection as the cause of a clients PROM?

Yellow-green fluid

Blue color on Nitrazine testing

Ferning

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Foul odor

16.

While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios based on which of the following? (Select all that apply.)

History of diabetes

Complaints of shortness of breath

Identifiable fetal parts on abdominal palpation

Difficulty obtaining fetal heart rate

Fundal height below that for expected gestataional age

17.

Maternal disease

Cervical insufficiency

Fetal genetic abnormalities

Uterine fibroids

18.

Fetal bradycardia

Abdominal tenderness

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Elevated maternal pulse rate

Decreased C-reactive protein levels

Cloudy malodorous fluid

19.

I need to keep a close eye on how active my baby is each day.

I need to call my doctor if my temperature increases.

Its okay for my husband and me to have sexual intercourse.

I can shower but I shouldnt take a tub bath.

20.

A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia?

Urine protein 300 mg/24 hours

Blood pressure 150/96 mm Hg

Mild facial edema

Hyperreflexia

21.

A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment of which of the following? (Select all that apply.)

Dark red vaginal bleeding

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Insidious onset

Absence of pain

Rigid uterus

Absent fetal heart tones

Use clean technique to administer the drug.

Keep the gel cool until ready to use.

Maintain the client for hour after administration.

Administer intramuscularly into the deltoid area.

23.

High body mass index

Urinary tract infection

Low socioeconomic status

Single gestations

Smoking

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22.

The health care provider orders PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which of the following would be most important for the nurse to do?

My mother lives next door and can drive me here if necessary.

I have a toddler and preschooler at home who need my attention.

w 24.

I know to call my health care provider right away if I start to bleed again.

I realize the importance of following the instructions for my care.

25.

A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make?

Make sure that anything around your waist is quite snug.

Try to eat three large meals a day with less snacking.

Drink fluids in between meals rather than with meals.

Lie down for about an hour after you eat

26.

A woman with gestational hypertension experiences a seizure. Which of the following would be the priority?

Fluid replacement

Oxygenation

Control of hypertension

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Delivery of the fetus

27.

3.3 mEq/L

6.1 mEq/L

8.4 mEq/L

10.8 mEq/L

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10.

8. 9.

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Answer Key

B C A

12.

13.

14.

16.

A, B, D

17.

18.

B, C, E

19.

20.

21.

A, D, E

22.

23.

B, C, E

C B B

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27.

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24.

26.

15.

Chapter 14 Before Conception MULTIPLE CHOICE 1. What is the total number of chromosomes contained in a mature sperm or ovum? a. 22 b. 23 c. 44 d. 46 ANS: B Gametes (sex chromosomes) contain 23 chromosomes.

DIF: Cognitive Level: Knowledge REF: Page 31 OBJ: 2 TOP: Gametogenesis KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

2. A pregnant woman states, My husband hopes I will give him a boy because we have three girls. What will the nurse explain to this woman? a. The sex chromosome of the fertilized ovum determines the gender of the child. b. When the sperm and ovum are united, there is a 75% chance the child will be a girl. c. When the pH of the female reproductive tract is acidic, the child will be a girl. d. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced. ANS: D When a Y-bearing sperm fertilizes an ovum, a male child is produced.

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DIF: Cognitive Level: Comprehension REF: Page 33 OBJ: 3 TOP: Sex Determination KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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3. What is the most common site for fertilization? a. Lower segment of the uterus b. Outer third of the fallopian tube near the ovary c. Upper portion of the uterus d. Area of the fallopian tube farthest from the ovary ANS: B Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.

DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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4. The embryo is termed a fetus at which stage of prenatal development? a. 2 weeks b. 4 weeks c. 9 weeks d. 16 weeks ANS: C The fetus (third stage of prenatal development) begins at the ninth week and continues until the 40th week of gestation or until birth. DIF: Cognitive Level: Knowledge REF: Page 36 OBJ: 4 TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries

ANS: A The umbilical vein transports richly oxygenated blood from the placenta to the fetus. DIF: Cognitive Level: Knowledge REF: Page 39-40 OBJ: 7 TOP: Fetal Circulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

6. Where is the usual location for implantation of the zygote? a. Upper section of the posterior uterine wall b. Lower portion of the uterus near the cervical os c. Inner third of the fallopian tube near the uterus d. Lateral aspect of the uterine wall ANS: A The zygote usually implants in the upper section of the posterior uterine wall.

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DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 3 TOP: Implantation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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7. What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the uterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis ANS: C The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.

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DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 4 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

8. Which hormone is responsible for converting the endometrium into decidual cells for implantation? a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone ANS: D At high levels, progesterone maintains the endometrial lining for implantation of the zygote. DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6 TOP: Placenta KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A patient asks the nurse when her infants heart will begin to pump blood. What will the nurse reply? a. By the end of week 3 b. Beginning in week 8

c. At the end of week 16 d. Beginning in week 24 ANS: A The fetal heart begins to pump by week 3 of gestation. DIF: Cognitive Level: Knowledge REF: Page 36 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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10. What organ does the ductus venosus shunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs d. Kidneys ANS: A Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava. DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 7 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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11. What complication can result from untreated respiratory distress in the newborn? a. Esophageal atresia b. Gastric dilation c. Cold stress d. Reopening of the foramen ovale ANS: D Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale. DIF: Cognitive Level: Comprehension REF: Page 40 OBJ: 7 TOP: Fetal Circulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

12. During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High birth-weight twins ANS: A Dizygotic twins always have two amnions and two chorions (placentas). DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8 TOP: Multifetal Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

13. A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin that is pink and smooth d. Eyes that are closed ANS: A By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus has definite periods of movement and sleeping.

DIF: Cognitive Level: Comprehension REF: Page 37-38, Table 3-1 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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14. At what point in prenatal development do the lungs begin to produce surfactant? a. 17 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: C During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur. DIF: Cognitive Level: Knowledge REF: Page 37, Table 3-1 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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15. A woman missed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test. Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen ANS: C Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization. DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent? a. Congenital heart defects b. Neural tube defects c. Mental retardation d. Premature birth

ANS: B It is now known that folic acid supplements can prevent neural tube defects such as spina bifida. DIF: Cognitive Level: Comprehension REF: Page 37 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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17. The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability? a. 14 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: B By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of viability). DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 5 TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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18. The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not? a. 10% b. 25% c. 50% d. 100% ANS: C If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.

DIF: Cognitive Level: Comprehension REF: Page 34 OBJ: 4 TOP: Dominant Traits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

19. The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition ANS: D The single placenta may not be able to provide adequate nutrition to two fetuses. DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8 TOP: Low Birth-weight Twins KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

20. The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix? a. They are destroyed by the acidic pH of the vagina. b. They survive up to 5 days and can cause pregnancy. c. They lose their motility in about 12 hours after intercourse. d. They are usually pushed out of the vagina by the muscular action of the vaginal wall. ANS: B Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.

DIF: Cognitive Level: Comprehension REF: Page 33 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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21. What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse? a. Age b. Estrogen level c. Body temperature d. Level of feminine hygiene ANS: B Estrogen levels and the pH of the female reproductive tract can affect the survival of the X- and Y-bearing sperm as well as their motility. DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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22. Of what is the normal umbilical cord comprised? a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus ANS: C The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus.

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6 TOP: Fetal Circulation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 23. What part of the fetal body derives from the mesoderm? a. Nails b. Oil glands c. Muscles d. Lining of the bladder ANS: C The mesoderm is responsible for the development of muscles. Nails and oil glands derive from the ectoderm. The lining of the bladder derives from the endoderm.

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1 OBJ: 4 TOP: Embryonic development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

24. A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound? a. 4 weeks gestational age b. 6 weeks gestational age c. 10 weeks gestational age d. 16 weeks gestational age ANS: C The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound examination.

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DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 5 TOP: Fetal Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE

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25. A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm ANS: A, B, C The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm.

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1 OBJ: 4 TOP: Primary Germ Layers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

26. What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus ANS: A, E The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin; allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for the fetus. Although the fetus does swallow amniotic fluid, it has no nutritional value.

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1 OBJ: 6 TOP: Amniotic Fluid KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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27. A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What facts will the nurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twins share a placenta. c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases with maternal age. ANS: C, D Dizygotic twins tend to repeat in families and have separate chorions. They can be the same sex or different sexes and have their own placenta. Incidence increases with maternal age. DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8 TOP: Dizygotic Twins KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION

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28. The nurse explains that prior to fertilization each cell is reduced from 46 chromosomes to 23 chromosomes. This is referred to as the __________ number. ANS: haploid

When each cell reduces its chromosomes from 46 to 23, it is called the haploid number.

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DIF: Cognitive Level: Knowledge REF: Page 32 OBJ: 2 TOP: Haploid Number KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

ANS: DNA

29. The component of development that programs the genetic code into the nucleus of the cell is ____________.

The DNA programs the genetic code to the nucleus of the cell to be replicated. DIF: Cognitive Level: Knowledge REF: Page 31 | Page 34 OBJ: 4 TOP: DNA KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 30. The vessels comprising the umbilical cord are cushioned and protected by a substance called ___________ _____________. ANS: Whartons jelly

Whartons jelly is a substance in the umbilical cord that cushions and protects the vessels. DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 1 TOP: Fetal Circulation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 31. The normal volume of amniotic fluid is approximately _______________ mL at 37 weeks gestation. ANS: 1000

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The volume of amniotic fluid steadily increases from about 30 mL at 10 weeks of pregnancy to 350 mL at 20 weeks. The volume of fluid is about 1000 mL at 37 weeks. In the latter part of pregnancy the fetus may swallow up to 400 mL of amniotic fluid per day and normally excretes urine into the fluid. DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 6 TOP: Amniotic Fluid KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 32. Organize the developmental stages in the correct order. Put a comma and space between each answer choice (a, b, c, d, etc.)

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ANS: B, E, D, C, A

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a. Fetus b. Zygote c. Embryo d. Blastocyst e. Morula

The development follows these stages: zygote, morula, blastocyst, embryo, and fetus.

DIF: Cognitive Level: Comprehension REF: Page 34-37 OBJ: 4 TOP: Fetal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

33. Put the embryonic/fetal characteristics in the correct order of occurrence from week 3 to week 36 of gestation. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Subcutaneous fat is present. b. Bone marrow forms blood cells. c. Spinal cord and brain appear. d. Skull and jaw ossify. e. Neural tube closes. ANS: C, E, D, B, A

Primitive spinal cord and brain appear at 3 weeks. Neural tube closes at 4 weeks. Skull and jaw ossify at 6 weeks. Spleen stops forming blood cells and bone marrow takes over at 29 weeks. Subcutaneous fat is present at 36 weeks.

Chapter 15 Pregnancy MULTIPLE CHOICE

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1. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patients obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110 ANS: C Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para.

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DIF: Cognitive Level: Application REF: Page 48, Box 4-1 OBJ: 1 TOP: Definition of Terms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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2. A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How frequently will the nurse assist the patient to schedule these appointments? a. Every 3 weeks until the 6th month, then every 2 weeks until delivery b. Every 4 weeks until the 7th month, after which appointments will become more frequent c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy ANS: B Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 to 3 weeks through 36 weeks. From 36 weeks until delivery, visits are weekly.

DIF: Cognitive Level: Application REF: Page 46 OBJ: 2 | 3 TOP: Prenatal Visits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present. What is Chadwicks sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline ANS: A Chadwicks sign is the purplish or bluish discoloration of the cervix and vagina.

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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DIF: Cognitive Level: Comprehension REF: Page 49 OBJ: 6 | 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during pregnancy. What would the nurse explain as the cause of Chadwicks sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area ANS: D Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area.

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5. The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that the woman understands the information? a. Blood pressure goes up toward the end of pregnancy. b. My breathing will get deeper and a little faster. c. Ill notice a decreased pigmentation in my skin. d. There will be a curvature in the upper spine area. ANS: B The pregnant woman breathes more deeply, and her respiratory rate may increase slightly.

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DIF: Cognitive Level: Comprehension REF: Page 52 OBJ: 7 | 13 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. A woman reports that her last normal menstrual period began on August 5, 2013. What is this womans expected delivery date using Ngeles rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014 ANS: C To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary. DIF: Cognitive Level: Analysis REF: Page 48, Box 4-2 OBJ: 5 TOP: Determining Estimated Date of Delivery KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks ANS: C The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device.

DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 3 | 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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8. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding. ANS: D The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy.

DIF: Cognitive Level: Application REF: Page 50 OBJ: 3 TOP: Assessing Fetal Heart Tone KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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9. A womans prepregnant weight is determined to be average for her height. What will the nurse advise the woman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds ANS: C The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds. DIF: Cognitive Level: Knowledge REF: Page 57 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the woman responds, I dont like milk. What dietary adjustments could the nurse recommend? a. Increase intake of organ meats. b. Eat more green leafy vegetables.

c. Choose more fresh fruits, particularly citrus fruits. d. Include molasses and whole-grain breads in the diet. ANS: B For women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables, and canned salmon and sardines that contain bones. DIF: Cognitive Level: Application REF: Page 60 OBJ: 8 | 13 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

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11. A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom? a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets. ANS: C The nurse can recommend eating dry toast or crackers before getting out of bed in the morning to alleviate nausea during pregnancy.

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DIF: Cognitive Level: Application REF: Page 65, Table 4-6 OBJ: 10 TOP: Common Discomforts in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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12. The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What is the nurses initial action? a. Assess food intake. b. Weigh the patient again. c. Take the blood pressure. d. Notify the physician. ANS: C The marked weight gain may be an indication of gestational hypertension. The blood pressure should be assessed before notifying the physician.

DIF: Cognitive Level: Application REF: Page 53 OBJ: 4 TOP: Gestational Hypertension KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables ANS: C Foods rich in DHA are red meat, flounder, halibut, and soybean and canola oil. Frying fish negatively alters the DHA.

DIF: Cognitive Level: Application REF: Page 55 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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DIF: Cognitive Level: Knowledge REF: Page 45 | Page 61 OBJ: 8 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

14. The nurse encourages adequate intake of folic acid for women of childbearing age before and during pregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neural tube defects ANS: D Folic acid can reduce the incidence of neural tube defects such as spina bifida and anencephaly.

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15. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCG detected in the urine d. Fetal heartbeat ANS: D Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner.

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DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 6 | 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope? a. 4 weeks b. 12 weeks c. 18 weeks d. 24 weeks ANS: C The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy. DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

17. A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move? What is the nurses best response? a. You may notice the baby moving around the 4th or 5th month. b. Quickening varies with every woman. c. Youll feel something by the end of the first trimester. d. The baby will be big enough for you to feel in your 8th month. ANS: A Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of gestation.

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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18. A pregnant woman inquires about exercising during pregnancy. What information should the nurse include when planning to educate this woman? a. Exercise elevates the mothers temperature and improves fetal circulation. b. Exercise increases catecholamines, which can prevent preterm labor. c. A regular schedule of moderate exercise during pregnancy is beneficial. d. Pregnant women should limit water intake during exercise. ANS: C In general, moderate exercise several times a week, from the 8th week through delivery, is advised during pregnancy. DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 9 | 13 TOP: Exercise During Pregnancy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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19. An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and counseling for adolescents different from other age populations? a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurses advice. ANS: A The pregnant adolescent must cope with two of lifes most stress-laden transitions simultaneously: adolescence and parenthood. DIF: Cognitive Level: Comprehension REF: Page 69 OBJ: 12 TOP: Psychological Adaptations to Pregnancy KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 20. At what age is a woman who becomes pregnant for the first time described as an elderly primip? a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old

ANS: D A woman over the age of 35 who becomes pregnant for the first time is described as an elderly primip. DIF: Cognitive Level: Knowledge REF: Page 69 OBJ: 12 TOP: Elderly Primip KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physical Adaptation

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21. The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the appropriate term for this sign? a. Chadwicks b. Hegars c. McDonalds d. Goodells ANS: D Goodells sign is one of the probable signs of pregnancy and describes a softened cervix and vagina. DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 1 | 6 | 7 TOP: Goodells Sign KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physical Adaptation

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22. When obtaining a prenatal history on a pregnant patient the nurse notes a family history of sickle cell disease. Given this information, what lab test can the nurse anticipate the physician will order? a. Endovaginal ultrasound b. Pap test c. Complete blood count d. Hemoglobin electrophoresis ANS: D Hemoglobin electrophoresis identifies presence of sickle cell trait or disease (in women of African or Mediterranean descent). It is ordered in the first trimester, if indicated.

DIF: Cognitive Level: Comprehension REF: Page 46, Table 4-1 OBJ: 3 TOP: Prenatal laboratory tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care 23. A pregnant woman is attending her second postpartum visit. Prenatal lab work indicates she is not immune to the rubella virus. What is the most appropriate nursing intervention? a. Provide the rubella vaccine as ordered by the physician immediately. b. Inform the woman she should receive the vaccine in the hospital after delivery. c. Hold all immunizations until 1 month postpartum. d. Encourage the patient to decide whether or not to get the rubella vaccine prenatally. ANS: B The rubella vaccine is contraindicated during pregnancy. A woman should be instructed to avoid pregnancy for at least 1 month following rubella immunization. It is not necessary to hold all immunizations until 1 month postpartum.

DIF: Cognitive Level: Application REF: Page 72 OBJ: 4 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care

24. A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does the nurse explain as the most likely cause of this symptom? a. Supine hypotension syndrome b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition ANS: A Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. Symptoms of supine hypotension syndrome include faintness, lightheadedness, dizziness, and agitation.

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DIF: Cognitive Level: Comprehension REF: Page 53 OBJ: 7 TOP: Physiological Changes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care MULTIPLE RESPONSE

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25. A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to Hawaii. What would the nurse recommend that the patient do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return. b. Eat a large meal before boarding the flight. c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently. ANS: C, D, E Because of the increase in clotting potential, the pregnant patient is prone to a thromboembolism. Adequate hydration, frequent position changes, and movement decrease the risk.

DIF: Cognitive Level: Application REF: Page 64-65 OBJ: 10 TOP: Flight Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

26. The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine ANS: A, B A waddling gait and joint instability are the only signs that relate to joint changes. The other discomforts are related to the enlarging uterus with its attendant weight.

DIF: Cognitive Level: Comprehension REF: Page 55 OBJ: 7 TOP: Joint Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. The nurse assesses the progress from the announcement stage of fatherhood to the acceptance stage when the patient reports which actions by the father? (Select all that apply.) a. Goes fishing every afternoon b. Has revised his financial plan c. Spends leisure time with his friends d. Traded his sports car for a sedan e. Helped select a crib ANS: B, D, E Active planning for an infant is an indication of the acceptance stage. Concentration on a hobby and spending time away from home are indicators of nonacceptance.

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DIF: Cognitive Level: Comprehension REF: Page 68-69 OBJ: 11 TOP: Stages of Fatherhood KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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28. What nursing interventions are appropriate for the prenatal patient in terms of prenatal care? (Select all that apply.) a. Offer nutritional counseling. b. Reinforce responsibility of parenthood. c. Reduce risk factors. d. Improve health practices. e. Make financial arrangements for delivery. ANS: A, B, C, D Nutritional counseling, reinforcing and discussing the responsibility of parenthood, reducing risk factors for the pregnant woman and the fetus, and improving health practices are all goals of prenatal care. DIF: Cognitive Level: Comprehension REF: Page 44-45 OBJ: 2 | 3 TOP: Goals of Prenatal Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

29. The nurse recognizes which behavior characteristic(s) of women in their first trimester of pregnancy? (Select all that apply.) a. Showing off her sonogram photos b. Ambivalence about pregnancy c. Emotional and labile mood d. Focusing on her infant e. Fatigue ANS: A, B, C, E Showing off photos, feeling ambivalence about the pregnancy, fragile emotions, and fatigue and sleepiness are all characteristic of behaviors seen in the first trimester. Women are not focused on their infant; they are focused on themselves and the physical changes they are experiencing.

DIF: Cognitive Level: Comprehension REF: Page 67 OBJ: 11 TOP: Behaviors of First Trimester KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 30. The number of years between menarche and the date of conception is known as ___________________ age. ANS: gynecological

Gynecological age is a term that refers to the number of years between the starting of the menses and the date of conception.

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DIF: Cognitive Level: Comprehension REF: Page 61 OBJ: 1 TOP: Gynecological Age KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

31. The nurse reminds the prenatal patient that she should add ________ kcal to her daily intake to nourish the fetus. ANS: 300

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The recommended dietary intake increase is 300 kcal a day.

DIF: Cognitive Level: Comprehension REF: Page 59 OBJ: 8 TOP: Nutrition During Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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32. The patient confesses to eating crushed ice 10 or 12 times daily. The nurse assesses this behavior as __________. ANS: pica

Pica is the craving and ingestion of nonfood substances such as clay, crushed ice, and ashes.

DIF: Cognitive Level: Comprehension REF: Page 61 OBJ: 8 TOP: Pica KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 33. The nurse is aware that ______________ maneuver can assess the position and presentation of the fetus. ANS: Leopolds Leopolds maneuver assesses the position and the presentation of the fetus by palpation.

DIF: Cognitive Level: Comprehension REF: Page 47 OBJ: 3 TOP: Leopolds Maneuver KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 34. Fathers go through phases similar to the expectant mother. Place the following phases in order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Focus phase b. Announcement phase c. Adjustment phase

ANS: B, C, A

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For fathers, the announcement phase begins when pregnancy is confirmed. The second phase of the fathers response is the adjustment phase. The third phase of the fathers response is the focus phase, in which active plans for participation in the labor process, birth, and change in lifestyle result in the partner feeling like a father. Chapter 16 Labor and Delivery MULTIPLE CHOICE

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1. What does the nurse note when measuring the frequency of a laboring womans contractions? a. How long the patient states the contractions last b. The time between the end of one contraction and the beginning of the next c. The time between the beginning and the end of one contraction d. The time between the beginning of one contraction and the beginning of the next ANS: D The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.

DIF: Cognitive Level: Comprehension REF: Page 120 OBJ: 9 TOP: Frequency of Contractions KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. Why is the relaxation phase between contractions important? a. The laboring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward delivery at these times. ANS: C Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus. DIF: Cognitive Level: Comprehension REF: Page 121-122 OBJ: 6 TOP: Interval KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. What contraction duration and interval does the nurse recognize could result in fetal compromise? a. Duration shorter than 30 seconds, interval longer than 75 seconds b. Duration shorter than 90 seconds, interval longer than 120 seconds c. Duration longer than 90 seconds, interval shorter than 60 seconds d. Duration longer than 60 seconds, interval shorter than 90 seconds ANS: C Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

DIF: Cognitive Level: Comprehension REF: Page 122, Safety Alert OBJ: 9 TOP: Contraction/Fetal Compromise KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk

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4. Vaginal examination reveals the presenting part is the infants head, which is well flexed on the chest. What is this presentation? a. Vertex b. Military c. Brow d. Face ANS: A In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

DIF: Cognitive Level: Comprehension REF: Page 122-123 OBJ: 9 TOP: Fetal Position KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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5. What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in the mother ANS: A Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise. DIF: Cognitive Level: Comprehension REF: Page 137 OBJ: 9 TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetuss hips are flexed and the knees are extended. How would the nurse record this presentation? a. Complete breech b. Frank breech c. Double footling

d. Buttocks presentation ANS: B When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders. DIF: Cognitive Level: Application REF: Page 123-124, Figure 6-7 OBJ: 9 TOP: Components of the Birth Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows that what indicates the beginning of true labor? a. Contractions that are relieved by walking b. Discomfort in the abdomen and groin c. A decrease in vaginal discharge d. Regular contractions becoming more frequent and intense ANS: D In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

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DIF: Cognitive Level: Application REF: Page 131, Table 6-2 OBJ: 7 TOP: Initiation of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. What is the nurses most informative response? a. When you feel increased fetal movement b. When contractions are 10 minutes apart c. When membranes have ruptured d. When abdominal or groin discomfort occurs ANS: C Ruptured membranes are an indication that the woman should go to the hospital or birthing center.

DIF: Cognitive Level: Application REF: Page 128 OBJ: 6 TOP: Admission to the Hospital or Birth Center KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this stage of labor? a. They get the infant positioned for delivery. b. They push the infant into the vagina. c. They dilate and efface the cervix. d. They get the mother prepared for true labor. ANS: C The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

DIF: Cognitive Level: Comprehension REF: Page 144, Table 6-6 OBJ: 6 TOP: First Stage of Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the womans change in behavior? a. Labor has progressed to the transition phase. b. She lacked adequate preparation for the labor experience. c. The woman would benefit from a different form of analgesia. d. The contractions have increased from mild to moderate intensity. ANS: A If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor. DIF: Cognitive Level: Analysis REF: Page 144, Table 6-6 OBJ: 6 TOP: Transition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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11. What is the function of contractions during the second stage of labor? a. Align the infant into the proper position for delivery b. Dilate and efface the cervix c. Push the infant out of the mothers body d. Separate the placenta from the uterine wall ANS: C The contractions push the infant out of the mothers body as the second stage of labor ends with the birth of the infant.

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DIF: Cognitive Level: Knowledge REF: Page 144-145, Table 6-6 OBJ: 6 TOP: Second Stage of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. What marks the end of the third stage of labor? a. Full cervical dilation b. Expulsion of the placenta and membranes c. Birth of the infant d. Engagement of the head ANS: B The third stage of labor extends from the birth of the infant until the placenta is detached and expelled. DIF: Cognitive Level: Knowledge REF: Page 145, Table 6-6 OBJ: 6 TOP: Third Stage of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

DIF: Cognitive Level: Comprehension REF: Page 145, Table 6-6 OBJ: 6 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

13. Why should the nurse encourage the mother to void during the fourth stage of labor? a. A full bladder could interfere with cervical dilation. b. A full bladder could obstruct progress of the infant through the birth canal. c. A full bladder could obstruct the passage of the placenta. d. A full bladder could predispose the mother to uterine hemorrhage. ANS: D A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.

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14. The nurse observes the patient bearing down with contractions and crying out, The baby is coming! What is the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the womans partner to locate a registered nurse. d. Assist with deep breathing to slow the labor process. ANS: B If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell. DIF: Cognitive Level: Application REF: Page 129 OBJ: 6 TOP: Imminent Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency ANS: A Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

DIF: Cognitive Level: Analysis REF: Page 135 OBJ: 9 TOP: Fetal Accelerations KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push? a. At the beginning of a contraction, hold your breath and push for 10 seconds. b. Take a deep breath and push between contractions. c. Begin pushing when a contraction starts and continue for the duration of the contraction. d. At the beginning of a contraction, take two deep breaths and push with the second exhalation. ANS: D

When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling. DIF: Cognitive Level: Application REF: Page 142 OBJ: 9 TOP: Instructions for Pushing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. What is the most important nursing intervention during the fourth stage of labor? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding. ANS: C Immediately after giving birth, every woman is assessed for signs of hemorrhage.

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DIF: Cognitive Level: Comprehension REF: Page 147 OBJ: 9 TOP: Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

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18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action? a. Check the fundus for position and firmness. b. Report to the doctor immediately. c. Change the pads and chart the time. d. Time how long it takes to soak one pad. ANS: A Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

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DIF: Cognitive Level: Application REF: Page 147 OBJ: 9 TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurses initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula. ANS: C Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased. DIF: Cognitive Level: Application REF: Page 136-137 OBJ: 9 TOP: Variable Decelerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. How should the nurse intervene to relieve perineal bruising and edema following delivery? a. Place an ice pack on the area for 12 hours. b. Place a warm pack on the perineal area for 24 hours. c. Administer aspirin to relieve inflammation. d. Change the perineal pad frequently. ANS: A An ice pack can be placed on the mothers perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours after delivery.

DIF: Cognitive Level: Application REF: Page 150 OBJ: 9 TOP: Ice Pack/Bruising KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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21. At 1 and 5 minutes of life, a newborns Apgar score is 9. What does the nurse understand that a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in stable condition. ANS: D Apgar scoring is a system for evaluating the infants need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is stable.

DIF: Cognitive Level: Comprehension REF: Page 151-152, Table 6-7 OBJ: 10 TOP: Care of the Infant After Birth KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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22. The husband of a woman in labor asks, What does it mean when the baby is at minus 1 station? After giving an explanation, what statement by the husband indicates that teaching was effective? a. Fetal head is above the ischial spines. b. Fetal head is below the ischial spines. c. Fetal head is engaged in the mothers pelvis. d. Fetal head is visible at the perineum. ANS: A Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines. Minus stations are above the ischial spines. DIF: Cognitive Level: Comprehension REF: Page 126 | Page 128, Figure 6-10 OBJ: 1 TOP: Mechanisms of Labor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fear related to the probable need for cesarean delivery.

c. Dysuria related to prolonged labor and decreased intake. d. Risk for injury related to hemorrhage. ANS: D In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage. DIF: Cognitive Level: Application REF: Page 147 OBJ: 6 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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24. The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warm fluids to drink b. By helping the patient to ambulate in the room c. By seating the patient upright in a straight-back chair d. By positioning the patient on her right side ANS: B Ambulation will stimulate effacement and intensify contractions if the patient is in true labor. DIF: Cognitive Level: Application REF: Page 131, Table 6-2 OBJ: 5 | 7 TOP: Differentiating Between True and False Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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25. What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine b. Decrease flow of intravenous (IV) fluids c. Increase oxygen to 10 L/minute d. Prepare to increase oxytocin drip ANS: C The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.

DIF: Cognitive Level: Application REF: Page 137 OBJ: 9 TOP: Late Decelerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. What is the nurse primarily concerned about maintaining in the initial care of the newborn? a. Fluid intake b. Feeding schedule c. Thermoregulation d. Parental bonding ANS: C Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.

DIF: Cognitive Level: Comprehension REF: Page 150 OBJ: 10 TOP: Thermoregulation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

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27. A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth? a. Eclampsia b. Placental abruption c. Congestive heart failure d. Uterine rupture ANS: D Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous cesarean birth. DIF: Cognitive Level: Comprehension REF: Page 143 OBJ: 8 TOP: VBAC KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk

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28. The physician performs an amniotomy on a laboring woman. What will be the nurses priority assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes ANS: A The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.

DIF: Cognitive Level: Application REF: Page 137 OBJ: 9 TOP: Rupture of Membranes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 29. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions? (Select all that apply.) a. Provide for extreme modesty. b. Assign a male caregiver. c. Arrange for the husband/partner to participate in labor. d. Provide adequate pain control. e. Respect protective amulets. ANS: A, D, E

Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and religious amulets. The husband is in attendance but not as a participant. Arabs prefer female caregivers. If a male is in attendance, then the husband will remain in the room as long as the male is there. DIF: Cognitive Level: Application REF: Page 117, Table 6-1 OBJ: 2 TOP: Cultural Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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30. What are the advantages of a freestanding birth center? (Select all that apply.) a. Home-like setting b. Designed for high-risk pregnancies c. Lower costs d. Attended by certified obstetricians e. Immediate emergency access ANS: A, C Advantages of a freestanding birth center include a homelike setting and lower costs because the center does not require expensive departments such as emergency or critical care. Freestanding birth centers are not designed for high-risk patients, are not attended by certified obstetricians, and do not have immediate emergency access.

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DIF: Cognitive Level: Comprehension REF: Page 116 OBJ: 3 TOP: Free-Standing Birth Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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31. What do late decelerations indicate? (Select all that apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression ANS: A, B, C This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord compression and early decelerations indicate head compressions.

DIF: Cognitive Level: Comprehension REF: Page 135 OBJ: 9 TOP: Late Decelerations KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 32. A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After a thorough examination and diagnostic testing, it is determined to be false (prodromal) labor. What signs and symptoms would lead the nurse to suspect false (prodromal) labor? (Select all that apply.) a. Leaking of vaginal fluid b. Contractions intensify with ambulation c. Pink spotting d. Painless tightening of abdominal muscles

e. Cervix thick and not effaced ANS: D, E Painless tightening of abdominal muscles (Braxton-Hicks contractions) and cervix thick and not effaced lend to the determination of false (prodromal) labor. Leaking of vaginal fluid may indicate rupture of membranes and is a sign of true labor. Contractions that intensify with ambulation and pink spotting (bloody show) are signs of true labor. DIF: Cognitive Level: Comprehension REF: Page 131, Table 6-2 OBJ: 7 | 8 TOP: False Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care

COMPLETION 33. After the pregnant woman is admitted to the labor suite, the nurse assesses the position of the infant as ROA; this means that the infants head is _________ __________ _________.

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ANS: right occiput anterior

Right occiput anterior means that the infants right occiput is toward the anterior aspect of the mothers body.

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DIF: Cognitive Level: Knowledge REF: Page 125, Box 6-1 OBJ: 9 TOP: Fetal Position KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

34. The nurse explains that the four Ps of the birth process are __________, __________, __________, and __________.

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ANS: powers, passenger, passage, psyche

The four interrelated components of the process of labor and birth, called the four Ps, are powers, passenger, passage, and psyche.

DIF: Cognitive Level: Knowledge REF: Page 116 OBJ: 5 TOP: Four Ps of the Birth Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. After the membranes have ruptured, the nurse should assess the fetal heart rate (FHR) for ________ minute(s). ANS: 1 The FHR is checked for 1 full minute to ensure that the infant is not in distress from cord compression resultant from the lost buoyancy. DIF: Cognitive Level: Application REF: Page 137 OBJ: 9 TOP: Assessment After Membrane Rupture

KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 36. The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called _____________________________ _____________________________. ANS: Leopolds maneuver

The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called Leopolds maneuver.

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DIF: Cognitive Level: Knowledge REF: Page 130 OBJ: 1 TOP: Leopolds Maneuver KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

37. A nursing student is observing prenatal exams in the office setting. The health care provider informs the student that the fetal position is LSA. The student interprets this as a ____________________ presentation. ANS: breech

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LSA is the abbreviation for Left Sacrum Anterior. This is a breech presentation.

DIF: Cognitive Level: Comprehension REF: Page 125, Box 6-1 OBJ: 6 TOP: Presentation KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care

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38. Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor. Place the seven mechanisms of labor in sequential order. Put a comma and space between each answer choice (a, b, c, d, etc.)

a. Extension b. Engagement c. Descent d. Flexion e. Expulsion f. Internal rotation g. External rotation ANS: C, B, D, F, A, G, E

The process by which a normal vaginal delivery is accomplished requires the infant to make the descent into the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled. Chapter 17 After Delivery

MULTIPLE CHOICE

DIF: Cognitive Level: Knowledge REF: Page 238, Safety Alert OBJ: 2 TOP: Hypovolemic Shock KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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2. Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction ANS: A Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.

DIF: Cognitive Level: Comprehension REF: Page 240 OBJ: 2 TOP: Atony KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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3. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location. ANS: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm. DIF: Cognitive Level: Application REF: Page 240-241 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurses next assessment be? a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain ANS: A

Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied. DIF: Cognitive Level: Application REF: Page 241 OBJ: 6 TOP: Bladder Distention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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5. Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfate c. Oxytocin d. Bromocriptine ANS: C Oxytocin (Pitocin) is the most common drug ordered to control uterine atony. DIF: Cognitive Level: Comprehension REF: Page 241 OBJ: 5 TOP: Oxytocin (Pitocin) for Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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6. A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the nurses most helpful response? a. Stop breastfeeding until the infection clears. b. Pump the breasts to continue milk production, but do not give breast milk to the infant. c. Begin all feedings with the affected breast until the mastitis is resolved. d. Breastfeeding can continue unless there is abscess formation. ANS: D The woman with mastitis can continue to breastfeed unless an abscess forms.

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DIF: Cognitive Level: Application REF: Page 246 OBJ: 6 TOP: Mastitis and Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

7. A woman had a vaginal delivery two days ago and is preparing for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability ANS: A Increased temperature is a sign of infection. The other choices are normal in the postpartum period. DIF: Cognitive Level: Application REF: Page 244 OBJ: 4 TOP: Puerperal Infections KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

DIF: Cognitive Level: Analysis REF: Page 243 OBJ: 2 TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis ANS: A The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient.

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9. Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage? a. My discharge would change to red after it has been pink or white. b. If I have a postpartum hemorrhage, I will have severe abdominal pain. c. I should be alert for an increase in bright red blood. d. I would pass a large clot that was retained from the placenta. ANS: A When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage.

DIF: Cognitive Level: Comprehension REF: Page 242 OBJ: 2 TOP: Color Change in Lochia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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10. During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants for 6 weeks b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day ANS: A Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism. DIF: Cognitive Level: Analysis REF: Page 243 OBJ: 5 TOP: Anticoagulant Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 11. What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions? a. I will apply cold compresses to the painful areas. b. I will take a warm shower before nursing the baby.

c. I will nurse first on the affected side. d. I will empty the affected breast every 8 hours. ANS: B Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast. DIF: Cognitive Level: Comprehension REF: Page 246 OBJ: 6 TOP: Mastitis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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12. What is the best response to a postpartum woman who tells the nurse she feels tired and sick all of the time since I had the baby 3 months ago? a. This is a normal response for the body after pregnancy. Try to get more rest. b. Ill bet you will snap out of this funk real soon. c. Why dont you arrange for a babysitter so you and your husband can have a night out? d. Lets talk about this further. I am concerned about how you are feeling. ANS: D If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive. DIF: Cognitive Level: Application REF: Page 247, Nursing Tip OBJ: 6 | 7 TOP: Depression KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sit in a chair for meals. b. Monitor vital signs every 4 hours and report any changes. c. Tell the woman to remain in bed with her legs elevated. d. Assist the woman with ambulation for short periods of time. ANS: D Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman.

DIF: Cognitive Level: Application REF: Page 243 OBJ: 4 TOP: Thrombus Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis ANS: C Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.

DIF: Cognitive Level: Analysis REF: Page 244, Table 10-2 OBJ: 2 TOP: Puerperal Infections KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this womans symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression ANS: B Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead. DIF: Cognitive Level: Analysis REF: Page 247 OBJ: 7 TOP: Major Depression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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16. Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now that she is here, I cant believe how different my life is from what I expected. What is the best nursing response to the womans statement? a. How is your partner adjusting to the change? b. I hear this from a lot of first-time mothers. c. Have you told anyone else about your feelings? d. Tell me how things are different. ANS: D The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mothers feelings about motherhood and her infant. DIF: Cognitive Level: Application REF: Page 247 OBJ: 6 | 7 TOP: Disorders of Mood KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

17. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments ANS: B Delivering a large infant and a prolonged labor are risk factors for hematoma formation. DIF: Cognitive Level: Analysis REF: Page 241 OBJ: 3 TOP: Hematoma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

18. A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy ANS: C Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall.

DIF: Cognitive Level: Knowledge REF: Page 242 OBJ: 2 TOP: Subinvolution of the Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

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19. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature. ANS: B Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication. DIF: Cognitive Level: Application REF: Page 243 OBJ: 2 | 6 TOP: Pulmonary Embolus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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20. While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding? a. Concerned and reports a probable cervical laceration b. Attentive and massages the uterus to expel retained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartum finding ANS: A The bright trickle of blood with a firm uterus suggests a cervical laceration. DIF: Cognitive Level: Application REF: Page 241 OBJ: 2 | 6 TOP: Laceration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse assesses a positive Homans sign when the patients leg is flexed and foot sharply dorsiflexed. Where does the patient report that the pain is felt? a. Groin b. Achilles tendon c. Top of the foot d. Calf of the leg ANS: D

A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign. Homans sign is suggestive of a deep vein thrombosis. DIF: Cognitive Level: Comprehension REF: Page 243 OBJ: 2 TOP: Homans Sign KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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22. The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further. ANS: D The patient should be assessed further for other signs of infection because a white blood cell (WBC) count of 20,000 to 30,000 cells/dL is normal in the early postpartum period. DIF: Cognitive Level: Analysis REF: Page 244 OBJ: 6 TOP: Elevated WBC KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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23. A postpartum patient experiences anaphylactic shock. What is the most likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder ANS: C Anaphylactic shock is caused by allergic responses to drugs administered. Cardiogenic shock may be caused by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders. DIF: Cognitive Level: Comprehension REF: Page 237 OBJ: 3 TOP: Shock KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K ANS: D The antidote for warfarin overdose is vitamin K. DIF: Cognitive Level: Knowledge REF: Page 243 OBJ: 5 TOP: Warfarin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE

25. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage ANS: B, C, D, E Hypertension is not a cause for postpartum shock; all the other options can cause shock.

DIF: Cognitive Level: Application REF: Page 237 OBJ: 3 TOP: Postpartum Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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26. The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus ANS: B, E Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.

DIF: Cognitive Level: Analysis REF: Page 240 OBJ: 4 TOP: Cessation of Lochia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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27. The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe ANS: A, C, E Legumes and foods containing vitamin C are conducive to healing. Starches are not. DIF: Cognitive Level: Comprehension REF: Page 245 OBJ: 4 TOP: Foods Conducive to Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers.

d. Wear a supportive bra. e. Pump breasts to ensure emptying. ANS: B, C, D, E Nursing mothers should take in about 3 liters of fluid a day. All the other options are interventions to reduce the risk of mastitis and milk accumulation in the breast. DIF: Cognitive Level: Comprehension REF: Page 246 OBJ: 4 TOP: Reduction of the Risk of Mastitis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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29. A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples ANS: A, B, C, D Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine.

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DIF: Cognitive Level: Comprehension REF: Page 244, Table 10-2 OBJ: 4 TOP: Urinary Tract Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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30. A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion ANS: A, B, C, E Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given. DIF: Cognitive Level: Application REF: Page 238 OBJ: 5 TOP: Hypovolemic Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 31. The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of _____ mL.

ANS: 15 The weight of 1 g in a perineal pad is equal to 1 mL of blood loss. DIF: Cognitive Level: Comprehension REF: Page 238 OBJ: 2 TOP: Weighing Perineal Pad KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 32. The nurse explains that a slower than expected return of the uterus to the nonpregnant state is called _______________.

ANS: subinvolution

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Subinvolution is the term applied to the uteruss slower than expected return to a nonpregnant state. DIF: Cognitive Level: Knowledge REF: Page 242 OBJ: 1 TOP: Subinvolution KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

ANS: hematoma

ba n

33. A(n) is a collection of blood within the tissues.

Chapter 18 The Newborn

A hematoma is a collection of blood within the tissues.

The neonate must have aspirated surfactant.

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MULTIPLE CHOICE 1. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. c.

d. ANS: D

If this baby was born vaginally, it could indicate a pneumothorax. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. Feedback

This is a common condition for infants delivered by cesarean section.

Surfactant is produced by the lungs, so aspiration is not a concern.

It is common to have some fluid left in the lungs; this will be absorbed within a few hours.

Lungs and liver

Eyes and ears Gastrointestinal system

kt an k. c

d. ANS: B

The condition will resolve itself within a few hours. For this common condition of newborns, surfac expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lun by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be a D circulatory and lymphatic systems. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 467 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. When teaching parents about their newborns transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. They are the a. Kidneys and adrenals

Feedback A

Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, wh through the kidneys.

Most of the fetal blood flow bypasses the nonfunctional lungs and liver.

Near term, the eyes are open and the fetus can hear.

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D The gastrointestinal system functions during fetal life. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 468 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the a. Transition period b.

First period of reactivity

Organizational stage

Second period of reactivity

d. ANS: B

Feedback

The transition period is the phase between intrauterine and extrauterine existence.

The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The alert during this phase.

There is no such phase as the organizational stage.

D The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of p PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 478 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 4. Nurses can prevent evaporative heat loss in the newborn by

Drying the baby after birth and wrapping the baby in a dry blanket

Keeping the baby out of drafts and away from air conditioners

Placing the baby away from the outside wall and the windows

d. ANS: A

Warming the stethoscope and nurses hands before touching the baby Feedback Because the infant is a wet with amniotic fluid and blood, heat loss by evaporation occurs quickly.

Heat loss by convection occurs when drafts come from open doors and air currents created by peopl

If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiatio

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D Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 470 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b.

Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood type

The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. This condition is also known as breast milk jaundice. Feedback

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d. ANS: C

Pathologic jaundice occurs during the first 24 hours of life.

Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocy investigated.

Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greate when the baby is approximately 3 days old. This finding is within normal limits for the newborn.

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D Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insuffici PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 476 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. To provide competent newborn care, the nurse understands that respirations are initiated at birth as a result of a. An increase in the PO2 and a decrease in PCO2 b.

The continued functioning of the foramen ovale

Chemical, thermal, sensory, and mechanical factors

d. ANS: C

Drying off the infant Feedback

The PO2 decreases at birth and the PCO2 increases.

The foramen ovale closes at birth.

A variety of these factors are responsible for initiation of respirations.

Left atrium

Hepatic system

d. ANS: A

Pulmonary veins

D Tactile stimuli aid in initiating respirations, but are not the main cause. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 468 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 7. In fetal circulation, the pressure is greatest in the a. Right atrium

kt an k. c

Feedback A

Pressure in fetal circulation is greatest in the right atrium, which allows a right-to-left shunting that the lungs during intrauterine life.

The pressure increases in the left atrium after birth and will close the foramen ovale.

The liver does not filter the blood during fetal life until the end. It is functioning by birth.

ba n

D Blood bypasses the pulmonary vein during fetal life. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 469 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of a. Increased pressure in the right atrium Increased pressure in the left atrium

Decreased blood flow to the left ventricle

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d. ANS: B

Changes in the hepatic blood flow Feedback

The pressure in the right atrium decreases at birth. It is higher during fetal life.

Blood flow increases to the left ventricle after birth.

With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and t functionally closed.

D The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 469 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 9. The nurse should alert the physician when a. The infant is dusky and turns cyanotic when crying. b.

Acrocyanosis is present at age 1 hour.

The infants blood glucose is 45 mg/dL.

d. ANS: A

The infant goes into a deep sleep at age 1 hour. Feedback

An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauteri

Acrocyanosis is an expected finding during the early neonatal life.

This is within normal range for a newborn.

100 to 120

120 to 160

d. ANS: C

150 to 180

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D Infants enter the period of deep sleep when they are about 1 hour old. PTS: 1 DIF: Cognitive Level: Application REF: dm. 484 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 10. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is _____ beats/min. a. 80 to 100

Feedback

The newborns heart rate may be about 85 to 100 beats/min while sleeping.

The infants heart rate typically is a bit higher when alert but quiet.

The average infant heart rate while awake is 120 to 160 beats/min.

ba n

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D A heart rate of 150 to 180 beats/min is typical when the infant cries. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 486 | Box 21-3 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. What is a result of hypothermia in the newborn? a. Shivering to generate heat Decreased oxygen demands

Increased glucose demands Decreased metabolic rate

d. ANS: C

Feedback

Shivering is not an effective method of heat production for newborns.

Oxygen demands increase with hypothermia.

In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requ

D The metabolic rate increases with hypothermia. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 471 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 12. The infant with the lowest risk of developing high levels of bilirubin is the one who

Was bruised during a difficult delivery

Developed a cephalhematoma

Uses brown fat to maintain temperature

d. ANS: D

Breastfeeds during the first hour of life Feedback Bruising will release more bilirubin into the system.

Cephalhematomas will release bilirubin into the system as the red blood cells die off.

Brown fat is normally used to produce heat in the newborn.

kt an k. c

The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the in D the circulation. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 475 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is a. Important in the production of red blood cells Necessary in the production of platelets

Not initially synthesized because of a sterile bowel at birth

d. ANS: C

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Responsible for the breakdown of bilirubin and prevention of jaundice Feedback

Vitamin K is important for blood clotting.

The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrom clotting factors.

The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is intro bowel.

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D Vitamin K is necessary to activate the clotting factors. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 473 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 14. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. Seen at age 3 days b.

The residue of a milk curd

Passed in the first 12 hours of life

d. ANS: C

Lighter in color and looser in consistency Feedback

Meconium stool is the first stool of the newborn.

Meconium stool is made up of matter in the intestines during intrauterine life.

Meconium stool is usually passed in the first 12 hours of life and 99% of newborns have their first s hours. If meconium is not passed by 48 hours, obstruction is suspected.

The gastrocolic reflex

An underdeveloped pyloric sphincter

d. ANS: D

A relaxed cardiac sphincter Feedback

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D Meconium is dark in color and sticky. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 474 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. When the newborn infant is fed, the most likely cause of regurgitation is a. Placing the infant in a prone position after a feeding

The infant should be placed in a supine position.

The gastrocolic reflex increases intestinal peristalsis after the stomach fills.

The pyloric sphincter goes from the stomach to the intestines.

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D The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 473 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 16. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. Enterohepatic circuit b.

Conjugation of bilirubin

Unconjugation of bilirubin Albumin binding

d. ANS: B

Feedback

This is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by is recycled into the intestine.

Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-solubl

Unconjugated bilirubin is fat soluble.

D Albumin binding is to attach something to a protein molecule. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 474 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 17. Which statement is correct regarding the fluid balance in a newborn versus that in an adult? a. The infant has a smaller percentage of surface area to body mass.

The infant has a smaller percentage of water to body mass.

The infant has a greater percentage of insensible water loss.

d. ANS: C

The infant has a 50% more effective glomerular filtration rate. Feedback

The infants surface area is large compared to an adults.

Infants have a larger percentage of water to body mass.

Insensible water loss is greater in the infant due to the newborns large body surface area and rapid r

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D The filtration rate is less than in adults; the kidneys are immature in a newborn. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 477 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 18. The most likely interpretation of an elevated immunoglobulin M (IgM) level in a newborn is a. The infant was breastfed during the first hours after birth b.

Transference of immune globulins from the placenta to the infant

An overwhelming allergic response to an antigen A recent exposure to a pathogenic agent Feedback

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d. ANS: D

This is the IgA.

This is the IgG.

This is not associated with elevated levels of IgM.

Quiet alert

Active alert

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D An elevated level of IgM is associated with exposure to infection in utero because IgM does not cro PTS: 1 DIF: Cognitive Level: Application REF: dm. 478 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 19. In which infant behavioral state is bonding most likely to occur? a. Drowsy

d. ANS: C

Crying Feedback

In the drowsy state the eyes may remain closed. If open they are unfocused. The infant is not interes environment at this time.

In the active alert state infants are often fussy, restless, and not focused.

In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the m both.

D During the crying state the infant does not respond to stimulation and cannot focus on parents. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 478 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b.

Given a bath

Placed in a drafty area of the room Wrapped in cool blankets

d. ANS: C

Feedback This is conduction.

This is evaporation.

Convection occurs when infants are exposed to cold air currents.

kt an k. c

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D This is conduction. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 471 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 21. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Ortolanis sign Thigh and gluteal creases are asymmetric

Negative Barlow test

d. ANS: B

Knee heights are equal

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Feedback

Positive Ortolanis sign yields a clunking sensation and indicates a dislocated femoral head moving i

Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip.

During a positive Barlow test, the examiner can feel the femoral head move out of acetabulum.

D If the hip is dislocated, the knee on the affected side will be lower. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 488 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 22. Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot? a. Babinski b.

Tonic neck

Stepping

d. ANS: A

Plantar grasp

Feedback A

The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex.

The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns whe position.

The stepping reflex occurs when infants are held upright with their heel touching a solid surface and to be walking.

Jaundice

Caput succedaneum

d. ANS: B

Erythema toxicum Feedback

kt an k. c

Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, D over the nurses finger. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 493 | Table 21-3 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 23. Infants in whom cephalhematomas develop are at increased risk for a. Infection

Cephalhematomas do not increase the risk for infections.

Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice.

Caput is an edematous area on the head from pressure against the cervix.

ba n

Erythema toxicum Cafe-au-lait spots

d. ANS: C

Mongolian spots

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D Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas. PTS: 1 DIF: Cognitive Level: Application REF: dm. 475 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 24. A maculopapular rash with a red base and a small white papule in the center is a. Milia

Feedback A

Milia are minute epidermal cysts on the face of the newborn.

Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sa

This is a description of erythema toxicum, a normal rash in the newborn.

D These spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 498 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

25. Plantar creases should be evaluated within a few hours of birth because a. The newborn has to be footprinted. b.

As the skin dries, the creases will become more prominent.

Heel sticks may be required.

d. ANS: B

Creases will be less prominent after 24 hours. Feedback Footprinting will not interfere with the creases.

As the infants skin begins to dry, the creases will appear more prominent, and the infants gestation c misinterpreted.

Heel sticks will not interfere with the creases.

Less than the 10th

Greater than the 90th

d. ANS: C

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D The creases will appear more prominent after 24 hours. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 503 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 26. A newborn who is large for gestational age (LGA) is _____ percentile for weight. a. Below the 90th

Between the 10th and 90th Feedback

An infant between the 10th and 90th percentiles is average for gestational age.

An infant in less than the 10th percentile is small for gestational age.

The LGA rating is based on weight and is defined as greater than the 90th percentile in weight.

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D This infant is considered average for gestational age. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 504 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 27. A new mother asks, Why are you doing a gestational age assessment on my baby? The nurses best response is a. This must be done to meet insurance requirements. b.

It helps us identify infants who are at risk for any problems.

The gestational age determines how long the infant will be hospitalized.

d. ANS: B

It was ordered by your doctor. Feedback

This is not accurate information.

The nurse should provide the mother with accurate information about various procedures performed

Gestational age does not dictate hospital stays. Problems that occur due to gestational age may prolo

D Assessing gestational age is a nursing assessment and does not have to be ordered. PTS: 1 DIF: Cognitive Level: Application REF: dm. 499 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 28. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. Maintain room temperature at 70 F.

Undress the infant completely for assessments so they can be finished quickly.

d. ANS: A

Take the rectal temperature every hour to detect early changes.

kt an k. c

Feedback A

Padding the scale prevents heat loss from the infant to a cold surface by conduction.

Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is w radiation will assist in maintaining body heat.

Undressing the infant completely will expose the child to cooler room temperatures and cause a dro temperature due to convection.

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D Hourly assessments are not necessary for a normal newborn with a stable temperature. PTS: 1 DIF: Cognitive Level: Application REF: dm. 471 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 29. What characteristic shows the greatest gestational maturity? a. Few rugae on the scrotum and testes high in the scrotum Infants arms and legs extended

Some peeling and cracking of the skin

d. ANS: C

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The arm can be positioned with the elbow beyond the midline of the chest

Few rugae on the scrotum show a younger age in the newborn.

Feedback B

Extended arms and legs is a sign of preterm infants.

Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn.

D This result of the scarf sign shows a younger newborn. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 501 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. A sign of illness in the newborn is a. More than two soft stools per day b.

Regurgitating a small amount of feeding

A yellow scaly lesion on the scalp

d. ANS: D

An axillary temperature greater than 37.5 C Feedback

This is an expected finding in the newborn.

This is a sign of cradle cap or seborrhea capitis.

Vascular nevi

Nevus flammeus

d. ANS: D

Mongolian spots

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Infants commonly respond to a variety of illnesses with an elevation in temperature. The normal ran D temperature in the newborn is 36.5 to 37.3 C. PTS: 1 DIF: Cognitive Level: Application REF: dm. 486 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 31. An African-American woman noticed some bruises on her newborn girls buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called a. Lanugo

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Feedback A

Lanugo is the fine, downy hair seen on a term newborn.

A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma.

A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.

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A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterio body. It is more commonly noted on the back and buttocks and most frequently is seen on infants w D are Mediterranean, Latin American, Asian, or African. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 498 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 32. What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth? a. Puncture the lateral pad of the heel. b.

Obtain a sample from the umbilical cord.

Puncture a fingertip.

d. ANS: A

Obtain a laboratory chemical determination. Feedback

A drop of blood obtained by heel stick is the quickest method of glucose screening. The calcaneus b avoided as osteomyelitis may result from injury to the foot.

Most umbilical cords are clamped in the delivery room and are not available for routine testing.

A neonates fingertips are too fragile to use for this purpose.

D Laboratory chemical determination is the most accurate but the lengthiest method. PTS: 1 DIF: Cognitive Level: Application REF: dm. 494 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 33. A new mother states that her infant must be cold because the babys hands and feet are blue. The nurse explains that this is a common and temporary condition called a. Acrocyanosis Erythema neonatorum

Harlequin color

d. ANS: A

Vernix caseosa

kt an k. c

Feedback A

Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instabil and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 1

Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles fle

The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the or bluish red with a line of demarcation.

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D Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 471 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 34. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them a. Infants can see very little until about 3 months of age. b.

Infants can track their parents eyes and can distinguish patterns; they prefer complex patterns.

The infants eyes must be protected. Infants enjoy looking at brightly colored stripes. Its important to shield the newborns eyes. Overhead lights help them see better.

d. ANS: B

Feedback

Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to clearest visual distance for the newborn appears to be 19 cm.

This is an accurate statement.

Infants prefer to look at complex patterns, regardless of the color.

D Infants prefer low illumination and withdraw from bright light. PTS: 1 DIF: Cognitive Level: Application REF: dm. 490 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 35. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, What is this black, sticky stuff in her diaper? The nurses best response is

Thats meconium, which is your babys first stool. Its normal.

Thats transitional stool.

That means your baby is bleeding internally.

d. ANS: A

Oh, dont worry about that. Its okay. Feedback This is an accurate statement and the most appropriate response.

Transitional stool is greenish brown to yellowish brown and usually appears by the third day after in

This statement is not accurate.

kt an k. c

This statement is not appropriate. It is belittling to the father and does not educate him about the nor D of his daughter. PTS: 1 DIF: Cognitive Level: Application REF: dm. 474 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 36. By knowing about variations in infants blood count, nurses can explain to their patients that a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the u b.

The early high white blood cell count (WBC) is normal at birth and should decrease rapidly.

Platelet counts are higher than in adults for a few months.

Even a modest vitamin K deficiency means a problem with the bloods ability to clot properly. Feedback

ba n

d. ANS: B

Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count.

The WBC is high the first day of birth and then declines rapidly.

The platelet count essentially is the same for newborns and adults.

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D Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 473 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 37. With regard to the newborns developing cardiovascular system, nurses should be aware that a. The heart rate of a crying infant may rise to 120 beats/min. b.

Heart murmurs heard after the first few hours are cause for concern.

The point of maximal impulse (PMI) often is visible on the chest wall.

d. ANS: C

Persistent bradycardia may indicate respiratory distress syndrome (RDS). Feedback

The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying in could have a heart rate of 180 beats/min.

Heart murmurs during the first few days of life have no pathologic significance; an irregular heart ra hours should be evaluated further.

The newborns thin chest wall often allows the PMI to be seen.

Surfactant

Caput succedaneum Acrocyanosis

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d. ANS: A

D Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 485 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 38. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called a. Vernix caseosa

Feedback A

This protection is needed because the infants skin is so thin.

Surfactant is a protein that lines the alveoli of the infants lungs.

Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head.

Convection

Radiation

Conduction

e. ANS: B

Urination

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D Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 497 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. What are modes of heat loss in the newborn? (Choose all that apply.) a. Perspiration

Correct

Feedback

Convection, radiation, evaporation, and conduction are the four modes of heat loss in th

Incorrect Perspiration and urination are not modes of heat loss in newborns. PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 470-471 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance COMPLETION 1. The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _____________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver. ANS:

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thermogenesis Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 471 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 2. The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infants risk of hypoglycemia. The nurse becomes concerned if the infants blood glucose concentration falls below ______ mg/dl. ANS: 40 If the newborn has a blood glucose level below 40 mg/dl intervention such as breastfeeding or bottle-feeding should be instituted. If levels remain low after this intervention an intravenous with dextrose may be warranted. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 494 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 3. A ________ succedaneum may appear over the vertex of the newborns head as a result of pressure against the mothers cervix while in utero. ANS: caput This pressure causes localized edema and appears as an edematous area on the infants head. The edema may cross suture lines, is soft to the touch, and varies in size. It usually resolves quickly and disappears entirely within the first few days after birth. Caput may also occur as the result of an operative delivery when a vacuum extractor is used during a vaginal birth. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 487 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance TRUE/FALSE 1. Part of the newborn assessment includes examination of the umbilical cord. The cord should contain 2 vessels: one vein and one artery. Is this statement true or false? ANS: F The umbilical cord contains 3 vessels: two small arteries and one large vein. A 2-vessel cord may be an isolated abnormality or it may be associated with chromosomal and renal defects. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 488 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 2. In many facilities protocols allow the nurses to obtain transcutaneous bilirubin measurements (TcB) using a bilirubin meter, without the order of a nurse practitioner or physician. Is this statement true or false? ANS: T Bilirubinometers are non-invasive devices to measure bilirubin levels in the infants skin, thus avoiding repeated skin punctures to obtain blood samples. Abnormal results of TcB be should be confirmed with a total serum bilirubin (TsB). The National Association of Neonatal Nurses recommends obtaining a TcB or TsB on all infants prior to discharge. Chapter 19 Conditions Existing Before Conception

MULTIPLE CHOICE 1. Which part of the mature sperm contains the male chromosomes? a. The head of the sperm b.

The middle portion of the sperm

X-bearing sperm

d. ANS: A

The tail of the sperm Feedback

The head of the sperm contains the male chromosomes that will join the chromosomes of the ovum.

The middle portion of the sperm supplies energy for the tails whip-like action.

If an X-bearing sperm fertilizes the ovum, the baby will be female.

Two arteries and two veins

Two veins and one artery

d. ANS: A

One artery and one vein

Feedback

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D The tail of the sperm helps propel the sperm toward the ovum. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 215 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. One of the assessments performed in the delivery room is checking the umbilical cord for blood vessels. Which finding is considered within normal limits? a. Two arteries and one vein

The umbilical cord contains two arteries and one vein to transport blood between the fetus and the p

This option is abnormal and may indicate other anomalies.

Any option other than two arteries and one vein is considered abnormal and requires further assessm

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The presence of one umbilical artery is considered an abnormal finding. This infant would require f D for other anomalies. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 229 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. The purpose of the ovums zona pellucida is to a. Make a pathway for more than one sperm to reach the ovum. b.

Allow the 46 chromosomes from each gamete to merge.

Prevent multiple sperm from fertilizing the ovum.

d. ANS: C

Stimulate the ovum to begin mitotic cell division. Feedback

Once one sperm has entered the ovum, the zona pellucida changes to prevent other sperm from ente

Each gamete (sperm and ovum) has only 23 chromosomes. There will be 46 chromosomes when the

Fertilization causes the zona pellucida to change its chemical composition so that multiple sperm ca ovum.

D Mitotic cell division begins when the nuclei of the sperm and ovum unite. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 216 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. While teaching an early pregnancy class, the nurse explains that the morula is a a. Fertilized ovum before mitosis begins Flattened disc-shaped layer of cells within a fluid-filled sphere

Double layer of cells that becomes the placenta

Solid ball composed of the first cells formed after fertilization

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d. ANS: D

Feedback A

The fertilized ovum is called the zygote.

This is the embryonic disc. It will develop into the baby.

The placenta is formed from two layers of cells: the trophoblast, which is the other portion of the fe the deciduas, which is the portion of the uterus where implantation occurs.

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The morula is so named because it resembles a mulberry. It is a solid ball of 12 to 16 cells that deve D fertilization. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 217 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. The upper uterus is the best place for the fertilized ovum to implant because it is here that the a. Placenta attaches most firmly Developing baby is best nourished

Uterine endometrium is softer

d. ANS: B

Maternal blood flow is lower

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Feedback If the placenta attaches too deeply, it does not easily detach after birth.

A B

The uterine fundus is richly supplied with blood and has the thickest endometrium, both of which pr nourishment of the fetus.

Softness is not a concern with implantation; attachment and nourishment are the major concerns.

D The blood supply is rich in the fundus, which allows for optimal nourishment of the fetus. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 217 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. Some of the embryos intestines remain within the umbilical cord during the embryonic period because the a. Umbilical cord is much larger at this time than it will be at the end of pregnancy.

Intestines begin their development within the umbilical cord.

Nutrient content of the blood is higher in this location.

d. ANS: D

Abdomen is too small to contain all the organs while they are developing. Feedback The intestines remain within the umbilical cord only until approximately week 10.

Intestines begin their development within the umbilical cord, but only because the liver and kidneys abdominal cavity. All the intestines are within the abdominal cavity around week 10.

Blood supply is adequate in all areas. Intestines stay in the umbilical cord for approximately 10 wee growing faster than the abdomen.

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The abdominal contents grow more rapidly than the abdominal cavity, so part of their development D umbilical cord. By 10 weeks, the abdomen is large enough to contain them. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 223 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. A woman is 16 weeks pregnant with her first baby. She asks how long it will be before she feels the baby move. The best answer is a. You should have felt the baby move by now. Within the next month, you should start to feel fluttering sensations.

The baby is moving, but you cant feel it yet.

d. ANS: B

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Some babies are quiet, and you dont feel them move.

Feedback

Because this is her first pregnancy, movement is felt toward the later part of the 17 to 20 weeks. Thi alarming to the woman.

Maternal perception of fetal movement usually begins 17 to 20 weeks after conception.

This is a true statement. The fetuss movements are not strong enough to be felt until 17 to 20 weeks statement does not answer the concern of the woman.

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Fetal movement should be felt by 17 to 20 weeks. If movement is not felt by the end of that time, fu D will be necessary. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 223 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. During a centering pregnancy group meeting, the nurse teaches patients that the fetal period is best described as one of a. Development of basic organ systems b.

Resistance of organs to damage from external agents

Maturation of organ systems

d. ANS: C

Development of placental oxygencarbon dioxide exchange

Feedback A

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 m organs will be. The greatest risk is when the organs are developing.

During the fetal period, the body systems grow in size and mature in function to allow independent

D The placental system is complete by week 12, but that is not the best description of the fetal period. PTS: 1 DIF: Cognitive Level: Knowledge REF: pp. 223-225 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. A new mother asks the nurse about the white substance covering her infant. The nurse explains that the purpose of vernix caseosa is to a. Protect the fetal skin from amniotic fluid. Promote normal peripheral nervous system development.

Allow transport of oxygen and nutrients across the amnion.

d. ANS: A

Regulate fetal temperature. Feedback

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Normal peripheral nervous system development is dependent on nutritional intake of the mother.

The amnion is the inner membrane that surrounds the fetus. It is not involved in the oxygen and nut

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Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the skin w protection of the vernix caseosa.

Boys and girls look alike until approximately 20 weeks after conception, and then they begin to look

It might be possible to determine your babys sex, but the external organs look very similar right now

d. ANS: B

The baby has developed enough that we can determine the sex by examining the genitals through ul

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D The amniotic fluid aids in maintaining fetal temperature. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 223 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 10. A woman who is 16 weeks pregnant asks the nurse, Is it possible to tell by ultrasound if the baby is a boy or girl yet? The best answer is a. A babys sex is determined as soon as conception occurs.

Feedback A

This is a true statement, but the external genitalia are similar in appearance until approximately the

Although gender is determined at conception, the external genitalia of males and females look simil week. By the 12th week, the external genitalia are distinguishable as male or female.

The external genitalia are similar in appearance until approximately 12 weeks, not 20 weeks.

D The external genitalia are different at approximately week 12. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 223

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 11. The placenta allows exchange of oxygen, nutrients, and waste products between the mother and fetus by a. Contact between maternal blood and fetal capillaries within the chorionic villi b.

Interaction of maternal and fetal pH levels within the endometrial vessels

A mixture of maternal and fetal blood within the intervillous spaces

d. ANS: A

Passive diffusion of maternal carbon dioxide and oxygen into the fetal capillaries

Feedback

The endometrial vessels are part of the uterus. There is no interaction with the fetal blood at this poi

Maternal and fetal blood do not normally mix.

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Fetal capillaries within the chorionic villi are bathed with oxygen- and nutrient-rich maternal blood intervillous spaces.

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D Maternal carbon dioxide does not enter into the fetal circulation. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 225 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. A patient is sent from the physicians office for assessment because of too little amniotic fluid. The nurse is aware that oligohydramnios can result in a. Excessive fetal urine secretion b.

Newborn respiratory distress

Central nervous system abnormality Gastrointestinal blockage

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Feedback

d. ANS: B

Oligohydramnios may be caused by a decreased in urine secretion.

Because an abnormally small amount of amniotic fluid restricts normal lung development, the infan inadequate respiratory function after birth, when the placenta no longer performs respiratory functio

Excessive amniotic fluid production may occur when the fetus has a central nervous system abnorm

Excessive amniotic fluid production may occur when the gastrointestinal tract prevents normal inge D fluid. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 229 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 13. When explaining twin conception, the nurse points out that dizygotic twins develop from a. A single fertilized ovum and are always of the same sex b.

A single fertilized ovum and may be the same sex or different sexes

Two fertilized ova and are the same sex

d. ANS: D

Two fertilized ova and may be the same sex or different sexes

Feedback A

A single fertilized ovum that produces twins is called monozygotic.

Monozygotic twins are always the same sex.

Dizygotic twins are from two fertilized ova and may or may not be the same sex.

At birth, all ova are contained in the females ovaries.

The oocytes complete their division during fetal life.

d. ANS: B

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Dizygotic twins are two different zygotes, each conceived from a single ovum and a single sperm. T D male, both female, or one male and one female. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 232 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. Oogenesis, the process of egg formation, begins during fetal life in the female. Which statement related to ovum formation is correct? a. Two million primary oocytes will mature.

Monthly, at least two oocytes mature. Feedback

Only 400 to 500 ova will mature during the approximately 35 years of a womans reproductive life.

All of the cells that may undergo meiosis in a womans lifetime are contained in the ovaries at birth.

The primary oocytes begin their first meiotic division during fetal life but remain suspended until pu

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Decidua vera

Decidua capsularis

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D Every month, one primary oocyte matures and completes meiotic division yielding two unequal cell PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 213 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. Between 6 and 10 days after conception, the trophoblast secretes enzymes that enable it to burrow into the endometrium until the entire blastocyst is covered. This is termed implantation. Tiny projections then develop out of the trophoblast and extend into the endometrium. These projections are referred to as a. Decidua basalis

d. ANS: D

Chorionic villi Feedback

The deciduas basalis is the portion of the endometrium where the chorionic villi tap into the materna

The deciduas capsularis is the portion of the endometrium that covers the blastocyst.

The portion of the endometrium that lines the rest of the uterus is called deciduas vera.

These villi are vascular processes that obtain oxygen and nutrients from the maternal bloodstream a dioxide and waste products into the maternal blood.

d. ANS: C

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 218 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. At approximately _____ weeks of gestation, lecithin is forming on the alveolar surfaces, the eyelids open, and the fetus measures approximately 27 cm crown to rump and weighs approximately 1110 g. a. 20

Feedback

These milestones would not be completed by 20 weeks of gestation.

These milestones in human development will not be completed at 24 weeks of gestation.

These are all milestones that occur at 28 weeks.

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D These specific milestones will be reached as early as 28 weeks, not 30 weeks of gestation. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 221 | Table 12-2 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 17. Sally comes in for her first prenatal examination. This is her first child. She asks you (the nurse), How does my baby get air inside my uterus? The correct response is a. The babys lungs work in utero to exchange oxygen and carbon dioxide. The baby absorbs oxygen from your blood system.

The placenta provides oxygen to the baby and excretes carbon dioxide into your bloodstream.

d. ANS: C

The placenta delivers oxygen-rich blood through the umbilical artery to the babys abdomen.

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Feedback

The fetal lungs do not function for respiratory gas exchange in utero.

The baby does not simply absorb oxygen from a womans blood system. Blood and gas transport occ placenta.

The placenta functions by supplying oxygen and excreting carbon dioxide to the maternal bloodstre

D The placenta delivers oxygen-rich blood through the umbilical vein, not artery. PTS: 1 DIF: Cognitive Level: Application REF: dm. 225 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 18. The most basic information a maternity nurse should have concerning conception is a. Ova are considered fertile 48 to 72 hours after ovulation. b.

Sperm remain viable in the womans reproductive system for an average of 12 to 24 hours.

Conception is achieved when a sperm successfully penetrates the membrane surrounding the ovum.

d. ANS: D

Implantation in the endometrium occurs 6 to 10 days after conception.

Feedback A

Ova are considered fertile for approximately 24 hours after ovulation.

Sperm remain viable in the womans reproductive system for an average of 2 to 3 days.

Penetration of the ovum by the sperm is called fertilization. Conception occurs when the zygote, the individual, is formed.

D After implantation, the endometrium is called the decidua. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 217 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 19. With regard to the structure and function of the placenta, the maternity nurse should be aware that a. As the placenta widens, it gradually thins to allow easier passage of air and nutrients. As one of its early functions, the placenta acts as an endocrine gland.

The placenta is able to keep out most potentially toxic substances, such as cigarette smoke, to which exposed.

d. ANS: B

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Optimal blood circulation is achieved through the placenta when the woman is lying on her back or Feedback

The placenta widens until week 20 and continues to grow thicker.

The placenta produces four hormones necessary to maintain the pregnancy.

Toxic substances such as nicotine and carbon monoxide readily cross the placenta into the fetus.

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D Optimal circulation occurs when the woman is lying on her side. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 225 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. The various systems and organs develop at different stages. Which statement is accurate? a. The cardiovascular system is the first organ system to function in the developing human. Hematopoiesis originating in the yolk sac begins in the liver at 10 weeks.

The body changes from straight to C-shaped at 8 weeks. The gastrointestinal system is mature at 32 weeks.

d. ANS: A

Feedback

The heart is developmentally complete by the end of the embryonic stage.

Hematopoiesis begins in the liver during the 6th week.

The body becomes C-shaped at 21 weeks.

D The gastrointestinal system is complete at 36 weeks. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 218 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE

1. Congenital disorders refer to those conditions that are present at birth. These disorders may be inherited and caused by environmental factors or maternal malnutrition. Toxic exposures have the greatest effect on development between 15 and 60 days of gestation. For the nurse to be able to conduct a complete assessment of the newly pregnant client, she should be knowledgeable regarding known human teratogens, which include (select all that apply) a. Infections b.

Radiation

Maternal conditions

Drugs

e. Chemicals ANS: A, B, C, D

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Feedback

Exposure to radiation and a number of infections may result in profound congenital def include varicella, rubella, syphilis, parvovirus, CMV, and toxoplasmosis. Certain mater as diabetes and PKU may also affect organs and other parts of the embryo during this d period. Drugs such as antiseizure medication and some antibiotics, as well as chemicals mercury, tobacco, and alcohol, also may result in structural and functional abnormalitie

Correct

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Incorrect Coffee is not considered a teratogen. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 218 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. Along with gas exchange and nutrient transfer, the placenta produces many hormones necessary for normal pregnancy. These include (select all that apply) a. Human chorionic gonadotropin (hCG) Insulin

Estrogen

Progesterone

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e. Testosterone ANS: A, C, D Feedback

Incorrect

Human placental lactogen promotes normal nutrition and growth of the fetus and mater development for lactation. This hormone decreases maternal insulin sensitivity and utili making more glucose available for fetal growth. If a Y chromosome is present in the ma causes the fetal testes to secrete testosterone necessary for the normal development of m structures.

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hCG causes the corpus luteum to persist and produce the necessary estrogens and proge 6 to 8 weeks. Estrogens cause enlargement of the womans uterus and breasts; cause gro system in the breasts; and, as term approaches, play a role in the initiation of labor. Prog endometrium to change, providing early nourishment. Progesterone also protects agains abortion by suppressing maternal reactions to fetal antigens and reduces unnecessary ut Other hormones produced by the placenta include hCT, hCA, and a number of growth f

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PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 228 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance COMPLETION 1. The ability of the fetus to survive outside the uterus is called ___________. ANS: viability In the past, the earliest age at which fetal survival could be expected was 28 weeks after conception. With modern technology and advancements in maternal and neonatal care, viability is now possible at 20 weeks after conception (22 weeks after last menstrual period [LMP], fetal weight of 500 g or more). PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 223 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 2. Very fine hairs, called __________, appear first on the fetuss eyebrows and upper lip at 12 weeks of gestation. By 20 weeks, they cover the entire body. By 28 weeks, the scalp hair is longer than these fine hairs, which thin and may disappear by term gestation. ANS: lanugo By 20 weeks of gestation, the eyelashes, eyebrows, and scalp hair also begin to grow. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 223 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance TRUE/FALSE 1. When teaching contraception, the nurse must be able to effectively communicate the nuances of conception. An ovum has the capacity to be fertilized for only 24 hours, whereas a sperm may remain fertile for up to 80 hours. Is this statement true or false? ANS: T Most sperm survive for no more than 1 or 2 days, although a few will remain fertile in the female reproductive tract for up to 80 hours. Conception requires correct timing for fertilization to occur. This information is important whether the patient is seeking to become pregnant or prevent pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: dm. 215 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 2. The nurse is precepting a student who asks about fetal circulation. The nurse explains that the fetal circulatory shunts are still required after birth. Is this statement true or false? ANS: F Fetal circulatory shunts are not needed after birth because the infant oxygenates blood in the lungs, metabolizes substances in the liver, and stops circulating blood to the placenta. As the infant breathes, blood flow to the lungs increases, pressure in the right-sided heart falls, and the foramen ovale closes. Chapter 20 Conditions Occurring During Pregnancy MULTIPLE CHOICE 1. A pregnant womans mother is worried that her daughter is not big enough at 20 weeks. The nurse palpates and measures the fundal height at 20 cm, which is even with the womans umbilicus. What should the nurse report to the woman and her mother? a. The body of the uterus is at the belly button level, just where it should be at this time.

Youre right. Well inform the practitioner immediately.

When you come for next months appointment, well check you again to make sure that the baby is gr

d. ANS: A

Lightening has occurred, so the fundal height is lower than expected. Feedback

At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a pred obstetric nurses should know that the uterus of 20 weeks of gestation is located at the level of the um

This is incorrect information. At 20 weeks the uterus should be at the umbilical level.

By avoiding the direction question, this might increase the anxiety of both the mother and grandmot

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D The descent of the fetal head (lightening) occurs in late pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 235 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. While you are assessing the vital signs of a pregnant woman in her third trimester, the patient complains of feeling faint, dizzy, and agitated. Which nursing intervention is 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.

Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms. Have the patient turn to her left side and recheck her blood pressure in 5 minutes. Feedback

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d. ANS: D

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 hypotensio

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Pressures are significantly higher when the patient is standing. This option causes an increase in sys pressures.

Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressu D vessels and quickly corrects supine hypotension. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 237 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 3. A pregnant woman has come to the emergency department with complaints of nasal congestion and epistaxis. What is the correct interpretation of these symptoms by the practitioner? a. These conditions are abnormal. Refer the patient to an ear, nose, and throat specialist. b.

Nasal stuffiness and nosebleeds are caused by a decrease in progesterone.

Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within

d. ANS: D

Estrogen causes increased blood supply to the mucous membranes and can result in congestion and Feedback

The patient should be reassured that these symptoms are within normal limits. No referral is needed

Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Proge increase during pregnancy.

Progesterone affects relaxation of the smooth muscles in the respiratory tract.

Glycosuria

Bacteria in the urine

d. ANS: B

Ketones in the urine Feedback

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As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and D causes these conditions, seen commonly during pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 238 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 4. Which finding in the urine analysis of a pregnant woman is considered a variation of normal? a. Proteinuria

The presence of protein could indicate kidney disease or preeclampsia.

Small amounts of glucose may indicate physiologic spilling.

Urinary tract infections are associated with bacteria in the urine.

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D An increase in ketones indicates that the patient is exercising too strenuously or has an inadequate fl PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 239 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. Which suggestion is appropriate for the pregnant woman who is experiencing nausea and vomiting? a. Eat only three meals a day so the stomach is empty between meals. b.

Drink plenty of fluids with each meal.

Eat dry crackers or toast before arising in the morning. Drink coffee or orange juice immediately on arising in the morning.

d. ANS: C

Feedback

Instruct the woman to eat five to six small meals rather than three full meals per day. Nausea is mor stomach is empty.

Fluids should be taken separately from meals. Fluids overstretch the stomach and may precipitate vo

This will assist with the symptoms of morning sickness. It is also important for the woman to arise s

Coffee and orange juice stimulate acid formation in the stomach. It is best to suggest eating dry carb D rising in the morning. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 252 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 6. Which statement related to changes in the breasts during pregnancy is the most accurate?

During the early weeks of pregnancy there is decreased sensitivity.

Nipples and areolae become more pigmented.

Montgomery tubercles are no longer visible around the nipples.

d. ANS: B

Venous congestion of the breasts is more visible in the multiparous woman. Feedback

Fullness, heightened sensitivity, tingling and heaviness of the breasts occur in the early weeks of ge to increased levels of estrogen and progesterone.

Nipples and areolae become more pigmented, and the nipples become more erectile and may expres

Montgomery tubercles may be seen around the nipples. These sebaceous glands may have a protect keep the nipples lubricated for breastfeeding.

Linea nigra

Striae gravidarum

d. ANS: C

Angiomas

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Feedback

ba n

kt an k. c

D Venous congestion in the breasts is more obvious in primigravidas. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 236 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 7. Alterations in hormonal balance and mechanical stretching are responsible for several changes in the integumentary system during pregnancy. Stretch marks often occur on the abdomen and breasts. These are referred to as a. Chloasma

Chloasma is a facial melasma also known as the mask of pregnancy. This condition is manifested by hyperpigmentation of the skin over the cheeks, nose and forehead especially in dark complexioned w

Linea nigra is a pigmented line extending from the symphysis pubis to the top of the fundus in the m

Striae gravidarum or stretch marks appear in 50% to 90% of pregnant women during the second hal They most often occur on the breasts and abdomen. This integumentary alteration is the result of sep underlying connective (collagen) tissue.

D Angiomas and other changes also may appear. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 240 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 8. The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to a. Compensate for decreased renal plasma flow. b.

Provide adequate perfusion of the placenta.

Eliminate metabolic wastes of the mother.

Prevent maternal and fetal dehydration.

ANS: B Feedback A

Renal plasma flow increases during pregnancy.

The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus

Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the i volume.

Increased pulse rate

Increased blood pressure

d. ANS: B

kt an k. c

D This is not the primary reason for the increase in volume. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 236 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 9. A number of cardiovascular system changes occur during pregnancy. Which finding is considered normal for a woman during pregnancy? a. Cardiac output rises by 25%

Decreased red blood cell (RBC) production Feedback

Cardiac output increases by 50% with half of this rise occurring in the first 8 weeks gestation.

The pulse increases about 15 to 20 beats/min, which persists to term.

In the first trimester, blood pressure usually remains the same as the prepregnancy level, but it gradu about 20 weeks of gestation. During the second trimester, both the systolic and diastolic pressures d to 10 mm Hg.

ba n

The fetus establishing iron stores

Dilution of hemoglobin concentration

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D Production of RBCs accelerates during pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 237 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 10. Physiologic anemia often occurs during pregnancy as a result of a. Inadequate intake of iron

d. ANS: B

Decreased production of erythrocytes Feedback

Inadequate intake of iron may lead to true anemia.

When blood volume expansion is more pronounced and occurs earlier than the increase in red blood will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather tha hemoglobin.

If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls the maternal system.

D There is an increased production of erythrocytes during pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 236 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 11. While assessing her patient, what does the nurse interpret as a positive sign of pregnancy? a. Fetal movement felt by the woman b.

Amenorrhea

Breast changes Visualization of fetus by ultrasound Feedback Fetal movement is a presumptive sign of pregnancy.

Amenorrhea is a presumptive sign of pregnancy.

Breast changes are a presumptive sign of pregnancy.

kt an k. c

d. ANS: D

Gravida 4 para 3

Gravida 4 para 2

d. ANS: C

Gravida 3 para 3

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ba n

The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus b D fetal movement felt by the examiner. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 245 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. A woman is currently pregnant; she has a 5-year-old son and a 3-year-old daughter. She had one other pregnancy that terminated at 8 weeks. Her gravida and para are a. Gravida 3 para 2

Feedback

Gravida 4 is correct, but she is a para 2. The pregnancy that was terminated at 8 weeks is classified

She has had four pregnancies, including the current one (gravida 4). She had two pregnancies that te weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion.

Because she is currently pregnant, she is classified as a gravida 4; the pregnancy that was terminated classified as an abortion.

D Since she is currently pregnant, she is classified as a gravida 4, not a 3. The para is correct. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 246 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. A womans last menstrual period was June 10. Her estimated date of delivery (EDD) is a. April 7 b.

March 17

March 27

d. ANS: B

April 17 Feedback

April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of ad

To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 10), and adds 7 days (March 17).

March is the correct month, but instead of adding 7 days, 17 days were added.

kt an k. c

D April 17 is subtracting 2 months instead of 3 months. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 247 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. A woman in her first trimester of pregnancy can expect to visit her physician every 4 weeks so that a. She develops trust in the health care team. b.

Her questions about labor can be answered.

The condition of the expectant mother and fetus can be monitored.

d. ANS: C

Problems can be eliminated.

ba n

Feedback A

Developing a trusting relationship should be established during these visits, but that is not the prima

Most women do not have questions concerning labor until the last trimester of the pregnancy.

This routine allows monitoring of maternal health and fetal growth and ensures that problems will b

It may be due to changes in hormones. It is related to an increase in glucose levels.

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D All problems cannot be eliminated because of prenatal visits, but they can be identified. PTS: 1 DIF: Cognitive Level: Knowledge REF: pp. 249-250 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. A patient in her first trimester complains of nausea and vomiting. She asks, Why does this happen? The nurses best response is a. It is due to an increase in gastric motility.

d. ANS: B

It is caused by a decrease in gastric secretions. Feedback

Gastric motility decreases during pregnancy.

Nausea and vomiting are believed to be caused by increased levels of hormones, decreased gastric m hypoglycemia.

Glucose levels decrease in the first trimester.

Gastric secretions do decrease, but this is not the main cause of nausea and vomiting.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 253 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 16. One of the most effective methods for preventing venous stasis is to a. Wear elastic stockings in the afternoons. b.

Sleep with the foot of the bed elevated.

Rest often with the feet elevated.

d. ANS: C

Sit with the legs crossed.

Feedback Elastic stockings should be applied before lowering the legs in the morning.

Elevating the legs at night may cause pressure on the diaphragm and increase breathing problems.

Elevating the feet and legs improves venous return and prevents venous stasis.

kt an k. c

D Sitting with the legs crossed will decrease circulation in the legs and increase venous stasis. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 253 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 17. A patient notices that the doctor writes positive Chadwicks sign on her chart. She asks the nurse what this means. The nurses best response is a. It refers to the bluish color of the cervix in pregnancy. It means the cervix is softening.

The doctor was able to flex the uterus against the cervix. That refers to a positive sign of pregnancy.

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Feedback

d. ANS: A

ba n

Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the cervix, called Chadwicks sign.

Softening of the cervix is Goodells sign.

The softening of the lower segment of the uterus (Hegars sign) can allow the uterus to be flexed aga

D Chadwicks sign is a probable indication of pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 238 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 18. Prenatal testing for the human immunodeficiency virus (HIV) is recommended for which women? a. All women, regardless of risk factors b.

A woman who has had more than one sexual partner

A woman who has had a sexually transmitted infection

d. ANS: A

A woman who is monogamous with her partner

Feedback A

An HIV test is recommended for all women, regardless of risk factors. The incidence of perinatal tra HIV-positive mother to her fetus ranges from 25% to 35%. Women who test positive for HIV can th

All women should be tested for HIV, although this patient is at increased risk of contracting the dise

Regardless of past sexual history, all women should have an HIV test completed prenatally.

Stretch and point the toe.

Dorsiflex the foot.

d. ANS: C

Apply a warm pack. Feedback

kt an k. c

D Although this patient is apparently monogamous, an HIV test is still recommended. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 249 | Table 13-3 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 19. To relieve a leg cramp, the patient should be instructed to a. Massage the affected muscle.

Since she is prone to blood clots in the legs, massaging the affected leg muscle is contraindicated.

Pointing the toes will contract the muscle and not relieve the pain.

Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle contraction.

ba n

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D Warm packs can be used to relax the muscle, but more immediate relief is necessary, such as dorsifl PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 253 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 20. The multiple marker screen is used to assess the fetus for which condition? a. Down syndrome b.

Diaphragmatic hernia

Congenital cardiac abnormality Anencephaly

d. ANS: A

Feedback

The maternal serum level of alpha-fetoprotein is used to screen for Trisomy 18 or 21, neural tube de chromosomal anomalies.

The quadruple marker test does not detect this fetal anomaly. Additional testing, such as ultrasonogr required to diagnose diaphragmatic hernia.

Congenital cardiac abnormality would most likely be identified during an ultrasound examination.

D The quadruple marker test would not detect anencephaly. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 249 | Table 13-3 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 21. Which complaint by a patient at 35 weeks of gestation requires additional assessment?

Shortness of breath when climbing stairs

Abdominal pain

Ankle edema in the afternoon

d. ANS: B

Backache with prolonged standing Feedback Shortness of breath is an expected finding by 35 weeks.

Abdominal pain may indicate preterm labor or placental abruption.

Ankle edema in the afternoon is a normal finding at this stage of pregnancy.

Palpation of the lumbar spine

Exercise pattern and duration

Ability to sleep for at least 6 hours uninterrupted Feedback

ba n

d. ANS: A

kt an k. c

D Backaches while standing is a normal finding during the later stages of pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 258 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 22. A gravida patient at 32 weeks of gestation reports that she has severe lower back pain. The nurses assessment should include a. Observation of posture and body mechanics

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 do pregnancy.

Certain exercises can help relieve back pain.

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D Rest is important for well-being, but the main concern with back pain is to assess posture and body PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 252-253 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 23. A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parents class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? My husband and I have agreed that my sister will be my coach since he becomes anxious with regar a. procedures and blood. He will be nearby and check on me every so often to make sure everything is b.

We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during la

We want the labor and birth to take place in a birthing room. My husband will come in the minute th

d. ANS: D

We do not want the fetal monitor used during labor, since it will interfere with movement and doing Feedback

This is an acceptable request for a laboring woman.

Using breathing techniques to alleviate pain is a realistic part of a birth plan.

Not all fathers are able to be present during the birth; however, this couple has made a realistic plan specific situation.

kt an k. c

Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by th should fully explain its importance. The option for intermittent electronic monitoring could be explo risk pregnancy and as long as labor is progressing normally. The birth plan is a tool with which pare D their childbirth options; however, the plan must be viewed as tentative. PTS: 1 DIF: Cognitive Level: Application REF: dm. 273, Box 13-2 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 24. Centering pregnancy is an example of an alternative model of prenatal care. Which statement accurately applies to the centering model of care? a. Group sessions begin with the first prenatal visit. b.

At each visit blood pressure, weight, and urine dipsticks are obtained by the nurse.

Eight to 12 women are placed in gestational-age cohort groups.

d. ANS: C

Outcomes are similar to traditional prenatal care. Feedback

Group sessions begin at 12 to 16 weeks of gestation and end with an early postpartum visit. Prior to patient has an individual assessment, physical examination, and history.

At the beginning of each group meeting, patients measure their own BP, weight, and urine dips and record. Fetal heart rate assessment and fundal height are obtained by the nurse.

Gestational age cohorts comprise the groups, with approximately 8 to 12 women in each group. Thi intact throughout the pregnancy. Individual follow-up visits are scheduled as needed.

w .te

ba n

Results evaluating this approach have been very promising. In a recent study of adolescent patients, D decrease in LBW infants and an increase in breastfeeding rates. PTS: 1 DIF: Cognitive Level: Application REF: dm. 250 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 25. Which comment by a woman in her first trimester indicates ambivalent feelings? a. I wanted to become pregnant, but Im scared about being a mother. b.

I havent felt well since this pregnancy began.

Im concerned about the amount of weight Ive gained.

d. ANS: A

My body is changing so quickly. Feedback

Ambivalence refers to conflicting feelings.

This does not reflect conflicting feelings.

By expressing concerns over a normal occurrence, the woman is trying to confirm the pregnancy.

The woman is trying to confirm the pregnancy when she expresses concerns over normal pregnancy D expressing conflicting feelings. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 259 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 26. A patient who is 7 months pregnant states, Im worried that something will happen to my baby. The nurses best response is a. There is nothing to worry about. b.

The doctor is taking good care of you and your baby.

Tell me about your concerns. Your baby is doing fine.

d. ANS: C

kt an k. c

Feedback A

This statement is belittling the patients concerns.

This statement is belittling the patients concerns by telling her she should not worry.

Encouraging the client to discuss her feelings is the best approach. Women during their third trimes that such fears are not unusual in pregnancy.

ba n

D This statement disregards the patients feelings and treats them as unimportant. PTS: 1 DIF: Cognitive Level: Application REF: dm. 261 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 27. Mimicry refers to observing and copying the behaviors of other mothers. An example might be a. Babysitting for a neighbors children Wearing maternity clothes before they are needed

Daydreaming about the newborn

d. ANS: B

Imagining oneself as a good mother

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Feedback

Babysitting other children is a form of role playing where the woman practices the expected role of

Wearing maternity clothes before they are needed helps the expectant mother feel what its like to be pregnant.

Daydreaming is a type of fantasy where the woman tries on a variety of behaviors in preparation for

Imagining herself as a good mother is the womans effort to look for a good role fit. She observes be D mothers and compares them with her own expectations. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 262 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 28. A step in maternal role attainment that relates to the woman giving up certain aspects of her previous life is termed a. Looking for a fit

Roleplaying

Fantasy

d. ANS: D

Grief work Feedback

This is when the woman observes the behaviors of mothers and compares them with her own expec

Roleplaying involves searching for opportunities to provide care for infants in the presence of anoth

Fantasies allow the woman to try on a variety of behaviors. This usually deals with how the child w characteristics of the child.

kt an k. c

The woman experiences sadness as she realizes that she must give up certain aspects of her previous D can never go back. PTS: 1 DIF: Cognitive Level: Knowledge REF: pp. 262-263 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 29. The maternal task that begins in the first trimester and continues throughout the neonatal period is called a. Seeking safe passage for herself and her baby Securing acceptance of the baby by others

Learning to give of herself

d. ANS: D

ba n

Developing attachment with the baby Feedback

This is a task that ends with delivery. During this task the woman seeks health care and cultural prac

This process continues throughout pregnancy as the woman reworks relationships.

This task occurs during pregnancy as the woman allows her body to give space to the fetus. She con to others in the form of food or presents.

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Developing attachment (strong ties of affection) to the unborn baby begins in early pregnancy when D that she is pregnant. By the second trimester, the baby becomes real and feelings of love and attachm PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 263 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. Which situation best describes a man trying on fathering behaviors? a. Spending more time with his siblings b.

Coaching a Little League baseball team

Reading books on newborn care

d. ANS: B

Exhibiting physical symptoms related to pregnancy Feedback

The man normally will seek closer ties with his father.

Interacting with children and assuming the behavior and role of a father best describes a man trying

Men do not normally read information that is provided in advance. The nurse should be prepared to information after the baby is born, when it is more relevant.

Being divorced

Her age

d. ANS: C

Age of the daughter Feedback

kt an k. c

D This is called couvade. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 264 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 31. A 36-year-old divorcee with a successful modeling career finds out that her 18-year-old married daughter is expecting her first child. What is a major factor in determining how the woman will respond to becoming a grandmother? a. Her career

Career responsibilities may have demands that make the grandparents not as accessible, but it is not determining the womans response to becoming a grandmother.

Being divorced is not a major factor that determines adaptation of grandparents.

Age is a major factor in determining the emotional response of prospective grandparents. Young gra be happy with the stereotype of grandparents as being old.

ba n

Practice preventive health care. Maintain an optimistic view of life.

d. ANS: B

Meet health needs as they occur.

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The age of the daughter is not a major factor that determines adaptation of grandparents. The age of D major factor. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 265 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 32. The nurse who practices in a prenatal clinic understands that a major concern of lower socioeconomic groups is to a. Maintain group health insurance on their families.

Feedback A

Lower socioeconomic groups usually do not have group health insurances.

Because of economic uncertainty, lower socioeconomic groups place more emphasis on meeting the present rather than on future goals.

They may value health care, but cannot afford preventive health care.

They may struggle for basic needs and often do not see a way to improve their situation. It is difficu optimism.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 267 | Table 13-6 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 33. What comment by a new mother exhibits understanding of her toddlers response to a new sibling? a. I cant believe he is sucking his thumb again. b.

He is being difficult, and I dont have time to deal with him.

My husband is going to stay with the baby so I can take our son to the park tomorrow.

d. ANS: C

When we brought the baby home, we made our son stop sleeping in the crib.

Feedback

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 the attention reassurance of parental love and affection are important.

It is important for a mother to seek time alone with her toddler to reassure him that he is loved.

kt an k. c

ba n

Changes in sleeping arrangements should be made several weeks before the birth so that the child d D displaced by the new baby. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 265 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 34. As a nurse in labor and delivery, you are caring for a Muslim woman during the active phase of labor. You note that when you touch her, she quickly draws away. You should a. Continue to touch her as much as you need to while providing care. Assume that she doesnt like you and decrease your time with.

Limit touching to a minimum, as this may not be acceptable in her culture. Ask the charge nurse to reassign you to another patient.

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d. ANS: C

Feedback

By continuing to touch her, the nurse is showing disrespect for her cultural beliefs.

A Muslims response to touch does not reflect like or dislike.

Touching is an important component of communication in various cultures, but if the patient appear offensive, the nurse should respect her cultural beliefs and limit touching her.

D This reaction may be offensive to the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 269 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 35. Early pregnancy classes offered in the first and second trimesters cover a. Phases and stages of labor b.

Coping with common discomforts of pregnancy

Methods of pain relief

Predelivery and postdelivery care of the patient having a cesarean delivery

ANS: B Feedback A

Phases and stages of labor are taught in childbirth preparation classes.

Early pregnancy classes focus on the first two trimesters and cover information on adapting to pregn early discomforts, and understanding what to expect in the months ahead.

Pain control is part of childbirth preparation classes.

kt an k. c

D This is taught in cesarean birth preparation classes. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 274 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. In some Middle Eastern and African cultures, female genital mutilation 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 her genitalia. When caring for this woman, the nurse can formulate a diagnosis with the understanding that the woman may be at risk for (select all that apply) a. Obstructed labor Increased signs of pain response

Laceration

Hemorrhage

ba n

e. Infection ANS: A, C, D, E

Feedback

Correct

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The woman is at risk for all of these complications. Female genital mutilation, cutting, or circumcision involves removal of some or all of the external female genitalia are often stitched together over the vaginal and urethral opening as part of this practice. 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 respo indicate lack of pain. In fact, pelvic examinations are likely to be very painful because t small and inelastic scar tissue makes the area especially sensitive. A pediatric speculum Incorrect and the patient should be made as comfortable as possible. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 269 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity 2. A pregnant woman 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.

Hepatitis A and B

Measles, mumps, rubella (MMR)

Influenza

e. Varicella ANS: A, B, D Feedback

Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are for women who have a risk for contracting or developing the disease.

Correct

Development of the operculum

Quickening

Ballottement

e. Lightening ANS: A, C, E Feedback

kt an k. c

Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallp Incorrect contraindicated during pregnancy because of the possible teratogenic effects on the fetu PTS: 1 DIF: Cognitive Level: Application REF: dm. 257 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 3. During pregnancy there are a number of changes that occur as a direct result of the presence of the fetus. Which of these adaptations meet this criteria? Select all that apply. a. Leukorrhea

ba n

Leukorrhea is a white or slightly gray vaginal discharge that develops in response to cer estrogen and progesterone. Quickening is the first recognition of fetal movements or fee life. Quickening is often described as a flutter and is felt earlier in multiparous women t Lightening occurs when the fetus begins to descent into the pelvis. This occurs two wee the nullipara and at the start of labor in the multipara.

Correct

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Mucous fills the cervical canal creating a plug otherwise known as the operculum. The barrier against bacterial invasion during the pregnancy. Passive movement of the uneng Incorrect referred to asballottement. PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 244-245 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity COMPLETION 1. While providing education to a primiparous woman regarding the normal changes of pregnancy, it is important for the nurse to explain that the uterus undergoes irregular contractions. These are known as _____________ contractions. ANS: Braxton Hicks Irregular painless contractions occur throughout pregnancy, although many women do not notice them until the third trimester. Women who are unsure, who have 5 or 6 regular contractions within one hour, or who demonstrate other signs of labor should contact their provider. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 245 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. During pregnancy many women become increasingly concerned about their ability to protect and provide for the fetus. This concern is often manifested as _____________. ANS:

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ba n

kt an k. c

narcissism Narcissism is an undue preoccupation with ones self and introversion (concentration on ones self and ones body). Selecting the right foods and clothing may be more important than ever before, out of concern for the growing fetus. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 259 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. In order to prevent neural tube defects, updated recommendations include an intake of 0.4 mg to 0.8 mg of ___________________ each day from one month prior to conception until 8 to 10 weeks of pregnancy. ANS: folic acid Pregnant women should take 0.6 mg of folic acid daily for the duration of their pregnancy. Women who have given birth to an infant with a neural tube defect previously should take 4 mg of folic acid in the 4 weeks prior to pregnancy and throughout the first trimester. PTS: 1 DIF: Cognitive Level: Application REF: dm. 246 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance TRUE/FALSE 1. Pelvic congestion during pregnancy may lead to heightened sexual interest and increased orgasmic experiences. Is this statement true or false? ANS: T Increased vascularity, edema, and connective tissue changes during pregnancy make the tissues of the vulva and perineum more pliable. This can lead to an increased interest in sexual activity and ease of orgasm. PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 260-261 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. Pregnancy is a hypercoagulable state, where the mothers blood clots more readily. Is this statement true or false? ANS: T This is because of an increase in factors that favor coagulation and a decrease in factors that inhibit coagulation. Fibrinogen increases by 50% and factors VII, VIII, IX, and X also rise.

Chapter 21 Complications Occurring Before Labor and Delivery

MULTIPLE CHOICE 1. The perinatal nurse is giving discharge instructions to a woman, status post suction and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse is

If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if y pregnancy, it would be better for you to use the most reliable method of contraception available.

The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by mea hormone that your body produces during pregnancy. If you were to get pregnant, it would make the cancer more difficult.

If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy improve your chance of a successful pregnancy, it is better not to get pregnant at this time.

Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregn

ANS: B

kt an k. c

Feedback

Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. hCG levels which increases the risk for choriocarcinoma.

This is an accurate statement. Beta-hCG levels will be drawn for 1 year to ensure that the mole is co There is an increased chance of developing choriocarcinoma after the development of a hydatidiform to achieve a zero hCG level. If the woman were to become pregnant, it may obscure the presence of carcinogenic cells.

The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present.

Any contraceptive method except an IUD is acceptable.

ba n

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 582 OBJ: Nursing Process: Planning and Implementation

MSC: Client Needs: Physiologic Integrity

2. Which maternal condition always necessitates delivery by cesarean section? a.

Partial abruptio placentae

Total placenta previa

Ectopic pregnancy

Eclampsia

ANS: B Feedback

In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vag occurred.

The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in

Labor can be safely induced if the eclampsia is under control.

kt an k. c

If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted. If the f vaginal delivery is preferred.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 583, 585

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 3. Spontaneous termination of a pregnancy is considered to be an abortion if The pregnancy is less than 20 weeks.

The fetus weighs less than 1000 g.

The products of conception are passed intact.

No evidence exists of intrauterine infection.

w .te

ANS: A

Feedback A

An abortion is the termination of pregnancy before the age of viability (20 weeks).

The weight of the fetus is not considered because some fetuses of an older age may have a low birth

A spontaneous abortion may be complete or incomplete.

A spontaneous abortion may be caused by many problems, one being intrauterine infection.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 576 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Inevitable

Missed

Incomplete

Threatened

kt an k. c

4. An abortion in which the fetus dies but is retained in the uterus is called _____ abortion.

Feedback

ba n

ANS: B

An inevitable abortion means that the cervix is dilating with the contractions.

Missed abortion refers to a dead fetus being retained in the uterus.

An incomplete abortion means that not all of the products of conception were expelled.

With a threatened abortion the woman has cramping and bleeding but not cervical dilation.

w .te

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 578 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. A placenta previa in which the placental edge just reaches the internal os is called a.

Total

Partial

Complete

Marginal

ANS: D

Feedback With a total placenta previa the placenta completely covers the os.

With a partial previa the lower border of the placenta is within 3 cm of the internal cervical os, but d cover the os.

A complete previa is termed total. The placenta completely covers the internal cervical os.

A placenta previa that does not cover any part of the cervix is termed marginal.

ba n

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 583

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

w .te

6. What condition indicates concealed hemorrhage in an abruptio placentae? Decrease in abdominal pain

Bradycardia

Hard, boardlike abdomen

Decrease in fundal height

ANS: C Feedback A

Abdominal pain may increase.

The patient will have shock symptoms that include tachycardia.

Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a he placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, board

The fundal height will increase as bleeding occurs.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 586

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

kt an k. c

7. The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to Assess fetal heart rate (FHR) and maternal vital signs.

Perform a venipuncture for hemoglobin and hematocrit levels.

Place clean disposable pads to collect any drainage.

Monitor uterine contractions.

ANS: A

The most important assessment is to check mother/fetal well-being. The blood levels can be obtaine

Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of th effect on the mother and fetus.

w .te

Feedback

ba n

It is important to assess future bleeding, but the top priority is mother/fetal well-being.

Monitoring uterine contractions is important, but not the top priority.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 587 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. A pregnant woman is being discharged from the hospital after placement of a cerclage because of a history of recurrent pregnancy loss secondary to an incompetent cervix. Discharge teaching should emphasize that Any vaginal discharge should be reported immediately to her care provider.

The presence of any contractions, rupture of membranes, or severe perineal pressure should be repo

She will need to make arrangements for care at home, because her activity level will be restricted.

She will be scheduled for a cesarean birth.

kt an k. c

ANS: B

Feedback

Vaginal bleeding needs to be reported to her primary care provider.

Nursing care should stress the importance of monitoring signs and symptoms of preterm labor.

Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, whi freedom to see her physician. Home uterine activity monitoring may be used to limit the womans ne safely monitor her status at home.

The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean planned.

w .te

ba n

PTS: 1 DIF: Cognitive Level: Application REF: dm. 579

OBJ: Nursing Process: Planning and Implementation MSC: Client Needs: Health Promotion and Maintenance 9. A woman with severe preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a.

Tocolytic

Anticonvulsant

Antihypertensive

Diuretic

ANS: B Feedback

Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous s seizure activity.

Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant ma

Diuresis is a therapeutic response to magnesium sulfate.

kt an k. c

A tocolytic drug does slow the frequency and intensity of uterine contractions but is not used for tha scenario.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 594

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

10. What is the only known cure for preeclampsia? Magnesium sulfate

Antihypertensive medications

Delivery of the fetus

w .te

Administration of acetylsalicylic acid (ASA) every day of the pregnancy

ANS: C Feedback A

Magnesium sulfate is one of the medications used to treat but not to cure preeclampsia.

Antihypertensive medications are used to lower the dangerously elevated blood pressures in preecla eclampsia.

If the fetus is viable and near term, delivery is the only known cure for preeclampsia.

Low doses of ASA (60 to 80 mg) have been administered to women at high risk for developing pree

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 593

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Edema

Proteinuria

Glycosuria

ANS: D

w .te

Feedback

ba n

Hypertension

kt an k. c

11. Which clinical sign is not included in the classic symptoms of preeclampsia?

The first indication of preeclampsia is usually an increase in the maternal blood pressure.

The first sign noted by the pregnant woman is a rapid weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension.

Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 592 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 12. Which assessment finding should convince the nurse to hold the next dose of magnesium sulfate?

Absence of deep tendon reflexes

Urinary output of 100 mL total for the previous 2 hours

Respiratory rate of 14 breaths/min

Decrease in blood pressure from 160/100 to 140/85

ANS: A

kt an k. c

Feedback

An hourly output of less than 30 mL could indicate toxicity.

A respiratory rate of less than 12 breaths/min could indicate toxicity.

Decrease in blood pressure is an expected side effect of magnesium sulfate.

ba n

Because absence of deep tendon reflexes is a sign of magnesium toxicity, the next scheduled dose s administered. Calcium gluconate is the antidote that should be administered.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 600

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Eclampsia

13. The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the womans latest laboratory test findings, which reveal a low platelet count, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician, because the lab results are indicative of

Disseminated intravascular coagulation

HELLP syndrome

Rh incompatibility

ANS: C

Feedback Eclampsia is determined by the presence of seizures.

DIC is a potential complication associated with HELLP syndrome.

HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepati characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP).

These are not clinical indications of Rh incompatibility.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 600-601

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

+2 edema

+3 edema

+4 edema

ANS: C

+1 edema

w .te

ba n

14. The nurse is explaining how to assess edema to the nursing students working on the antepartum unit. Which score indicates edema of lower extremities, face, hands, and sacral area?

Feedback

Edema classified as +1 indicates minimal edema of the lower extremities.

Marked edema of the lower extremities is termed +2 edema.

Edema of the extremities, face, and sacral area is classified as +3 edema.

Generalized massive edema (+4) includes accumulation of fluid in the peritoneal cavity.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 593 | Table 25-2

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Blood pressure increase to 138/86 mm Hg

Weight gain of 0.5 kg during the past 2 weeks

A dipstick value of 3+ for protein in her urine

Pitting pedal edema at the end of the day

kt an k. c

15. A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?

ANS: C Feedback

Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week.

Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value the nurse that additional testing or assessment should be made.

Edema occurs in many normal pregnancies as well as in women with preeclampsia. Therefore, the p no longer considered diagnostic of preeclampsia.

w .te

ba n

Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm H diastolic pressure.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 592

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 16. A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate a.

Anxiety due to hospitalization

Worsening disease and impending convulsion

Effects of magnesium sulfate

Gastrointestinal upset

ANS: B Feedback These are danger signs and should be treated.

Headache and visual disturbances are due to increased cerebral edema. Epigastric pain indicates dis hepatic capsules and often warns that a convulsion is imminent.

She has not been started on magnesium sulfate as a treatment yet. Also, these are not expected effec

These are danger signs showing increased cerebral edema and impending convulsion.

kt an k. c

PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 599-600

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

17. Rh incompatibility can occur if the woman is Rh negative and her Fetus is Rh positive

Husband is Rh positive

Fetus is Rh negative

Husband and fetus are both Rh negative

w .te

ANS: A

Feedback A

For Rh incompatibility to occur, the mother must be Rh negative and her fetus Rh positive.

The husbands Rh factor is a concern only as it relates to the possible Rh factor of the fetus.

If the fetus is Rh negative, the blood types are compatible and no problems should occur.

If the fetus is Rh negative, the blood type with the mother is compatible. The husbands blood type d the problem.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 601 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. In which situation is a dilation and curettage (D&C) indicated? Complete abortion at 8 weeks

Incomplete abortion at 16 weeks

Threatened abortion at 6 weeks

Incomplete abortion at 10 weeks

Feedback

ba n

ANS: D

kt an k. c

If all the products of conception have been passed (complete abortion), a D&C is not used.

D&C is used to remove the products of conception from the uterus and can be done safely until wee

If the pregnancy is still viable (threatened abortion), a D&C is not used.

D&C is used to remove the products of conception from the uterus and can be used safely until wee

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 578 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 19. What order should the nurse expect for a patient admitted with a threatened abortion? a.

Bed rest

Ritodrine IV

NPO

Narcotic analgesia every 3 hours, prn

ANS: A

Feedback

Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continu

Ritodrine is not the first drug of choice for tocolytic medications.

There is no reason for having the woman NPO. At times dehydration may produce contractions, so important.

Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions.

ba n

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 577

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

w .te

20. What data on a patients health history places her at risk for an ectopic pregnancy? Use of oral contraceptives for 5 years

Recurrent pelvic infections Ovarian cyst 2 years ago

Heavy menstrual flow of 4 days duration

ANS: B Feedback A

Oral contraceptives do not increase the risk for ectopic pregnancies.

Infection and subsequent scarring of the fallopian tubes prevents normal movement of the fertilized uterus for implantation.

Ovarian cysts do not cause scarring of the fallopian tubes.

This will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnanc

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 580 | Box 25-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

kt an k. c

21. What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole? Complaint of frequent mild nausea

Blood pressure of 120/80 mm Hg

Fundal height measurement of 18 cm

History of bright red spotting for 1 day, weeks ago

ANS: C

w .te

Feedback

ba n

Nausea increases in a molar pregnancy because of the increased production of hCG.

A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension.

The history of bleeding is normally described as being brownish.

The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of pregnancy.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 582 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 22. What routine nursing assessment is contraindicated in the patient admitted with suspected placenta previa?

Monitoring FHR and maternal vital signs

Observing vaginal bleeding or leakage of amniotic fluid

Determining frequency, duration, and intensity of contractions

Determining cervical dilation and effacement

ANS: D

kt an k. c

Feedback

Monitoring FHR and maternal vital signs is a necessary part of the assessment for this woman.

Monitoring for bleeding and rupture of membranes is not contraindicated with this woman.

Monitoring contractions is not contraindicated with this woman.

Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrh

ba n

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 584

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Rupture of membranes

Vaginal bleeding

w .te

23. The primary symptom present in abruptio placentae that distinguishes it from placenta previa is

Presence of abdominal pain

Changes in maternal vital signs

ANS: C Feedback

Both may have vaginal bleeding.

Rupture of membranes may occur with both conditions.

Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within th previa manifests with painless vaginal bleeding.

Maternal vital signs may change with both if bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 585

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

24. Which laboratory marker is indicative of disseminated intravascular coagulation (DIC)? Bleeding time of 10 minutes

Presence of fibrin split products

Thrombocytopenia

Hyperfibrinogenemia

ba n

w .te

ANS: B Feedback

Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys vascula

Bleeding time in DIC is normal.

Low platelets may occur with but are not indicative of DIC because they may result from other coag

Hypofibrinogenemia occurs with DIC.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 578 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

25. A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should Vigorously stimulate the woman.

Instruct her to take deep breaths.

Administer calcium gluconate.

Increase her IV fluids.

kt an k. c

ANS: C Feedback

Stimulation will not increase the respirations.

This will not be successful in reversing the effects of the magnesium sulfate.

Calcium gluconate reverses the effects of magnesium sulfate.

Increasing her IV fluids will not reverse the effects of the medication.

ba n

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 595 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Bed rest and analgesics are the recommended treatment.

26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that

She will be unable to conceive in the future.

A D&C will be performed to remove the products of conception.

Hemorrhage is the major concern.

ANS: D

Feedback The recommended treatment is to remove the pregnancy before hemorrhaging.

If the tube must be removed, her fertility will decrease but she will not be infertile.

A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes.

Severe bleeding occurs if the fallopian tube ruptures.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 580

kt an k. c

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

27. Approximately 12% to 26% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion? Chromosomal abnormalities

Infections

Endocrine imbalance

Immunologic factors

w .te

ANS: A

ba n

At least 60% of pregnancy losses result from chromosomal abnormalities that are incompatible with

Feedback

Maternal infection may be a cause of early miscarriage.

Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy lo

Women who have repeated early pregnancy losses appear to have immunologic factors the play a ro abortion incidents.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 576

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. Methotrexate is recommended as part of the treatment plan for which obstetric complication? Complete hydatidiform mole

Missed abortion

Unruptured ectopic pregnancy

Abruptio placentae

kt an k. c

ANS: C Feedback

Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform m

Methotrexate is not indicated or recommended as a treatment option for missed abortions.

Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman wh pregnancy is unruptured and less than 4 cm in diameter.

Methotrexate is not indicated or recommended as a treatment option for abruptio placentae.

w .te

ba n

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 580

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

29. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment involves a.

Corticosteroids to reduce inflammation

IV therapy to correct fluid and electrolyte imbalances

An antiemetic, such as pyridoxine, to control nausea and vomiting

Enteral nutrition to correct nutritional deficits

ANS: B Feedback

Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum, but they are initial treatment for this disorder.

Initially, the woman who is unable to down clear liquids by mouth requires IV therapy for correctio electrolyte imbalances.

Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribe

In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to nutritional deprivation. This is not an initial treatment for this patient.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 590

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

ba n

30. A woman with preeclampsia has a seizure. The nurses primary duty during the seizure is to Insert an oral airway.

Suction the mouth to prevent aspiration.

Administer oxygen by mask.

Stay with the patient and call for help.

w .te

ANS: D

Feedback

Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should the airway patent by turning the patients head to the side to prevent aspiration.

Once the seizure has ended, it may be necessary to suction the patients mouth.

Oxygen would be administered after the convulsion has ended.

If a patient becomes eclamptic, the nurse should stay with her and call for help. Nursing actions dur directed towards ensuring a patent airway and patient safety.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 597 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

kt an k. c

1. Throughout the world the rate of ectopic pregnancy has increased dramatically over the past 20 years. This is believed to be due primarily to scarring of the fallopian tubes as a result of pelvic infection, inflammation, or surgery. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for symptoms such as (select all that apply) Pelvic pain

Abdominal pain

Unanticipated heavy bleeding

Vaginal spotting or light bleeding

Missed period

w .te

ANS: A, B, D, E

ba n

Feedback

Correct

Incorrect

A missed period or spotting can easily be mistaken by the patient as early signs of pregn signs depend on exactly where the implantation occurs. The nurse must be thorough in h because pain is not a normal symptom of early pregnancy.

As the fallopian tube tears open and the embryo is expelled, the patient often exhibits se accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock even no external bleeding. In about half of women, shoulder and neck pain occurs due t diaphragm from the hemorrhage.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 580 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Iron supplementation

Resumption of intercourse at 6 weeks post-procedure

Referral to a support group if necessary

Expectation of heavy bleeding for at least 2 weeks

Emphasizing the need for rest

ANS: A, C, E Feedback

kt an k. c

2. A patient who has undergone a D&C for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, that bleeding has been controlled, and that the woman has adequately recovered from the administration of anesthesia. In order to promote an optimal recovery, discharge teaching should include (select all that apply)

Incorrect

Nothing should be placed in the vagina for 2 weeks postprocedure. This includes tampo intercourse. The purpose of this recommendation is to prevent infection. Should infectio may be prescribed. The patient should expect a scant, dark discharge for 1 to 2 weeks. S profuse, or bright bleeding occur she should be instructed to contact her provider.

w .te

ba n

Correct

The woman should be advised to consume a diet high in iron and protein. For many wo supplementation also is necessary. Acknowledge that the patient has experienced a loss can be taught to expect mood swings and possibly depression. Referral to a support gro professional counseling may be necessary. Discharge teaching should emphasize the ne

PTS: 1 DIF: Cognitive Level: Application REF: dm. 579, 583

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity COMPLETION 1. Recurrent spontaneous abortion refers to a condition in which a woman experiences three or more consecutive abortions or miscarriages. This is also known as ________ abortion. ANS: habitual

Primary causes are believed to be genetic or chromosomal abnormalities of the fetus. For the mother who repeatedly aborts, the cause is often an anomaly of the reproductive tract such as bicornate uterus or incompetent cervix. Systemic illnesses such as lupus erythematosus and diabetes mellitus have been implicated in this condition as well. Treatment depends entirely on the cause and therefore varies between medical and surgical approaches. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 578 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

2. The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _____________.

kt an k. c

ANS: placenta previa

In placenta previa, the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 583

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. The antidote administered to reverse magnesium toxicity is ______________.

w .te

ANS: calcium gluconate

Calcium gluconate is the antidote necessary to reverse magnesium toxicity. The nurse caring for this patient should keep calcium gluconate in the room along with secured, syringes and needles.

Chapter 22 Complications Occurring During Labor and Delivery MULTIPLE CHOICE

1. Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with

Frequent episodes of maternal hypoglycemia

kt an k. c

Congenital anomalies in the fetus

ba n

Polyhydramnios

w .te

ANS: B

Hyperemesis gravidarum

Feedback

Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage.

kt an k. c

Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies.

ba n

Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically, it is seen in the third trimester of pregnancy.

w .te

Hyperemesis gravidarum may exacerbate hypoglycemic events as the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 609

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

2. In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the patient states

I will need to increase my insulin dosage during the first 3 months of pregnancy.

kt an k. c

Insulin dosage will likely need to be increased during the second and third trimesters.

ba n

Episodes of hypoglycemia are more likely to occur during the first 3 months.

w .te

Insulin needs should return to normal within 7 to 10 days after birth if I am bottle feeding.

ANS: A

Feedback

Insulin needs are reduced in the first trimester due to increased insulin production by the pancreas and increased peripheral sensitivity to insulin.

kt an k. c

This statement is accurate and signifies understanding. Insulin resistance begins as early as 14 to 16 weeks of gestation and continues to rise until it stabilizes during the last few weeks of pregnancy.

ba n

This statement is correct. During the first trimester maternal blood glucose levels are reduced and the insulin response to glucose is enhanced therefore this is when an episode of hypoglycemia is most likely to occur.

w .te

For the non-breastfeeding mother insulin levels return to normal within 7 to 10 days. Lactation utilized maternal glucose, therefore the mothers insulin requirements will remain low during lactation. On completion of weaning the mothers prepregnancy insulin requirement is reestablished.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 608

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

3. Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for

kt an k. c

Macrosomia

ba n

Congenital anomalies of the central nervous system

w .te

Preterm birth

Low birth weight

ANS: A

Feedback

Poor glycemic control later in pregnancy increases the rate of fetal macrosomia.

kt an k. c

Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies.

ba n

w .te

Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes.

Increased weight, or macrosomia, is the greatest risk factor for this woman.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 609

OBJ: Nursing Process: Planning and Implementation

MSC: Client Needs: Physiologic Integrity

4. In terms of the incidence and classification of diabetes, maternity nurses should know that

ba n

Type 2 diabetes often goes undiagnosed.

kt an k. c

Type 1 diabetes is most common.

w .te

There is only one type of gestational diabetes.

Type 1 diabetes may become type 2 during pregnancy.

ANS: B

Feedback

Type 2, sometimes called adult onset diabetes, is the most common.

kt an k. c

Type 2 often goes undiagnosed, because hyperglycemia develops gradually and often is not severe.

ba n

There are 2 subgroups of gestational diabetes. Type GDM A1 is diet-controlled whereas Type GDM A2 is controlled by insulin and diet.

w .te

People do not go back and forth between type 1 and type 2 diabetes.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 608 | Box 26-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

5. Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should know that

Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own.

kt an k. c

Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester, because they are consuming more sugar.

ba n

w .te

During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus.

Maternal insulin requirements steadily decline during pregnancy.

ANS: C

Feedback

Insulin never crosses the placenta; the fetus starts making its own around the tenth week.

kt an k. c

As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels).

ba n

Pregnant women develop increased insulin resistance during the second and third trimesters.

w .te

Maternal insulin requirements may double or quadruple by the end of pregnancy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 608

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother?

Hypoglycemia

kt an k. c

Hypercalcemia

ba n

Hypobilirubinemia

w .te

ANS: A

Hypoinsulinemia

Feedback

The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, leading to hypoglycemia.

kt an k. c

Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother.

ba n

Excess erythrocytes are broken down after birth, releasing large amounts of bilirubin into the neonates circulation, which results in hyperbilirubinemia.

w .te

Because fetal insulin production is accelerated during pregnancy, the neonate shows hyperinsulinemia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 610

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

7. Which factor is known to increase the risk of gestational diabetes mellitus?

Underweight before pregnancy

kt an k. c

Maternal age younger than 25 years

ba n

Previous birth of large infant

w .te

ANS: C

Previous diagnosis of type 2 diabetes mellitus

Feedback

Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes.

A woman younger than 25 generally is not at risk for gestational diabetes mellitus.

kt an k. c

Previous birth of a large infant suggests gestational diabetes mellitus.

ba n

The person with type 2 diabetes mellitus already is a diabetic and will continue to be so after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 613

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

8. Glucose metabolism is profoundly affected during pregnancy because:

Pancreatic function in the islets of Langerhans is affected by pregnancy.

kt an k. c

The pregnant woman increases her dietary intake significantly.

The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman.

ba n

Placental hormones are antagonistic to insulin, resulting in insulin resistance.

Feedback

w .te

ANS: D

Pancreatic functioning is not affected by pregnancy.

The glucose requirements differ because of the growing fetus.

The pregnant woman should increase her intake by 200 calories a day.

kt an k. c

Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is broken down more quickly by the enzyme placental insulinase.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 607

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

9. To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by

Eating six small equal meals per day

Reducing carbohydrates in her diet

Eating her meals and snacks on a fixed schedule

Increasing her consumption of protein

ba n

ANS: C

kt an k. c

w .te

Feedback

It is more important to have a fixed meal schedule than equal division of food intake.

Approximately 45% of the food eaten should be in the form of carbohydrates.

Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications.

kt an k. c

Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 612, 614

ba n

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

w .te

10. When the pregnant diabetic experiences hypoglycemia while hospitalized, the nurse should have the patient

Eat 6 saltine crackers.

Drink 8 oz of orange juice with 2 tsp of sugar added.

Drink 4 oz of orange juice followed by 8 oz of milk.

kt an k. c

Eat hard candy or commercial glucose wafers.

ANS: A

ba n

Feedback

w .te

Crackers provide carbohydrates in the form of polysaccharides.

Orange juice and sugar will increase the blood sugar, but not provide a slow-burning carbohydrate to sustain the blood sugar.

Milk is a disaccharide and orange juice is a monosaccharide. This will provide an increase in blood sugar but will not sustain to level.

kt an k. c

PTS: 1 DIF: Cognitive Level: Application REF: dm. 616

This provides only monosaccharides.

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

ba n

11. Nursing intervention for the pregnant diabetic is based on the knowledge that the need for insulin

w .te

Increases throughout pregnancy and the postpartum period

Decreases throughout pregnancy and the postpartum period

Varies depending on the stage of gestation

Should not change because the fetus produces its own insulin

kt an k. c

ANS: C

Feedback

ba n

w .te

Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor.

Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells.

Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 612

The insulin needs change during the pregnancy.

kt an k. c

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

ba n

12. With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that

w .te

Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.

Hydramnios occurs approximately twice as often in diabetic pregnancies.

Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies.

Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

ANS: A

kt an k. c

Feedback

ba n

Prompt treatment of DKA is necessary to save the fetus and the mother.

w .te

Hydramnios occurs 10 times more often in diabetic pregnancies.

Infections are more common and more serious in pregnant women with diabetes.

Mild to moderate hypoglycemic episodes do not appear to have significant effects on fetal wellbeing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 616

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

kt an k. c

13. What form of heart disease in women of childbearing years usually has a benign effect on pregnancy?

Cardiomyopathy

ba n

w .te

Rheumatic heart disease

Congenital heart disease

Mitral valve prolapse

ANS: D

Feedback

kt an k. c

Cardiomyopathy produces congestive heart failure during pregnancy.

ba n

w .te

Rheumatic heart disease can lead to heart failure during pregnancy.

Some congenital heart diseases will produce pulmonary hypertension or endocarditis during pregnancy.

Mitral valve prolapse is a benign condition that is usually asymptomatic.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 618

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. When teaching the pregnant woman with class II heart disease, the nurse should

kt an k. c

Advise her to gain at least 30 lb.

ba n

w .te

Explain the importance of a diet high in calcium.

Instruct her to avoid strenuous activity.

Inform her of the need to limit fluid intake.

ANS: C

Feedback

Weight gain should be kept at a minimum with heart disease.

kt an k. c

ba n

Iron and folic acid intake is important to prevent anemia.

w .te

Activity may need to be limited so that cardiac demand does not exceed cardiac capacity.

Fluid intake should not be limited during pregnancy. She may also be put on a diuretic. Fluid intake is necessary to prevent fluid deficits.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 619

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

15. Prophylaxis of subacute bacterial endocarditis (SBE) is given before and after birth when a pregnant woman has

kt an k. c

Valvular disease

ba n

Congestive heart disease

w .te

Arrhythmias

Postmyocardial infarction

ANS: A

Feedback

Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve prolapse.

kt an k. c

Prophylaxis for intrapartum endocarditis is not indicated for a patient with congestive heart disease.

ba n

w .te

Prophylaxis for intrapartum endocarditis is not necessary for a woman with underlying arrhythmias.

A woman who is postmyocardial infarction does not require prophylaxis for intrapartum endocarditis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 618

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. When caring for a pregnant woman with suspected cardiomyopathy, the nurse must be alert for signs and symptoms of cardiac decompensation, which include

A regular heart rate and hypertension

kt an k. c

An increased urinary output, tachycardia, and dry cough

ba n

w .te

Shortness of breath, bradycardia, and hypertension

Dyspnea; crackles; and an irregular, weak pulse

ANS: D

Feedback

These symptoms are not generally associated with cardiac decompensation.

kt an k. c

Of these symptoms, only tachycardia is indicative of cardiac decompensation.

ba n

Of these symptoms, only dyspnea is indicative of cardiac decompensation.

w .te

Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, rapid pulse; rapid respirations; a moist, frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nail beds.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 619

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

17. While providing care in an obstetric setting, the nurse should understand that postpartum care of the woman with cardiac disease

Is the same as that for any pregnant woman

kt an k. c

Includes rest, stool softeners, and monitoring of the effect of activity

ba n

Includes ambulating frequently alternating with active range of motion

w .te

Includes limiting visits with the infant to once per day

ANS: B

Feedback

Care of the woman with cardiac disease in the postpartum period is tailored to the womans functional capacity.

Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid.

kt an k. c

ba n

The woman will be on bed rest to conserve energy and reduce the strain on the heart.

w .te

Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 620-621

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

18. In caring for a pregnant woman with sickle cell anemia the nurse is aware that signs and symptoms of sickle cell crisis include

Anemia

Endometritis

kt an k. c

w .te

Urinary tract infection

ba n

Fever and pain

ANS: C

Feedback

Women with sickle cell anemia are not iron deficient. Therefore routine iron supplementation, even that found in prenatal vitamins should be avoided in order to prevent iron overload.

Women with sickle cell trait usually are at greater risk for postpartum endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis.

kt an k. c

ba n

Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia or acidosis.

w .te

These women are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 622

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

19. With regard to anemia, nurses should be aware that

It is the most common medical disorder of pregnancy.

kt an k. c

It can trigger reflex brachycardia.

ba n

The most common form of anemia is caused by folate deficiency.

w .te

Thalassemia is a European version of sickle cell anemia.

ANS: A

Feedback

Iron deficiency anemia causes 75% of anemias in pregnancy. It is difficult to meet the pregnancy needs for iron through diet alone.

Reflex bradycardia is a slowing of the heart in response to the blood flow increases immediately after birth.

kt an k. c

The most common form of anemia is iron deficiency anemia.

ba n

Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas.

w .te

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 621

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

20. For which of the infectious diseases can a woman be immunized?

Toxoplasmosis

Rubella

kt an k. c

Cytomegalovirus

Herpesvirus type 2

ba n

Feedback

w .te

ANS: B

There is no vaccine available for toxoplasmosis.

Rubella is the only infectious disease for which a vaccine is available.

There is no vaccine available for cytomegalovirus.

kt an k. c

There is no vaccine available for herpesvirus type 2.

ba n

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 626

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. A woman who delivered her third child yesterday has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?

The womans two children should be treated with acyclovir before she goes home from the hospital.

The baby will acquire immunity from the woman and will not be susceptible to chickenpox.

The children can visit their mother and sibling in the hospital as planned but must wear gowns and masks.

kt an k. c

ba n

The woman must make arrangements to stay somewhere other than her home until the children are no longer contagious.

ANS: D

w .te

Feedback

Acyclovir is used to treat varicella pneumonia.

The baby is already born and has received the immunities. If the mother never had chickenpox, she cannot transmit the immunities to the baby.

Varicella infection occurring in a newborn may be life threatening.

kt an k. c

Varicella (chickenpox) is highly contagious. Although the baby inherits immunity from the mother, it would not be safe to expose either the mother or the baby.

ba n

PTS: 1 DIF: Cognitive Level: Application REF: dm. 627

OBJ: Nursing Process: Implementation

w .te

MSC: Client Needs: Safe and Effective Care Environment

22. A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action?

Provide a low-protein diet.

Offer the vaccine.

Discuss the recommendation to bottle-feed her baby.

kt an k. c

ba n

Practice respiratory isolation.

ANS: B

w .te

Feedback

Care is supportive and includes bed rest and a high protein, low fat diet.

A person who has a history of high-risk behaviors should be offered the hepatitis B vaccine.

The first trimester is too early to discuss feeding methods with a woman in the high-risk category.

kt an k. c

Hepatitis B is transmitted through blood.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 628

ba n

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

w .te

23. A woman has tested human immunodeficiency virus (HIV)positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?

Even though my test is positive, my baby might not be affected.

I know I will need to have an abortion as soon as possible.

This pregnancy will probably decrease the chance that I will develop AIDS.

kt an k. c

My baby is certain to have AIDS and die within the first year of life.

ANS: A

ba n

Feedback

w .te

The fetus is likely to test positive for HIV in the first 6 months until the inherited immunity from the mother wears off. Many of these babies will convert to HIV-negative status.

With the newer drugs, the risk for infection of the fetus has decreased.

The pregnancy will increase the chance of converting.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 629

With the newer drugs, the risk for infection of the fetus has decreased. Also, the life span of an infected newborn has increased.

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

w .te

ba n

24. Toxoplasmosis is a protozoal infection transmitted through organisms in raw and undercooked meat or through contact with contaminated cat feces. While providing education to the pregnant woman, the nurse evaluates the learning and understands that the patient requires further instruction when she states

I will be certain to empty the litter boxes regularly.

I wont eat raw eggs.

I had better wash all of my fruits and vegetables.

kt an k. c

ANS: A

I need to be cautious when cooking meat.

ba n

Feedback

w w

w .te

The patient should avoid contact with materials that are possibly contaminated with cat feces while pregnant. This includes cat litter boxes, sand boxes, and garden soil. She should wash her hands thoroughly after working with soil or handling animals.

The patient should avoid undercooked eggs and unpasteurized milk.

All fruits and vegetables should be washed thoroughly before eating.

kt an k. c

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 630

Meat should be cooked thoroughly to an internal temperature of at least 160 F or as high as 180 F for poultry. All surfaces should be washed after they come into contact with uncooked meat. The patient should be instructed not to use the same utensils or cutting board for meat and produce.

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

ba n

MULTIPLE RESPONSE

w w

w .te

1. Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion or both. Over time diabetes causes significant maternal changes in the microvascular and macrovascular circulations. These complications include (select all that apply)

Atherosclerosis

Retinopathy

IUFD

kt an k. c

Nephropathy

Neuropathy

Feedback

w .te

ANS: A, B, D, E

ba n

Correct

These structural changes are most likely to affect a variety of systems, including the heart, eyes, kidneys, and nerves.

Incorrect

Intrauterine fetal death (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 607

kt an k. c

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

2. Congenital anomalies can occur with the use of antiepileptic drugs, including (select all that apply)

ba n

w .te

Cleft lip

Congenital heart disease

Neural tube defects

Gastroschisis

Diaphragmatic hernia

kt an k. c

ANS: A, B, C

ba n

Feedback

Correct

Incorrect

w .te

Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, limb reduction, mental retardation and neural tube defects. This is referred to assess fetal hydantoin syndrome.

These congenital anomalies are not associated with the use of AEDs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 624

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

3. Systemic lupus erythematosus is a chronic multisystem inflammatory disease that affects skin, joints, kidney, lungs, CNS, liver, and other organs. Maternal risks include (select all that apply)

kt an k. c

Premature rupture of membranes (PROM)

ba n

Fetal death resulting in stillbirth

w .te

Hypertension

Preeclampsia

Renal complications

ANS: A, C, D, E

Feedback

Correct

kt an k. c

PROM, hypertension, preeclampsia, and renal complications are all maternal risks associated with SLE.

ba n

Incorrect

Stillbirth and prematurity are fetal risks of SLE.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 623

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

COMPLETION

1. The leading cause of life threatening perinatal infections in the United States is ________ (GBS).

ANS:

group B streptococcus

kt an k. c

PTS: 1 DIF: Cognitive Level: Application REF: dm. 630

This gram-positive bacteria is colonized in the rectum, anus, vagina, and urethra of pregnant and non-pregnant women. UTI, chorioamnionitis, and endometritis can occur during pregnancy. Transmission to the fetus can cause the most serious of infections. GBS testing of all women should be performed at 35 to 37 weeks of gestation and treatment with antibiotics should be initiated if indicated.

TRUE/FALSE

ba n

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

ANS: F

w .te

1. Diabetes mellitus is a medical condition that could adversely affect pregnancy. Its frequency is increasing along with obesity and abnormal lipid profiles. Women who have GDM in pregnancy have no greater risk of developing type 2 diabetes. Is this statement true or false?

Women who develop GDM have a 35% to 60% likelihood of developing diabetes in the next 10 to 20 years. About 7% of all pregnancies are affected by GDM with higher rates among African Americans, Latinas, and American Indians.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 608

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. Hashimotos thyroiditis is also known by the more common name of chronic lymphocytic thyroiditis and is the cause of most cases of hypothyroidism and women. Untreated hypothyroidism during pregnancy can adversely affect the childs mental development. Is this statement true or false?

kt an k. c

ANS: T

Thyroid-stimulating hormone levels should be tested either before pregnancy or early in pregnancy, and hypothyroidism should be corrected during the first trimester. Chapter 23 Conditions Occurring After Delivery

ba n

MULTIPLE CHOICE

w .te

1. Which statement by a postpartum woman indicates that further teaching is not needed regarding thrombus formation?

Ill stay in bed for the first 3 days after my baby is born.

Ill keep my legs elevated with pillows.

Ill sit in my rocking chair most of the time.

Ill put my support stockings on every morning before rising.

kt an k. c

ANS: D

ba n

Feedback

w .te

As soon as possible, the woman should ambulate frequently.

The mother should avoid knee pillows because they increase pressure on the popliteal space.

Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities.

kt an k. c

PTS: 1 DIF: Cognitive Level: Application REF: dm. 675

Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning.

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

ba n

2. The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is

w .te

Uterine atony

Uterine inversion

Vaginal hematoma

Vaginal laceration

kt an k. c

ANS: A

Feedback

ba n

w .te

Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage.

Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patients bleeding. Furthermore, if the woman was experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus.

A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 667

A vaginal laceration may cause hemorrhage; however, it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

ba n

3. The nurse knows that a measure for preventing late postpartum hemorrhage is to

w .te

Administer broad-spectrum antibiotics.

Inspect the placenta after delivery.

Manually remove the placenta.

Pull on the umbilical cord to hasten the delivery of the placenta.

ANS: B

kt an k. c

Feedback

ba n

Broad-spectrum antibiotics will be given if postpartum infection is suspected.

w .te

If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage.

Manual removal of the placenta increases the risk of postpartum hemorrhage.

The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 670

kt an k. c

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

ba n

4. A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should

w .te

Continue to massage the fundus.

Notify the physician.

Recheck vital signs.

Insert a Foley catheter.

ANS: B

kt an k. c

Feedback

ba n

The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.

w .te

Treatment of excessive bleeding requires the collaboration of the physician and the nurses. Do not leave the patient alone.

The nurse should call the clinician while a second nurse rechecks the vital signs.

The woman has voided successfully, so a Foley catheter is not needed at this time.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 672

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

kt an k. c

5. Early postpartum hemorrhage is defined as a blood loss greater than

ba n

500 mL in the first 24 hours after vaginal delivery

w .te

750 mL in the first 24 hours after vaginal delivery

1000 mL in the first 48 hours after cesarean delivery

1500 mL in the first 48 hours after cesarean delivery

ANS: A

kt an k. c

The average amount of bleeding after a vaginal birth is 500 mL.

Feedback

ba n

The average amount of bleeding after a vaginal birth is 500 mL.

w .te

Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean averages 1000 mL.

Early postpartum hemorrhage is within the first 24 hours. Late postpartum hemorrhage is 48 hours and later.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 666

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she feels all wet underneath. You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action?

kt an k. c

Call for help.

w .te

Assess the fundus for firmness.

ba n

Take her blood pressure.

Check the perineum for lacerations.

ANS: B

Feedback

kt an k. c

The first action should be to assess the fundus.

ba n

Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated.

w .te

Assessing blood pressure is an important assessment with a bleeding patient, but the top priority is to control the bleeding. This is done by first assessing the fundus for firmness.

If bleeding continues in the presence of a firm fundus, lacerations may be the cause.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 667-668

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

7. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests

kt an k. c

Uterine atony

ba n

Lacerations of the genital tract

w .te

Perineal hematoma

Infection of the uterus

ANS: B

Feedback

The fundus is not firm with uterine atony.

kt an k. c

Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction.

ba n

w .te

A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be.

With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 669

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n)

5-lb, 2-oz infant with outlet forceps

kt an k. c

6.5-lb infant after a 2-hour labor

w .te

7-lb infant after an 8-hour labor

ba n

8-lb infant after a 12-hour labor

ANS: B

Feedback

This woman is at risk for lacerations because of the forceps.

kt an k. c

A rapid (precipitous) labor and delivery may cause exhaustion of the uterine muscle and prevent contraction.

ba n

This is a normal labor progression. Less than 3 hours is rapid and can produce uterine muscle exhaustion.

w .te

This is a normal labor progression. Less than 3 hours is a rapid delivery and can cause the uterine muscles not to contract.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 667 | Box 28-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

9. What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications?

Palpate the fundus daily to ensure that it is soft.

kt an k. c

Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.

ba n

Report any decrease in the amount of brownish red lochia.

w .te

ANS: B

The passage of clots as large as an orange can be expected.

Feedback

The fundus should stay firm.

An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication.

The lochia should decrease in amount.

ba n

kt an k. c

Large clots after discharge are a sign of complications and should be reported.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 670

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

10. Which woman is at greatest risk for early postpartum hemorrhage?

A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress

kt an k. c

A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor

A woman with severe preeclampsia on magnesium sulfate whose labor is being induced

ba n

A primigravida in spontaneous labor with preterm twins

Feedback

w .te

ANS: B

Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.

Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony.

kt an k. c

Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.

ba n

Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.

w .te

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 667 | Box 28-1

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

11. When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is

Absence of cyanosis in the buccal mucosa

Cool, dry skin

kt an k. c

Diminished restlessness

Decreased urinary output

ba n

Feedback

w .te

ANS: D

The assessment of the buccal mucosa for cyanosis can be subjective in nature.

The presence of cool, pale, clammy skin is an indicative finding associated with hypovolemic shock.

Hypovolemic shock is associated with lethargy, not restlessness.

kt an k. c

ba n

Hemorrhage may result in hypovolemic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 671

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. The nurse should expect medical intervention for subinvolution to include

Oral methylergonovine maleate (Methergine) for 48 hours

Oxytocin intravenous infusion for 8 hours

ba n

Intravenous fluid and blood replacement

ANS: A

w .te

Feedback

kt an k. c

Oral fluids to 3000 mL/day

Methergine provides long-sustained contraction of the uterus.

Oxytocin provides intermittent contractions.

There is no correlation between dehydration and subinvolution.

kt an k. c

There is no indication that excessive blood loss has occurred.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 668

ba n

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

w .te

13. If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

Hysterectomy

Laparoscopy

Laparotomy

kt an k. c

D&C

ANS: D

ba n

Feedback

w .te

Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus.

Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity.

Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 670

D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots.

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. The mother-baby nurse must be able to recognize what sign of thrombophlebitis?

w .te

Visible varicose veins

Positive Homans sign

Local tenderness, heat, and swelling

Pedal edema in the affected leg

kt an k. c

ANS: C

Feedback

ba n

w .te

Varicose veins may predispose the woman to thrombophlebitis, but are not a sign.

A positive Homans sign may be caused by a strained muscle or contusion.

Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation.

Edema may be more involved than pedal.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 674

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth?

ba n

w .te

Roll a bath blanket and place it firmly behind the knees.

Limit oral intake of fluids for the first 24 hours.

Assist the patient in performing gentle leg exercises.

Ambulate the patient as soon as her vital signs are stable.

ANS: C

kt an k. c

Feedback

ba n

The blanket behind the knees will cause pressure and decrease venous blood flow.

w .te

Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis.

Leg exercises and passive range of motion promote venous blood flow and prevent venous stasis while the patient is still on bed rest.

The patient may not have full return of leg movements, and ambulating is contraindicated.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 675

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

ba n

Fatigue continuing for longer than 1 week

kt an k. c

16. One of the first symptoms of puerperal infection to assess for in the postpartum woman is

w .te

Pain with voiding

Profuse vaginal bleeding with ambulation

Temperature of 38 C (100.4 F) or higher on 2 successive days starting 24 hours after birth

ANS: D

kt an k. c

Fatigue is a late finding associated with infection.

Feedback

ba n

w .te

Pain with voiding may indicate a UTI, but it is not typically one of the earlier symptoms of infection.

Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.

Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38 C (100.4 F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 678

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

kt an k. c

17. The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by

ba n

Subinvolution of the uterus

w .te

Defective vascularity of the decidua

Cervical lacerations

Coagulation disorders

ANS: A

Feedback

kt an k. c

Late PPH may be the result of subinvolution of the uterus. Recognized causes of subinvolution included retained placental fragments and pelvic infection.

ba n

w .te

Although defective vascularity of the decidua may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

Although cervical lacerations may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

Although coagulation disorders may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 670

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

18. The patient who is being treated for endometritis is placed in Fowlers position because it

kt an k. c

Promotes comfort and rest

w .te

Facilitates drainage of lochia

ba n

Prevents spread of infection to the urinary tract

Decreases tension on the reproductive organs

ANS: B

Feedback

This may not be the position of comfort, but it does allow for drainage.

kt an k. c

ba n

Lochia and infectious material are eliminated by gravity drainage.

w .te

Hygiene practice aids in preventing the spread of infection to the urinary tract.

The position is to aid in the drainage of lochia and infectious material.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 679

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

19. Nursing measures that help prevent postpartum urinary tract infection include

Promoting bed rest for 12 hours after delivery

kt an k. c

Discouraging voiding until the sensation of a full bladder is present

ba n

w .te

Forcing fluids to at least 3000 mL/day

Encouraging the intake of orange, grapefruit, or apple juice

ANS: C

Feedback

The woman should be encouraged to ambulate early.

kt an k. c

With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. She needs to be encouraged to void frequently.

ba n

Adequate fluid intake of 2500 to 3000 ml/day prevents urinary stasis, dilutes urine, and flushes out waste products.

w .te

Juices such as cranberry juice can discourage bacterial growth.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 680

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

20. Which measure may prevent mastitis in the breastfeeding mother?

Initiating early and frequent feedings

Nursing the infant for 5 minutes on each breast

kt an k. c

ba n

Wearing a tight-fitting bra

w .te

Applying ice packs before feeding

ANS: A

Feedback

Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis.

Five minutes does not adequately empty the breast. This will produce stasis of the milk.

kt an k. c

A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound.

ba n

Warm packs before feeding will increase the flow of milk.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 680

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

21. A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that

The infant is protected from infection by immunoglobulins in the breast milk.

kt an k. c

The organisms that cause mastitis are not passed to the milk.

The infant is not susceptible to the organisms that cause mastitis.

ba n

The organisms will be inactivated by gastric acid.

Feedback

w .te

ANS: C

The mother is just producing the immunoglobulin from this infection, so it is not available for the infant.

Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk.

kt an k. c

The organisms are localized in the breast tissue and are not excreted in the breast milk.

ba n

The organism will not get into the infants gastrointestinal system.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 681

w .te

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

22. If the nurse suspects a uterine infection in the postpartum patient, she should assess the

Pulse and blood pressure

Odor of the lochia

Episiotomy site

kt an k. c

ba n

Abdomen for distention

ANS: B

w .te

Feedback

The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and more specific.

An abnormal odor of the lochia indicates infection in the uterus.

The infection may move to the episiotomy site if proper hygiene is not followed.

kt an k. c

The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section.

ba n

PTS: 1 DIF: Cognitive Level: Application REF: dm. 682

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

w w

w .te

23. Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?

Postpartum depression

Postpartum psychosis

Postpartum bipolar disorder

kt an k. c

Postpartum blues

ba n

ANS: D

Feedback

w .te

Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported.

Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder.

Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes.

kt an k. c

Postpartum blues or baby blues is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 683

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

w .te

24. When a woman is diagnosed with postpartum psychosis, one of the main concerns is that she may

Have outbursts of anger

Neglect her hygiene

Harm her infant

kt an k. c

Lose interest in her husband

ANS: C

ba n

Feedback

w .te

Although outbursts of anger is a symptom is attributable to PPD, the major concern would be the potential of harm to herself or to her infant.

Neglect of personal hygiene is symptom is attributable to PPD; however, the major concern would be the potential of harm to herself or to her infant.

Thoughts of harm to ones self or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 684

Although this patient is likely to lose interest in her spouse, the major concern is the potential of harm to herself or to her infant.

ba n

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

25. According to Becks studies, what risk factor for postpartum depression (PPD) is likely to have the greatest effect on the womans condition?

w .te

Prenatal depression

Single-mother status

Low socioeconomic status

kt an k. c

ANS: A

Unplanned or unwanted pregnancy

ba n

Feedback

w .te

Depressive symptoms during pregnancy or previous ppd are strong predictors for subsequent episodes of PPD.

Single-mother status is a small-relation predictor for PPD.

Low socioeconomic status is a small-relation predictor for PPD.

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 685

An unwanted pregnancy may contribute to the risk for PPD; however, it does not pose as great an effect as prenatal depression.

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

ba n

26. Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is

A phobia

w .te

Panic disorder

Posttraumatic stress disorder (PTSD)

Obsessive-compulsive disorder (OCD)

kt an k. c

ANS: C

Feedback

ba n

w .te

Phobias are irrational fears that may lead a person to avoid certain objects, events, or situations.

Panic disorders include episodes of intense apprehension, fear, and terror. Symptoms may manifest themselves as palpitations, chest pain, choking, or smothering.

In PTSD, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 684

OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck her infant once he or she is born, even though she realizes that this is irrational. OCD is best treated with medications.

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

ba n

27. To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD)

w .te

Is the baby blues plus the woman has a visit with a counselor or psychologist

Is more common among older, Caucasian women because they have higher expectations

Is distinguished by pervasive sadness that lasts at least 2 weeks

Will disappear on its own without outside help

ANS: C

kt an k. c

Feedback

ba n

PPD is more serious and persistent than postpartum baby blues.

w .te

PPD is more common among younger mothers and African-American mothers.

PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she is able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders.

Most women need professional help to get through PPD, including pharmacologic intervention.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 683

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

ba n

kt an k. c

28. With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to

w .te

Stay home and avoid outside activities to ensure adequate rest.

Be certain that you are the only caregiver for your baby in order to facilitate infant attachment.

Keep feelings of sadness and adjustment to your new role to yourself.

Realize that this is a common occurrence that affects many women.

ANS: D

kt an k. c

Feedback

ba n

Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so that the new mother can obtain adequate rest. It is also important that she not isolate herself at home by herself during this time of role adjustment.

w .te

Even if breastfeeding, other family members can participate in the infants care. If depression occurs, the symptoms can often interfere with mothering functions and this support will be essential.

The new mother should share her feelings with someone else. It is also important that she not overcommit herself or feel as though she has to be superwoman. A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.

kt an k. c

PTS: 1 DIF: Cognitive Level: Application REF: pp. 685-686

Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of.

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

ba n

MULTIPLE RESPONSE

1. Medications used to manage postpartum hemorrhage include (select all that apply)

w .te

Pitocin

Methergine

Terbutaline

Hemabate

kt an k. c

ANS: A, B, D

ba n

Magnesium sulfate

w .te

Feedback

Correct

Pitocin, Methergine, and Hemabate are all used to manage PPH.

Incorrect

Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 668

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

kt an k. c

1. The nurse is in the process of assessing the comfort level of her postpartum patient. Excess bleeding is not obvious; however, the new mother complains of deep, severe pelvic pain. The registered nurse (RN) has noted both skin and vital sign changes. This patient may have formed a(n) ________.

ba n

ANS:

w .te

hematoma

Hematomas occur as a result of bleeding into loose connective tissue while the overlying tissue remains intact. A hematoma can develop after either a spontaneous or an instrumental vaginal delivery when blood vessels are injured. They are most likely to occur in the vulvar, vaginal, or retroperitoneal areas. The nurse should examine the vulva for a bulging mass or skin discoloration and intervene as necessary.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 669

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. _______________ is the most common postpartum infection.

ANS:

Endometritis

kt an k. c

Endometritis usually begins as a localized infection at the placental site; however, can spread to involve the entire endometrium. Assessment for signs of endometritis may reveal a fever, elevated pulse, chills, anorexia, fatigue, pelvic pain, uterine tenderness or foul-smelling profuse lochia.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 679

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

ANS:

w .te

3. Of all pregnant women being treated for depression, approximately one-third have a first occurrence during pregnancy. All pregnant and postpartum women should be screened for perinatal mood disorders by using the _________ Postnatal Depression Scale.

Edinburgh

The 10-item Edinburgh Postnatal Depression Scale accurately identifies depression in pregnant and postpartum women.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 685

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

TRUE/FALSE

kt an k. c

1. Should a postpartum complication such as hemorrhage occur, the nursing staff will spring into action to ensure that patient safety needs are met. This level of activity is very reassuring to both the new mother and her family members as they can see that the patient is receiving the best care. Is this statement true or false?

ba n

ANS: F

w .te

On the contrary, the unusual activity of the hospital staff may make the mother and her family very anxious. Keeping the family informed is one of the most effective ways of reducing unnecessary anxiety. A comment such as, I know that all of this activity must be frightening. She is bleeding a little more than we would like, and we are doing several things at once would be very helpful.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 673

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. Pulmonary embolism (PE) is a serious complication of deep vein thrombosis (DVT) and the leading cause of maternal mortality. As many as 15% to 25% of all DVTs lead to PEs if not recognized and treated. Is this statement true or false?

ANS: T

This statement is correct. PE occurs with fragments of a blood clot dislodge and are carried to the lungs. Treatment is aimed at dissolving the clot and maintaining pulmonary circulation. Oxygen is used to decrease hypoxia, and narcotic analgesics are given to reduce pain and apprehension. Chapter 24 Conditions in the Newborn Related to Gestational Age, Size, Injury, and Pain

kt an k. c

1. What is most helpful in preventing premature birth?

ba n

High socioeconomic status

w .te

Adequate prenatal care

Transitional Assistance to Needy Families

MULTIPLE CHOICE

Women, Infants, and Children nutritional program

ANS: B

Feedback

kt an k. c

People with higher socioeconomic status are more likely to seek adequate prenatal care. The care is the most helpful in prevention.

ba n

w .te

Prenatal care is vital in identifying possible problems.

Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor.

This aids in the nutritional status of the pregnant woman, but the most helpful aid in prevention of premature births is adequate prenatal care.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 692

ba n

Few blood vessels visible though the skin

w .te

More subcutaneous fat

kt an k. c

2. Compared to the term infant, the preterm infant has

Well-developed flexor muscles

Greater surface area in proportion to weight

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

ANS: D

Feedback

kt an k. c

Preterm infants have greater surface area in proportion to their weight.

ba n

This is an indication of a more mature infant.

w .te

This is an indication of a more mature infant.

Preterm infants have greater surface area in proportion to their weight.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 693

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. Decreased surfactant production in the preterm lung is a problem because surfactant

kt an k. c

Causes increased permeability of the alveoli

ba n

Provides transportation for oxygen to enter the blood supply

w .te

Keeps the alveoli open during expiration

Dilates the bronchioles, decreasing airway resistance

ANS: C

Feedback

Surfactant prevents the alveoli from collapsing.

kt an k. c

By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose.

ba n

Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing.

w .te

It does not affect the bronchioles.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 692

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to

Suggest that the parents visit for only a short time to reduce their anxieties.

ba n

Encourage the parents to touch her.

kt an k. c

Reassure the parents that the baby is progressing well.

w .te

Discuss the care they will give her when she goes home.

ANS: C

Feedback

Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant.

It is important to keep the parents informed about the infants progression, but the nurse needs to be honest with the explanations.

kt an k. c

ba n

Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. This is the most appropriate response by the nurse.

w .te

This is an important part of parent teaching, but it is not the most important priority during the first visit.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 705

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

5. Late preterm infants need closer monitoring during her hospital stay than term infants. In order to prevent unrecognized cold-stress the nurse should perform all except

Wean the infant to an open crib.

Encourage kangaroo care.

ba n

w .te

Place infant on a radiant warmer.

ANS: A

Feedback

kt an k. c

Check temperature every 3 to 4 hours.

The infant can be placed in an open bassinet after the nurse is assured that the baby is not experiencing cold stress and can maintain his or her body temperature.

LPI infants should have their temperature checked every 3 to 4 hours, depending on need and agency policy.

kt an k. c

ba n

Kangaroo care (a method of providing skin to skin contact between infants and their parents) should be encouraged.

w .te

If the infant cannot maintain normal temperature they should be placed on a radiant warmer or in an incubator.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 691, 694

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

6. The preterm infant who should receive gavage feedings instead of a bottle is the one who

Sometimes gags when a feeding tube is inserted

ba n

Sucks on a pacifier during gavage feedings

kt an k. c

Is unable to coordinate sucking and swallowing

w .te

Has an axillary temperature of 98.4 F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: B

Feedback

The presence of the gag reflex is important before initiating bottle-feeding.

Infants less than 34 weeks of gestation or who weigh less than 1500 g generally have difficulty with bottle-feeding.

kt an k. c

Providing a pacifier during gavage feedings gives positive oral stimulation and helps associate the comfortable feeling of fullness with sucking.

ba n

w .te

These vital signs are within expected limits and an indication that the infant is not having respiratory problems at that time.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 700

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?

Group all care activities together to provide long periods of rest.

While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation.

kt an k. c

ba n

Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.

w .te

Keep charts on top of the incubator so the nurses can write on them there.

ANS: C

Feedback

This may understimulate the infant during those long periods and overtire the infant during the procedures.

This may cause overstimulation.

kt an k. c

Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant.

ba n

Placing objects on top of the incubator or using it as a writing surface increases the noise inside.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 698

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to

Severe immaturity

Environmental stress

kt an k. c

Physiologic distress

ANS: B

Feedback

w .te

Behavioral responses

ba n

Although the infant may be severely immature in this case she is responding to environmental stress.

This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation.

kt an k. c

Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use and depression of the immune system.

ba n

w .te

The infants behavioral response in the case is crying. The nursing diagnosis should reflect the cause of this response, which is environmental stress.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 698-699

OBJ: Nursing Process: Diagnosis

MSC: Client Needs: Safe and Effective Care Environment

9. In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?

Necrotizing enterocolitis (NEC)

ba n

Bronchopulmonary dysplasia (BPD)

w .te

ANS: B

Intraventricular hemorrhage (IVH)

Feedback

kt an k. c

Retinopathy of prematurity (ROP)

NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site.

ROP is thought to occur as a result of high levels of oxygen in the blood.

kt an k. c

BPD is caused by the use of positive pressure ventilation against the immature lung tissue.

ba n

w .te

IVH is due to rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 709

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

10. With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that

Infants will stay in the NICU until they are ready to go home.

Once discharged to home, the high risk infant should be treated like any healthy term newborn.

kt an k. c

ba n

Parents of high risk infants need special support and detailed contact information.

w .te

If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

ANS: C

Feedback

Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU.

Just because high-risk infants are discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential.

kt an k. c

High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby.

ba n

w .te

Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 707

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

11. Which combination of expressing pain could be demonstrated in a neonate?

Low-pitched crying, tachycardia, eyelids open wide

Cry face, flaccid limbs, closed mouth

kt an k. c

High-pitched, shrill cry, withdrawal, change in heart rate

ba n

ANS: D

Feedback

w .te

Cry face, eye squeeze, increase in blood pressure

Cry and an increased heart rate are manifestations of neonatal pain. Typically, infants will close their eyes tightly when in pain, not open them wide.

Infants may cry in response to pain. Additionally, they may display a rigid posture with the mouth open.

kt an k. c

A high-pitched, shrill cry is associated with genetic/neurologic anomalies. The infant may cry, withdraw limbs, and become tachycardic with pain.

ba n

These manifestations are indicative of pain in the neonate.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 697

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. Which is true about newborns classified as small for gestational age (SGA)?

They weigh less than 2500 g.

They are born before 38 weeks of gestation.

kt an k. c

Placental malfunction is the only recognized cause of this condition.

ba n

They are below the 10th percentile on gestational growth charts.

Feedback

w .te

ANS: D

SGA infants are defined as below the 10th percentile in growth when compared to other infants of the same gestational age. SGA is not defined by weight.

Infants born before 38 weeks are defined as preterm.

There are many causes of SGA babies.

kt an k. c

SGA infants are defined as below the 10th percentile in growth when compared with other infants of the same gestational age.

ba n

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 711

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. What nursing action is especially important for the SGA newborn?

Observe for respiratory distress syndrome.

Observe for and prevent dehydration.

Promote bonding.

kt an k. c

Prevent hypoglycemia by early and frequent feedings.

ba n

ANS: D

w .te

Feedback

Respiratory distress syndrome is seen in preterm infants.

Dehydration is a concern for all infants and is not specific for SGA infants.

Promoting bonding is a concern for all infants and is not specific for SGA infants.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 712

The SGA infant has poor glycogen stores and is subject to hypoglycemia.

ba n

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

w .te

14. What will the nurse note when assessing an SGA infant with asymmetric intrauterine growth restriction?

One side of the body appears slightly smaller than the other.

All body parts appear proportionate.

The head seems large compared with the rest of the body.

The extremities are disproportionate to the trunk.

kt an k. c

ANS: C

ba n

Feedback

w .te

The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head.

The body parts are out of proportion, with the body looking smaller than expected due to the lack of subcutaneous fat.

In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infants body is long and thin due to lack of subcutaneous fat.

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 711

The body, arms, and legs have lost subcutaneous fat so they will look small compared to the head.

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. Which statement is true about large for gestational age (LGA) infants?

w .te

They weigh more than 3500 g.

They are above the 80th percentile on gestational growth charts.

They are prone to hypoglycemia, polycythemia, and birth injuries.

Postmaturity syndrome and fractured clavicles are the most common complications.

kt an k. c

ANS: C

Feedback

ba n

w .te

LGA infants are determined by their weight compared to their age.

They are above the 90th percentile on the gestational growth charts.

All three of these complications are common in LGA infants.

Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 712

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

16. Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome?

w .te

Pulse more than 160 beats/min

ba n

Circumoral cyanosis

Grunting

Substernal retractions

ANS: C

Feedback

kt an k. c

ba n

Grunting is more indicative of respiratory distress syndrome.

w .te

Grunting is more indicative of respiratory distress syndrome.

Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient.

Grunting is more indicative of this syndrome.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 708

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

kt an k. c

17. While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of

ba n

Hypoxia in utero

w .te

NEC

Placental insufficiency

Rapid use of glycogen stores

ANS: A

Feedback

kt an k. c

When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may passed meconium as a result of hypoxia before or during labor increasing the risk of meconium aspiration.

ba n

w .te

Necrotizing enterocolitis (NEC) is a serious inflammatory condition of the intestinal tract that may lead to death of areas of the mucosa of the intestines. SGA infants are at increased risk for NEC.

If placental insufficiency is present, decreased amniotic fluid volume and umbilical cord compression is likely to occur. This resulted in both hypoxia and malnourishment of the fetus.

Postterm infants should be assessed for hypoglycemia because of the rapid use of glycogen stores.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 710

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. Which data should alert the nurse that the neonate is postmature?

kt an k. c

ba n

Cracked, peeling skin

w .te

Short, chubby arms and legs

Presence of vernix caseosa

Presence of lanugo

ANS: A

Feedback

kt an k. c

Loss of vernix caseosa, which protects the fetal skin in utero, may leave the skin macerated.

ba n

Postmature infants usually have long, thin arms and legs.

w .te

Vernix caseosa decreases in the postmature infant.

Absence of lanugo is common in postmature infants.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 711

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. Because of the premature infants decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?

kt an k. c

Delayed growth and development

ba n

Ineffective thermoregulation

w .te

Ineffective infant feeding pattern

Risk for infection

ANS: D

Feedback

kt an k. c

Thermoregulation may be affected, but only indirectly.

Growth and development may be affected, but only indirectly.

ba n

Feeding may be affected, but only indirectly.

w .te

The nurse needs to know that decreased immune functioning increases the risk for infection.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 696

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

20. To maintain optimal thermoregulation for the premature infant, the nurse should

Bathe the infant once a day.

ba n

Assess the infants hydration status.

kt an k. c

Put an undershirt on the infant in the incubator.

w .te

Lightly clothe the infant under the radiant warmer.

ANS: B

Feedback

Bathing causes evaporative heat loss.

Air currents around an unclothed infant will result in heat loss.

kt an k. c

This is an important assessment but will not maintain thermoregulation.

ba n

Clothing is not worn when the infant is under a radiant warmer.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 694

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (select all that apply)

Problems with thermoregulation

kt an k. c

Cardiac distress

ba n

Hyperbilirubinemia

w .te

Sepsis

Hyperglycemia

ANS: A, C, D

Feedback

Correct

All of these conditions are related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. AWHONN has recently launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications.

kt an k. c

Incorrect

These infants are at risk for respiratory distress and hypoglycemia.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 690

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. An important nursing factor during the care of the infant in the NICU is assessment for signs of adequate parental attachment. The nurse must observe for signs that bonding is not occurring as expected. These include (select all that apply)

Using positive terms to describe the infant

Showing interest in other infants equal to that of their own

ba n

Decreasing the number and length of visits

kt an k. c

Naming the infant

w .te

Refusing offers to hold and care for the infant

ANS: B, D, E

Feedback

Correct

These are all indications that parental attachment may be delayed. The parent may also show a decrease in or lack of eye contact and spend last time talking to or smiling at their infant.

Incorrect

kt an k. c

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 704

Failing to give the infant a name or use their name is a sign that bonding may be delayed. Refusing offers to hold their infant or learn how to care for them may initially be an expression of fear; however, over time this may indicate delayed bonding.

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

ba n

COMPLETION

ANS:

w .te

1. The NICU nurse begins her shift by assessing one of the preterm infants assigned to her care. The infants color is pale, his O2 saturation has decreased, and he is grimacing. This infant is displaying common signs of ________.

pain

These are all nonverbal cues to newborn pain. Other signs include moaning, whimpering, tense rigid muscles, increased or decreased heart rate, apnea, increased blood pressure, sleep-wake pattern changes, or display of a cry face. The nurse should discuss the infants response to pain with his provider to ensure that appropriate medications are available. Ordered medications should always be given before any painful procedure.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 697

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

2. Approximately 30% of preterm infants weighing less than 1500 g develop bleeding around and into the ventricles of the brain. This condition is known as _______________.

kt an k. c

ANS:

intraventricular hemorrhage

ba n

Rupture of the fragile blood vessels in the germinal matrix, located around the ventricles of the brain results in germinal matrix bleeding or intraventricular hemorrhage. It is associated with increased or decreased blood pressure, asphyxia, mechanical ventilation, and increased or fluctuating cerebral blood flow.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 709

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

TRUE/FALSE

1. Breast milk is best source of food almost all infants and especially for preterm infants. Breastfeeding has numerous benefits for the preterm infant. One of the most important of these benefits is reducing the incidence of necrotizing enterocolitis (NEC). Is this statement true or false?

ANS: T

Is important for the nurse to explain to parents that the immunologic benefits of breast milk are particularly important to the preterm infant who did not receive passive immunity during fetal life. Human milk may stimulate the immune system and promotes gastrointestinal maturation. Breast milk provides protection against infection and decreases the incidence of NEC in the premature infant.

Chapter 25 Acquired Conditions and Congenital Abnormalities in the Newborn

kt an k. c

MULTIPLE CHOICE

ba n

1. The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first?

w .te

Glucose water in a bottle

D5W intravenously

Formula via nasogastric tube

Breast milk

ANS: D

kt an k. c

Feedback

ba n

High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin.

w .te

Oral feedings are tried first; intravenous lines should be a later choice if the hypoglycemia continues.

Formula does provide longer normal glucose levels but would be administered via bottle, not by tube feeding.

Breast milk is metabolized more slowly and provides longer normal glucose levels.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 729

kt an k. c

2. The most common cause of pathologic hyperbilirubinemia is

Hepatic disease

ba n

w .te

Hemolytic disorders in the newborn

Postmaturity

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Congenital heart defect

ANS: B

Feedback

kt an k. c

Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause.

ba n

w .te

Hemolytic disorders in the newborn are the most common cause of pathologic jaundice.

Prematurity is a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause.

Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 721

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

ba n

Extracorporeal membrane oxygenation

kt an k. c

3. An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment?

w .te

Respiratory support with ventilator

Insertion of laryngoscope and suctioning of the trachea

Insertion of an endotracheal tube

ANS: A

Feedback

kt an k. c

Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infants lungs to rest and recover.

ba n

The infant is likely to have been first connected to a ventilator.

w .te

Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath.

An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 720

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

4. Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority?

kt an k. c

Start an intravenous line with D5W.

ba n

Notify the clinician stat.

w .te

Document the event in the nurses notes.

Test for blood glucose level.

ANS: D

Feedback

It is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer.

kt an k. c

ba n

Test blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results.

w .te

Documentation can wait until the infant has been tested and treated if a problem is present.

These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 728

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

5. It is important for the nurse to remember that when performing neonatal resuscitation, the priority action should be to

ba n

Stimulate the infant by rubbing the back.

kt an k. c

Suction the mouth and nose.

w .te

Perform the Apgar test.

Dry the infant and position the head.

ANS: D

Feedback

The neonate is not breathing, so drying the neonate to prevent heat loss and positioning the neonate takes priority over the suctioning.

kt an k. c

Stimulating the infant is a step in the process, but not the first action.

ba n

w .te

The Apgar can be delayed until steps have been taken to initiate breathing. By assessing the lack of breathing, some of the Apgar has already been completed.

Drying the infant to prevent heat loss is the first action. It is followed by positioning to open the airway.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 718

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

6. Which infant is most likely to have Rh incompatibility?

kt an k. c

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor

ba n

Infant who is Rh negative and whose mother is Rh negative

w .te

Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor

Infant who is Rh positive and whose mother is Rh positive

ANS: A

Feedback

If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility.

kt an k. c

Only the Rh-positive offspring of an Rh-negative mother are at risk.

ba n

w .te

If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.

There is no risk for incompatibility with this scenario.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 721

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

7. Transitory tachypnea of the newborn (TTN) is thought to occur as a result of

A lack of surfactant

kt an k. c

Hypoinflation of the lungs

ba n

w .te

Delayed absorption of fetal lung fluid

A slow vaginal delivery associated with meconium-stained fluid

ANS: C

Feedback

Lack of surfactant causes respiratory distress syndrome.

TTN is caused by delayed absorption of fetal lung fluid.

kt an k. c

ba n

Delayed absorption of fetal lung fluid is thought to be the reason for TTN.

w .te

A slow vaginal delivery will help prevent TTN.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 717

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. The nurse must continually assess the infant who has meconium aspiration syndrome (MAS) for the complication of

Persistent pulmonary hypertension

ba n

Transitory tachypnea of the newborn

kt an k. c

Bronchopulmonary dysplasia

w .te

Left-to-right shunting of blood through the foramen ovale

ANS: A

Feedback

Persistent pulmonary hypertension can result from the aspiration of meconium.

Bronchopulmonary dysplasia is due to the use of positive pressure oxygenation that stretches the immature lung membranes.

kt an k. c

Transitory tachypnea of the newborn is due to delayed absorption of fetal lung fluid.

ba n

This is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 720

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

9. The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid?

The infant needed vigorous stimulation immediately after birth to initiate crying.

An IV was started immediately after birth to treat dehydration.

kt an k. c

No meconium was found below the vocal cords when they were examined.

ba n

The parents spent an hour bonding with the baby after birth.

Feedback

w .te

ANS: C

Vigorous stimulation in the presence of meconium fluid is contraindicated to prevent aspiration.

There is no relationship between dehydration and meconium fluid.

A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome.

kt an k. c

This is an expected occurrence.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 720

w .te

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

10. In conjunction with phototherapy, which intervention is most effective in reducing the indirect bilirubin in an affected newborn?

Increase the frequency of feedings.

Increase oral intake of water between feedings.

Offer an exchange transfusion.

kt an k. c

ba n

Wrap the infant in triple blankets to prevent cold stress.

ANS: A

w .te

Feedback

Frequent feedings prevent hypoglycemia, provide protein to maintain albumin levels in the blood and promote gastrointestinal motility and removal of bilirubin in the stools. More frequent breastfeeding should be encouraged.

Avoid offering water between feedings, because the infant may decrease their milk intake. Breast milk or formula is more effective at removing bilirubin from the intestines.

Exchange transfusions are seldom necessary; but, may be performed when phototherapy cannot reduce high bilirubin levels quickly enough.

kt an k. c

ba n

Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 723

w .te

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

11. A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse?

Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be.

My baby will be watched closely for signs of low blood sugar, especially during the early days after birth.

kt an k. c

The red appearance of my babys skin is due to an excessive number of red blood cells.

ba n

My babys pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy.

Feedback

w .te

ANS: D

This is a correct statement.

Neonates of diabetic mothers are prone to hypoglycemia.

High hematocrits in neonates of diabetic mothers have a ruddy look.

kt an k. c

Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 728

w .te

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

12. Newborns whose mothers are substance abusers frequently have what behavior?

Circumoral cyanosis, hyperactive Babinski reflex, and constipation

Decreased amounts of sleep, hyperactive Moro (startle) reflex, and difficulty feeding

Hypothermia, decreased muscle tone, and weak sucking reflex

kt an k. c

Excessive sleep, weak cry, and diminished grasp reflex

ba n

ANS: B

w .te

Feedback

They will have diarrhea and increased muscle tone.

The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior.

They will have an uncoordinated sucking and swallowing reflex and decreased muscle tone.

kt an k. c

They will have poor sleeping patterns, increased reflexes, and a high-pitched cry.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 730

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

w .te

13. Nursing care of the infant with neonatal abstinence syndrome should include

Positioning the infants crib in a quiet corner of the nursery

Feeding the infant on a 2-hour schedule

Placing stuffed animals and mobiles in the crib to provide visual stimulation

Spending extra time holding and rocking the infant

kt an k. c

ANS: A

ba n

Feedback

w .te

Placing the crib in a quiet corner helps avoid excessive stimulation of the infant.

These infants have an increase calorie needs, but poor suck and swallow coordination. Feeding should occur to meet these needs.

Stimulation should be kept to a minimum.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 731

The neonate needs to have reduced handling and disturbances.

kt an k. c

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

ba n

14. The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice

w .te

Usually results in kernicterus

Appears during the first 24 hours of life

Results from breakdown of excessive erythrocytes not needed after birth

Begins on the head and progresses down the body

ANS: B

kt an k. c

Feedback

ba n

Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs.

w .te

Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life.

Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is due to a pathologic condition, such as Rh incompatibility.

Jaundice proceeds from the head down.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 721

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

kt an k. c

15. The goal of treatment of the infant with phenylketonuria (PKU) is to

Cure mental retardation.

ba n

w .te

Prevent central nervous system (CNS) damage, which leads to mental retardation.

Prevent gastrointestinal symptoms.

Cure the urinary tract infection.

ANS: B

Feedback

kt an k. c

No known cure exists for mental retardation.

ba n

w .te

CNS damage can occur as a result of toxic levels of phenylalanine.

Digestive problems are a clinical manifestation of PKU.

PKU does not involve any urinary problems.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 733

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

16. Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. The nurse should explain that treatment of PKU involves _____ diet.

kt an k. c

Sodium restrictions in the

A phenylalanine-free

w .te

A phenylalanine-enriched

ba n

A protein-rich

ANS: B

Feedback

Sodium restriction is not an issue in phenylketonuria.

kt an k. c

ba n

Phenylketonuria is treated with a special diet that restricts phenylalanine intake.

w .te

Phenylalanine is eliminated from the diet to prevent CNS damage.

A specially prepared milk substitute is used to control the amount of protein in the infants diet, thereby decreasing the amount of phenylalanine.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 733

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

17. Nursing care of the neonate undergoing jaundice phototherapy includes

ba n

Keeping the infant supine at all times

kt an k. c

Keeping the infants eyes covered under the light

w .te

Restricting parenteral and oral fluids

Keeping the infant dressed in only a T-shirt and diaper

ANS: A

Feedback

Retinal damage from phototherapy should be prevented by using eye shields on the infant under the light.

kt an k. c

To ensure total skin exposure, the infants position is changed frequently.

ba n

Special attention to increasing fluid intake ensures that the infant is well hydrated.

w .te

To ensure total skin exposure, the infant is not dressed.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 721

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

18. An infant with hypocalcemia is receiving an intravenous bolus of calcium. Which sign signals the nurse to stop the administration of this medication?

Tachypnea of the newborn

kt an k. c

Bradycardia

ba n

Decrease of acrocyanosis

w .te

ANS: B

Gastric irritation (diarrhea)

Feedback

Tachypnea is seen in many neonates delivered by cesarean section, but it is not associated with the administration of calcium.

If bradycardia or dysrhythmias occur during administration, stop the drug infusion immediately.

kt an k. c

Acrocyanosis is not a major problem of calcium administration.

ba n

w .te

Gastric irritation is usually seen with administration of oral calcium.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 729

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

19. A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurses most appropriate action is to

Leave the infant in the room with the mother.

kt an k. c

Take the infant immediately to the nursery.

ba n

Perform a gestational age assessment to determine whether the infant is large for gestational age.

w .te

Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

ANS: D

Feedback

Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. This can be achieved in the mothers room with nursing interventions, depending on the condition of the fetus. It may be more appropriate for observation to occur in the nursery.

Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. Observation may occur in the nursery or in the mothers room, depending on the condition of the fetus.

kt an k. c

ba n

Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight over 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be observed closely.

w .te

This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 728

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

20. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborns distress is most likely

Hypoglycemia

kt an k. c

Phrenic nerve injury

Respiratory distress syndrome

w .te

Sepsis

ANS: D

Feedback

ba n

A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia.

Phrenic nerve injury is usually the result of traction on the neck and arm during birth and is not applicable to this situation.

kt an k. c

ba n

The earliest signs of sepsis are characterized by lack of specificityi.e., lethargy, poor feeding, and irritabilitynot respiratory distress syndrome.

w .te

The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 724-725

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

21. The most important nursing action in preventing neonatal infection is

Good handwashing

Isolation of infected infants

kt an k. c

w .te

Standard Precautions

ba n

Separate gown technique

ANS: A

Feedback

Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units.

Overcrowding must be avoided in nurseries and infants with infectious processes should be isolated; however, the most important nursing action for preventing neonatal infection is effective handwashing.

kt an k. c

ba n

Separate gowns should be worn in caring for each individual infant. Soiled linens should be disposed of in an appropriate manner; however, the most important nursing action for preventing neonatal infection is effective handwashing.

w .te

Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. The most important nursing action for preventing neonatal infection is effective handwashing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 727

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

22. A plan of care for an infant experiencing symptoms of drug withdrawal should include

kt an k. c

Feeding every 4 to 6 hours to allow extra rest

ba n

Swaddling the infant snugly and holding the baby tightly

w .te

Playing soft music during feeding

ANS: C

Feedback

Administering chloral hydrate for sedation

Phenobarbital or diazepam may be administered to decrease CNS irritability.

The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration.

kt an k. c

ba n

The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions.

w .te

The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 732

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

23. HIV may be perinatally transmitted

Only in the third trimester from the maternal circulation

ba n

Only through the ingestion of amniotic fluid

kt an k. c

From the use of unsterile instruments

w .te

Through the ingestion of breast milk from an infected mother

ANS: D

Feedback

Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages.

This is highly unlikely as most health care facilities must meet sterility standards for all instrumentation.

kt an k. c

Transmission of HIV may occur during birth from blood or secretions.

ba n

Postnatal transmission of HIV through breastfeeding may occur.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 725 | Table 30-1

OBJ: Nursing Process: Planning

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

24. A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infants eyes when the mother asks, What is that medicine for? The nurse responds

It is an eye ointment to help your baby see you better.

kt an k. c

It is to protect your baby from contracting herpes from your vaginal tract.

ba n

Erythromycin is given prophylactically to prevent a gonorrheal infection.

w .te

ANS: C

This medicine will protect your babys eyes from drying out over the next few days.

Feedback

Erythromycin has no bearing on enhancing vision.

Erythromycin is used to prevent an infection caused by gonorrhea, not herpes.

kt an k. c

With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum.

ba n

Erythromycin is given to prevent infection, not for lubrication.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 725 | Table 30-1

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

25. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of

Gonorrhea

Herpes simplex virus infection

kt an k. c

Congenital syphilis

ba n

ANS: C

Feedback

w .te

HIV

This rash is not an indication that the neonate has contracted gonorrhea. The neonate with gonorrheal infection might present with septicemia, meningitis, conjunctivitis and scalp abscesses.

Infants affected with HSV will display growth restriction, skin lesions, microcephaly, hypertonicity and seizures.

kt an k. c

This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities.

ba n

Typically the HIV infected neonate is asymptomatic at birth. Most often the infant will develop an opportunistic infection and rapid progression of immunodeficiency.

w .te

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 726 | Table 30-1

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

26. Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is

Pharmacologic treatment

Reduction of environmental stimuli

Neonatal abstinence syndrome scoring

ba n

kt an k. c

ANS: C

Feedback

w .te

Adequate nutrition and maintenance of fluid and electrolyte balance

Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium.

Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system disturbances.

ba n

kt an k. c

Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly.

w .te

Poor feeding is one of the GI symptoms common to this patient population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 730

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

1. Some infants develop hypoxic-ischemic encephalopathy after asphyxia. Therapeutic hypothermia has been used to improve neurologic outcomes for these infants. Criteria for the use of this modality include (select all that apply)

ba n

Have evidence of an acute hypoxic event.

kt an k. c

The infant must be 28 weeks gestation or greater.

w .te

Be in a facility they can initiate treatment within 6 hours.

The infant must be 36 or more weeks gestation.

The treatment must be initiated within the first 12 hours of life.

ANS: B, C, D

Feedback

Correct

kt an k. c

These criteria are all correct.

Incorrect

ba n

The infant must be at least 36 weeks of gestation to meet the criteria for therapeutic hypothermia. Treatment should be initiated within the first 6 hours of life, ideally at a tertiary care center.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 716

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

TRUE/FALSE

1. Persistent pulmonary hypertension of the newborn (PPHN) is a condition in which the vascular resistance of the lungs does not decrease after birth and consequently normal changes to neonatal circulation are impaired. The neonatal nurse knows that there are numerous underlying causes for this condition, one of which is maternal use of nonsteroidal antiinflammatory drugs (NSAIDs). Is this statement true or false?

ANS: T

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 720

Other probable causes of PPHN include abnormal lung development, the use of aspirin, or reasons unknown. PPHN is often associated with meconium aspiration, sepsis, asphyxia, polycythemia, diaphragmatic hernia, diabetes, and respiratory distress syndrome. Nursing care is similar to that of other infants with severe respiratory disease.

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

ba n

COMPLETION

ANS:

asphyxia

w .te

1. A lack of O2 and an increase in CO2 in the blood is known as __________. This condition in the neonate may occur while in utero, at birth, or later.

Complications during pregnancy, labor, or birth increase the infants risk for asphyxia. If the mother receives narcotics shortly before birth, the infant may be too physiologically depressed to breathe spontaneously. Resuscitative measures must be initiated immediately to prevent permanent brain damage or death.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 716

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. ______________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth.

kt an k. c

ANS:

Methadone

ba n

Methadone withdrawal is more severe and prolonged than withdrawal from heroin. Signs of withdrawal include tremors, irritability, hypertonicity, vomiting, nasal stuffiness and disturbed sleep patterns. This infant is also at increased risk for SIDS.

w .te

MULTIPLE CHOICE

Chapter 26 Wellness and Health Promotion

1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test?

Gloves and eye protectors

Speculum

Fixative agent

kt an k. c

Lubricant

ba n

ANS: D

w .te

Feedback

The examiner should always use Standard Precautions.

A speculum is needed to see the cervix.

A fixative agent is applied to the slide to prevent drying or disruption of the specimen.

Lubricants interfere with the accuracy of the cytology report.

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 775

ba n

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

w .te

2. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called

Bimanual palpation

Rectovaginal palpation

A Papanicolaou test

DNA testing

kt an k. c

ANS: C

ba n

Feedback

w .te

Bimanual palpation is a physical examination of the vagina; the Pap test is a microscopic examination for cancer.

Rectovaginal palpation is a physical examination performed through the rectum; the Pap test is a microscopic examination for cancer.

The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the patients age.

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 775

DNA testing for the various types of HPV that cause cervical cancer is now available. Samples are collected in the same way as a Pap test.

ba n

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

3. The nurse providing care in a womens health care setting must be aware that which sexually transmitted disease (STD) can be cured?

Herpes

w .te

Acquired immunodeficiency syndrome (AIDS)

Venereal warts

Chlamydia

kt an k. c

ANS: D

ba n

Feedback

w .te

Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections.

Because no cure is known for AIDS, prevention and early detection are the main focus.

Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus.

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: pp. 797-799

The usual treatment for chlamydia bacterial infection is doxycycline or azithromycin. Concurrent treatment of all sexual partners is needed to prevent recurrence.

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

ba n

4. Which statement by a woman diagnosed with premenstrual syndrome indicates that further health teaching is needed?

w .te

I will not eat chips or pickles.

Coffee and chocolate can make me more irritable and nervous.

Drinking alcohol makes me more depressed.

Ill eat only three meals per day.

ANS: D

kt an k. c

Feedback

ba n

Less intake of salty foods helps decrease fluid retention.

w .te

Caffeine consumption increases irritability, insomnia, anxiety, and nervousness.

Alcohol consumption aggravates depression.

The woman should be encouraged to eat six small meals a day to decrease risk of hypoglycemia.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 787

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

kt an k. c

5. Which statement by the patient indicates that she understands breast self-examination?

ba n

I will examine both breasts in two different positions.

w .te

I will perform breast self-examination 1 week after my menstrual period starts.

I will examine the outer upper area of the breast only.

I will use the palm of the hand to perform the examination.

ANS: B

Feedback

kt an k. c

She should use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down.

ba n

w .te

The woman should examine her breasts when hormonal influences are at a low level.

The entire breast needs to be examined, including the outer upper area.

She should use the sensitive pads of the middle three fingers.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 772

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

6. A benign breast condition that includes dilation and inflammation of the collecting ducts is called

kt an k. c

Ductal ectasia

Intraductal papilloma

w .te

Chronic cystic disease

ba n

Fibroadenoma

ANS: A

Feedback

kt an k. c

Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge.

ba n

Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts.

w .te

Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated.

Fibroadenoma is fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 777

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. Which patient is most at risk for fibroadenoma of the breast?

kt an k. c

A 38-year-old woman

ba n

A 50-year-old woman

w .te

A 16-year-old woman

A 27-year-old woman

ANS: C

Feedback

Ductal ectasia becomes more common as a woman approaches menopause.

kt an k. c

Intraductal papilloma develops most often just before or during menopause.

ba n

Although it may occur at any age, fibroadenoma is most common in the teenage years.

w .te

Fibrocystic breast changes are more common during the reproductive years.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 777

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. Adjuvant treatment with tamoxifen may be recommended for patients with breast cancer if the tumor is

Smaller than 5 cm

Contained only in the breast

ba n

w .te

Estrogen receptive

ANS: D

Feedback

kt an k. c

Located in the upper outer quadrant only

Tamoxifen is used depending on age, stage, and hormone receptor status, not size.

Location of the cancer does not determine the usefulness of tamoxifen.

kt an k. c

Stage of the cancer is a consideration, but more important is its sensitivity to estrogen.

ba n

w .te

Tamoxifen is antiestrogen therapy for tumors stimulated by estrogen.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 779

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

9. Which statement is true about primary dysmenorrhea?

It occurs in young multiparous women.

kt an k. c

It may be due to excessive endometrial prostaglandin.

ba n

It is unaffected by oral contraceptives.

Feedback

w .te

ANS: C

It occurs in young nulliparous women.

It is experienced by all women.

It is not experienced by all women.

Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping.

kt an k. c

Oral contraceptives can be a treatment choice.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 785

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

10. In helping a patient manage PMS, the nurse should

Recommend a diet with more body-building and energy food, such as red meat and sugar.

Suggest herbal therapies, and massage.

Tell the patient to push for medications from the physician as soon as symptoms occur so as to lessen their severity.

kt an k. c

Discourage the use of diuretics.

ba n

ANS: B

w .te

Feedback

Limiting red meat, refined sugar, caffeinated beverages, and alcohol improves the diet and may mitigate symptoms.

Herbal therapies, conscious relaxation and massage have all been reported to have a beneficial effect on PMS.

kt an k. c

Natural diuretics may help reduce fluid retention.

Medication usually is begun only if lifestyle changes fail to provide significant relief.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 787

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

w .te

11. With regard to endometriosis, nurses should be aware that

It is characterized by the presence and growth of endometrial tissue inside the uterus.

It affects 25% of all women.

It may worsen with repeated cycles or remain asymptomatic and disappear after menopause.

kt an k. c

It is unlikely to affect sexual intercourse or fertility.

ANS: C

ba n

Feedback

w .te

With endometriosis, the endometrial tissue is outside the uterus. Symptoms vary among women, ranging from nonexistent to incapacitating.

Endometriosis affects 10% of all women and is found equally in Caucasian and AfricanAmerican women.

Symptoms vary among women, ranging from nonexistent to incapacitating.

kt an k. c

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 785

Women can experience painful intercourse and impaired fertility.

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

ba n

12. A 49-year-old patient confides to the nurse that she has started experiencing pain with intercourse and asks, Is there anything I can do about this? The nurses best response is

w .te

You need to be evaluated for a sexually transmitted disease.

Water-soluble vaginal lubricants may provide relief.

No, it is part of the aging process.

You may have vaginal scar tissue that is producing the discomfort.

kt an k. c

ANS: B

Feedback

ba n

w .te

This is a normal occurrence with the aging process and does not indicate STDs.

Loss of lubrication with resulting discomfort in intercourse is a symptom of estrogen deficiency.

It is part of the aging process, but the use of lubrication will help relieve the symptoms.

It is due to loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 790

kt an k. c

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

13. A 70-year-old woman should be taught to report what condition to her health care provider?

w .te

Vaginal bleeding

Pain with intercourse

Breasts become smaller

ba n

Skin becomes thinner

ANS: A

Feedback

kt an k. c

ba n

Vaginal bleeding after menopause should always be investigated. It is highly suggestive of endometrial cancer.

w .te

Pain with intercourse is an expected change that occurs due to the aging process.

Breast shrinkage is an expected change that occurs due to the aging process.

Skin thinning is an expected change that occurs due to the aging process.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 789

14. Which woman is most likely to have osteoporosis?

kt an k. c

ba n

A 50-year-old woman receiving estrogen therapy

w .te

A 60-year-old woman who takes supplemental calcium

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A 55-year-old woman with a sedentary lifestyle

A 65-year-old woman who walks 2 miles each day

ANS: C

Feedback

kt an k. c

Hormone therapy may prevent bone loss.

ba n

Supplemental calcium will help prevent bone loss, especially when combined with vitamin D.

w .te

Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary lifestyle, family history of the disease, and a high-fat diet.

Weight-bearing exercises have been shown to increase bone density.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 791-792

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. A woman with a history of a cystocele should contact the physician if she experiences

kt an k. c

Involuntary loss of urine when she coughs

ba n

Constipation

Backache

w .te

Urinary frequency and burning

ANS: D

Feedback

kt an k. c

Constipation may be a problem with rectoceles.

Involuntary loss of urine during coughing is stress incontinence and is not an emergency.

ba n

Back pain is a symptom of uterine prolapse.

w .te

Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 792

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. To assist the woman in regaining control of the urinary sphincter, the nurse should teach her to

Practice Kegel exercises.

kt an k. c

Void every hour while awake.

ba n

Allow the bladder to become distended before voiding.

w .te

Drink 8 to 10 glasses of water each day.

ANS: A

Feedback

Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter.

A prescribed schedule may help, but every hour is too frequent.

kt an k. c

Overdistention of the bladder will cause incontinence.

ba n

w .te

Restricting fluids will cause bladder irritation that increases the problem. Drinking adequate fluids will not help the problem.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 794

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

17. The physician diagnoses a 3 cm ovarian cyst in a 28-year-old woman. The nurse expects the initial treatment to include

Beginning hormone therapy

Examining the woman after her next menstrual period

kt an k. c

ba n

Scheduling a laparoscopy as soon as possible, to remove the cyst

w .te

Aspirating the cyst as soon as possible and sending the fluid to pathology

ANS: B

Feedback

Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point.

Most ovarian cysts regress spontaneously.

kt an k. c

It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle.

ba n

A transvaginal ultrasound examination will help determine if the cyst is fluid filled or solid. The cyst can then be removed if warranted.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

18. The drug of choice to treat gonorrhea is

Penicillin G

Tetracycline

kt an k. c

Ceftriaxone

ba n

Acyclovir

Feedback

w .te

ANS: C

Penicillin is used to treat syphilis.

Tetracycline is used to treat chlamydial infections.

Ceftriaxone is effective for treatment of all gonococcal infections.

Acyclovir is used to treat herpes genitalis.

kt an k. c

ba n

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 798

w .te

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

19. When a nurse is counseling a woman for primary dysmenorrhea, which non-pharmacologic intervention might be recommended?

Increasing the intake of red meat and simple carbohydrates

Reducing the intake of diuretic foods, such as peaches and asparagus

Temporarily substituting physical activity for a sedentary lifestyle

kt an k. c

Using a heating pad on the abdomen to relieve cramping

ba n

ANS: D

w .te

Feedback

Dietary changes such as eating less red meat may be recommended for women experiencing dysmenorrhea.

Increasing the intake of diuretics, including natural diuretics such as asparagus, cranberry juice, peaches, parsley, and watermelon may help ease the symptoms associated with dysmenorrhea.

Exercise has been found to help relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia.

kt an k. c

Heat minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia.

ba n

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 785

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

w .te

20. Nafarelin (Synarel) is currently used as a treatment for mild to severe endometriosis. The nurse should tell the woman taking this medication that the drug

Stimulates the secretion of gonadotropin-releasing hormone (GnRH), thereby stimulating ovarian activity

Should be sprayed into one nostril every other day

kt an k. c

Can cause her to experience some hot flashes and vaginal dryness

Should be injected into subcutaneous tissue BID

ba n

ANS: D

Feedback

w .te

Nafarelin is a GnRH agonist that suppresses the secretion of gonadotrophin-releasing hormone.

Nafarelin is administered twice daily by nasal spray.

Nafarelin is administered intranasally.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 786

Nafarelin is a GnRH agonist, and its side effects are similar to those of menopause. The hypoestrogenism effect results in hot flashes and vaginal dryness.

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

ba n

21. The nurse who is teaching a group of women about breast cancer should tell the women that

w .te

Risk factors identify almost all women who will develop breast cancer.

African-American women have a higher rate of breast cancer.

One in 10 women in the United States will develop breast cancer in her lifetime.

The exact cause of breast cancer is unknown.

kt an k. c

ANS: D

Feedback

ba n

w .te

Risk factors help identify a small percentage of women in whom breast cancer eventually will develop.

Caucasian women have a higher incidence of breast cancer; however, African-American women have a higher rate of dying of breast cancer after they are diagnosed.

One in eight women in the United States will develop breast cancer in her lifetime.

The exact cause of breast cancer in unknown.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 778

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

22. The nurse providing education regarding breast care should explain to the woman that fibrocystic changes in breasts are

ba n

w .te

A disease of the milk ducts and glands in the breasts

A pre-malignant disorder characterized by lumps found in the breast tissue

Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women during menstrual cycles

Lumpiness accompanied by tenderness after menses

ANS: C

kt an k. c

Feedback

ba n

Fibrocystic changes are palpable thickenings in the breast.

w .te

Fibrocystic changes are no pre-malignant changes. This information is inaccurate.

Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. The pain and tenderness fluctuate with the menstrual cycle.

Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. Most often tenderness occurs prior to menses.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 777

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

kt an k. c

23. Which diagnostic test is used to confirm a suspected diagnosis of breast cancer?

ba n

Mammogram

Ultrasound

w .te

Core needle biopsy

CA 15-3

ANS: C

Feedback

kt an k. c

Mammography is a clinical screening tool that may aid early detection of breast cancers.

ba n

w .te

Transillumination, thermography, and ultrasound breast imaging are being explored as methods of detecting early breast carcinoma.

When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a core needle biopsy or needle localization biopsy.

CA-15 is a serum tumor marker that is used to test for the presence of breast cancer.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 777

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

24. A 36-year-old woman has been diagnosed as having uterine fibroids. When planning care for this patient, the nurse should know that

kt an k. c

Fibroids are malignant tumors of the uterus that require radiation or chemotherapy.

ba n

w .te

Fibroids will increase in size during the perimenopausal period.

Abnormal uterine bleeding is a common finding.

Hysterectomy should be performed.

ANS: C

Feedback

kt an k. c

Fibroids are benign tumors of the smooth muscle of the uterus, and their etiology is unknown.

ba n

Fibroids are estrogen-sensitive and shrink as levels of estrogen decline.

w .te

The major symptoms associated with fibroids are menorrhagia and the physical effects produced by large leimyomas.

A hysterectomy may be performed if the woman does not want more children and other therapies are not successful.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

25. When assessing a woman for menopausal discomforts, the nurse expects the woman to describe the most frequently reported discomfort, which is

kt an k. c

Headaches

ba n

Hot flashes

Mood swings

w .te

Vaginal dryness with dyspareunia

ANS: B

Feedback

Headaches may be associated with a decline in hormone levels; however, it is not the most frequently reported discomfort for menopausal women.

kt an k. c

ba n

Vasomotor instability, in the form of hat flashes or flushing, is a result of fluctuating estrogen levels and is the most common disturbance of the perimenopausal woman.

w .te

Mood swings may be associated with a decline in hormone levels; however, it is not the most frequently reported discomfort for menopausal women.

Vaginal dryness and dyspareunia may be associated with a decline in hormone levels; however, it is not the most frequently reported discomfort for menopausal women.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 790

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

26. While evaluating a patient for osteoporosis, the nurse should be aware of what risk factor?

African-American race

kt an k. c

ba n

Low protein intake

w .te

Obesity

Cigarette smoking

ANS: D

Feedback

Women at risk for osteoporosis are likely to be Caucasian or Asian.

kt an k. c

Inadequate calcium intake is a risk factor for osteoporosis.

ba n

Women at risk for osteoporosis are likely to be small boned and thin. Obese women have higher estrogen levels as a result of the conversion of androgens in the adipose tissue. Mechanical stress from extra weight also helps preserve bone mass.

w .te

Smoking is associated with earlier and greater bone loss and decreased estrogen production.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 791

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

27. When discussing estrogen replacement therapy (ERT) with a perimenopausal woman, the nurse should include the risks of

Breast cancer

ba n

Osteoporosis

w .te

Arteriosclerosis

ANS: A

Feedback

kt an k. c

Vaginal and urinary tract atrophy

Women with a high risk of breast cancer should be counseled against using ERT.

Estrogen prevents atrophy of vaginal and urinary tract tissue.

kt an k. c

Estrogen protects against the development of osteoporosis.

ba n

w .te

Estrogen has a favorable effect on circulating lipids, reducing low density lipoprotein (LDL) and total cholesterol and increasing high density lipoprotein (HDL). It also has a direct antiatherosclerotic effect on the arteries.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 790

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

28. During her annual gynecologic checkup, a 17-year-old woman states that recently she has been experiencing cramping and pain during her menstrual periods. The nurse should document this complaint as

Amenorrhea

Dysmenorrhea

kt an k. c

ba n

Dyspareunia

w .te

PMS

ANS: B

Feedback

Amenorrhea is the absence of menstrual flow.

Dysmenorrhea is pain during or shortly before menstruation. Pain is described as sharp and cramping or sometimes as a dull ache. It may radiate to the lower back or upper thighs.

kt an k. c

Dyspareunia is pain during intercourse.

ba n

PMS is a cluster of physical, psychologic, and behavioral symptoms that begin in the luteal phase of the menstrual cycle and resolve within a couple of days of the onset of menses.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 785

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

29. Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a patient with this condition should be aware that the optimal pharmacologic therapy for pain relief is

Acetaminophen

kt an k. c

Nonsteroidal antiinflammatory drugs (NSAIDs)

Oral contraceptives (OCPs)

ba n

Aspirin

Feedback

w .te

ANS: C

Preparations containing acetaminophen are less effective for dysmenorrhea because they lack the antiprostaglandin properties of NSAIDs.

OCPs are a reasonable choice for women who also want birth control. The benefit of OCPs is the reduction of menstrual flow and irregularities. OCPs may be contradicted for some women and have a number of potential side effects.

kt an k. c

This pharmacologic agent has the strongest research results for pain relief. Often, if one NSAID is not effective, another one will provide relief.

ba n

NSAIDs are the drug of choice. However, if a woman is taking an NSAID, she should avoid taking aspirin as well.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 785

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

30. A woman is 6 weeks pregnant and has elected to terminate her pregnancy. The nurse knows that the most common technique used for medical termination of a pregnancy in the first trimester is

Administration of prostaglandins

Dilation and evacuation

Vacuum aspiration

ba n

kt an k. c

Intravenous administration of Pitocin

Feedback

w .te

ANS: A

The most common technique for medical termination of a pregnancy within the first 7 weeks of pregnancy is administration of prostaglandins.

This is the most common method of surgical abortion used if medical abortion fails.

kt an k. c

Intravenous administration of Pitocin is used to induce labor in a woman with a third trimester fetal demise.

ba n

Vacuum aspiration is used for abortions in the first trimester.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 788

w .te

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

31. The nurse should be aware that a pessary is most effective in the treatment of what disorder?

Cystocele

Uterine prolapse

Rectocele

kt an k. c

ba n

Stress urinary incontinence

ANS: B

w .te

Feedback

A pessary is not used for the patient with a cystocele.

A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct position.

A rectocele cannot be corrected by the use of a pessary.

kt an k. c

It is unlikely that a pessary be the most effective treatment for stress incontinence.

ba n

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 794

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

w .te

32. A postmenopausal woman who is 54 years old has been diagnosed with two leiomyomas. What assessment finding is most commonly associated with the presence of leiomyomas?

Abnormal uterine bleeding

Diarrhea

Weight loss

kt an k. c

Acute abdominal pain

ba n

ANS: A

Feedback

w .te

Most women are asymptomatic. Abnormal uterine bleeding is the most common symptom of leiomyomas, or fibroids.

Diarrhea is not commonly associated with leiomyomas (fibroids).

Weight loss does not usually occur in the woman with leiomyomas (fibroids).

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795

The patient with leiomyomas (fibroids) is unlikely to experience abdominal pain.

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

w .te

1. While interviewing a 48-year-old patient during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this patient to begin annual screening, it is important for her to understand the reasons why women avoid testing. These reasons include (select all that apply)

Reluctance to hear bad news

Fear of x-ray exposure

Belief that lack of family history makes this test unnecessary

kt an k. c

Expense of the procedure

ba n

w .te

Having heard that the test is painful

ANS: A, B, D, E

Feedback

Correct

All of these are reasons for women to avoid having a mammogram done. Although the test is expensive, it is usually covered by health insurance, and many communities offer low-cost or free screening to women without insurance. It is important to acknowledge that some discomfort occurs with screening. Scheduling the test immediately at the end of a period makes it less

painful. The risk of radiation exposure is minimal to none. Nurses play a vital role in providing information and reassurance to help women overcome these fears.

Incorrect

kt an k. c

Even patients with no family history should have regular screening done. The nurse should emphasize that a combination of breast self-examination and mammography needs to be performed at regular intervals. Women with a family history may need to begin screening at a younger age and have additional testing such as ultrasound performed.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 775

ba n

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

w .te

2. Which medications can be taken by postmenopausal women to treat and/or prevent osteoporosis? Select all that apply.

Calcium

Evista

Fosamax

kt an k. c

Actonel

Correct

Feedback

w .te

ANS: A, B, C, D

ba n

Vitamin C

All of these medications can be used by postmenopausal women to treat or prevent osteoporosis. Calcitonin is another medication available for treatment of osteoporosis.

Incorrect

Vitamin D is essential for calcium to be absorbed from the intestine. Recommended supplemental vitamin D Intake is 600 international units per day.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 791-792

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

kt an k. c

3. The exact cause of breast cancer remains undetermined. Researchers have found that there are a number of common risk factors that increase a womans chance of developing a malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? Select all that apply.

w .te

Family history

ba n

Late menarche

Early menopause

Race

kt an k. c

ANS: A, D, E

Nulliparity or first pregnancy after age 30

ba n

Feedback

Correct

w .te

Family history, race, and nulliparity are known risk factors for the development of breast cancer. Others include age, personal history of cancer, high socioeconomic status, sedentary lifestyle, hormone replacement therapy, recent use of oral contraceptives, never having breastfed a child, and drinking more than one alcoholic beverage per day.

Incorrect

Early menarche and late menopause are risk factors for breast malignancy, not late menarche and early menopause.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 774 | Box 32-2

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

TRUE/FALSE

1. The nurse understands that further health teaching is necessary when her young patient who has just had an abortion states, I guess Ill have to wear a tampon for the next week. Is this statement true or false?

kt an k. c

ANS: T

ba n

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 788

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

2. Women in the U.S. are now more likely to die of cardiac disease than all cancers combined. Is this statement true or false?

ANS: T

Heart disease is now the leading cause of death for women in the United States, killing 26% of women who died in 2006. Almost twice as many American women die of heart disease or stroke than any form of cancer including breast cancer. Chapter 27 Common Gynecologic Conditions MULTIPLE CHOICE

kt an k. c

1. The perinatal nurse is giving discharge instructions to a woman, status post suction and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse is

ba n

If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available.

w .te

The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult.

If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time.

Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.

ANS: B

kt an k. c

Feedback

ba n

Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. Pregnancy raises hCG levels which increases the risk for choriocarcinoma.

w .te

This is an accurate statement. Beta-hCG levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a zero hCG level. If the woman were to become pregnant, it may obscure the presence of the potentially carcinogenic cells.

The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present.

Any contraceptive method except an IUD is acceptable.

MSC: Client Needs: Physiologic Integrity

kt an k. c

OBJ: Nursing Process: Planning and Implementation

PTS: 1 DIF: Cognitive Level: Application REF: dm. 582

ba n

2. Which maternal condition always necessitates delivery by cesarean section?

w .te

Partial abruptio placentae

Total placenta previa

Ectopic pregnancy

Eclampsia

ANS: B

kt an k. c

Feedback

ba n

w .te

If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted. If the fetus has died, a vaginal delivery is preferred.

In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred.

The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester.

Labor can be safely induced if the eclampsia is under control.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 583, 585

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. Spontaneous termination of a pregnancy is considered to be an abortion if

ba n

w .te

The pregnancy is less than 20 weeks.

The fetus weighs less than 1000 g.

The products of conception are passed intact.

No evidence exists of intrauterine infection.

ANS: A

Feedback

kt an k. c

ba n

An abortion is the termination of pregnancy before the age of viability (20 weeks).

w .te

The weight of the fetus is not considered because some fetuses of an older age may have a low birth weight.

A spontaneous abortion may be complete or incomplete.

A spontaneous abortion may be caused by many problems, one being intrauterine infection.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 576

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. An abortion in which the fetus dies but is retained in the uterus is called _____ abortion.

kt an k. c

ba n

Inevitable

w .te

Missed

Incomplete

Threatened

ANS: B

Feedback

kt an k. c

An inevitable abortion means that the cervix is dilating with the contractions.

ba n

Missed abortion refers to a dead fetus being retained in the uterus.

w .te

An incomplete abortion means that not all of the products of conception were expelled.

With a threatened abortion the woman has cramping and bleeding but not cervical dilation.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 578

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

5. A placenta previa in which the placental edge just reaches the internal os is called

Total

kt an k. c

ba n

Partial

w .te

Complete

Marginal

ANS: D

Feedback

With a total placenta previa the placenta completely covers the os.

kt an k. c

With a partial previa the lower border of the placenta is within 3 cm of the internal cervical os, but does not completely cover the os.

ba n

A complete previa is termed total. The placenta completely covers the internal cervical os.

w .te

A placenta previa that does not cover any part of the cervix is termed marginal.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 583

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. What condition indicates concealed hemorrhage in an abruptio placentae?

Decrease in abdominal pain

kt an k. c

Bradycardia

ba n

Hard, boardlike abdomen

w .te

ANS: C

Decrease in fundal height

Feedback

Abdominal pain may increase.

The patient will have shock symptoms that include tachycardia.

kt an k. c

Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen.

ba n

The fundal height will increase as bleeding occurs.

w .te

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 586

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to

Assess fetal heart rate (FHR) and maternal vital signs.

Perform a venipuncture for hemoglobin and hematocrit levels.

kt an k. c

Place clean disposable pads to collect any drainage.

ANS: A

Feedback

w .te

Monitor uterine contractions.

ba n

Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus.

The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later.

kt an k. c

It is important to assess future bleeding, but the top priority is mother/fetal well-being.

ba n

Monitoring uterine contractions is important, but not the top priority.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 587

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Any vaginal discharge should be reported immediately to her care provider.

The presence of any contractions, rupture of membranes, or severe perineal pressure should be reported.

kt an k. c

She will need to make arrangements for care at home, because her activity level will be restricted.

ba n

ANS: B

Feedback

w .te

She will be scheduled for a cesarean birth.

Vaginal bleeding needs to be reported to her primary care provider.

Nursing care should stress the importance of monitoring signs and symptoms of preterm labor.

kt an k. c

Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, which allows her the freedom to see her physician. Home uterine activity monitoring may be used to limit the womans need for visits and to safely monitor her status at home.

ba n

The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean birth can be planned.

w .te

PTS: 1 DIF: Cognitive Level: Application REF: dm. 579

OBJ: Nursing Process: Planning and Implementation

MSC: Client Needs: Health Promotion and Maintenance

9. A woman with severe preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is

Tocolytic

Anticonvulsant

kt an k. c

Antihypertensive

ba n

ANS: B

Feedback

w .te

Diuretic

A tocolytic drug does slow the frequency and intensity of uterine contractions but is not used for that purpose in this scenario.

Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity.

kt an k. c

Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate.

ba n

Diuresis is a therapeutic response to magnesium sulfate.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 594

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

10. What is the only known cure for preeclampsia?

Magnesium sulfate

Antihypertensive medications

kt an k. c

Delivery of the fetus

ba n

Administration of acetylsalicylic acid (ASA) every day of the pregnancy

Feedback

w .te

ANS: C

Magnesium sulfate is one of the medications used to treat but not to cure preeclampsia.

Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia.

If the fetus is viable and near term, delivery is the only known cure for preeclampsia.

kt an k. c

Low doses of ASA (60 to 80 mg) have been administered to women at high risk for developing preeclampsia.

ba n

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 593

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

11. Which clinical sign is not included in the classic symptoms of preeclampsia?

Hypertension

Edema

Proteinuria

kt an k. c

Glycosuria

ba n

ANS: D

w .te

Feedback

The first indication of preeclampsia is usually an increase in the maternal blood pressure.

The first sign noted by the pregnant woman is a rapid weight gain and edema of the hands and face.

Proteinuria usually develops later than the edema and hypertension.

kt an k. c

Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 592

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

w .te

12. Which assessment finding should convince the nurse to hold the next dose of magnesium sulfate?

Absence of deep tendon reflexes

Urinary output of 100 mL total for the previous 2 hours

Respiratory rate of 14 breaths/min

kt an k. c

Decrease in blood pressure from 160/100 to 140/85

ANS: A

ba n

Feedback

w .te

Because absence of deep tendon reflexes is a sign of magnesium toxicity, the next scheduled dose should not be administered. Calcium gluconate is the antidote that should be administered.

An hourly output of less than 30 mL could indicate toxicity.

A respiratory rate of less than 12 breaths/min could indicate toxicity.

kt an k. c

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 600

Decrease in blood pressure is an expected side effect of magnesium sulfate.

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

ba n

Eclampsia

w .te

Disseminated intravascular coagulation

HELLP syndrome

Rh incompatibility

kt an k. c

ANS: C

ba n

Feedback

w .te

Eclampsia is determined by the presence of seizures.

DIC is a potential complication associated with HELLP syndrome.

HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP).

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 600-601

These are not clinical indications of Rh incompatibility.

kt an k. c

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

ba n

14. The nurse is explaining how to assess edema to the nursing students working on the antepartum unit. Which score indicates edema of lower extremities, face, hands, and sacral area?

w .te

+1 edema

+2 edema

+3 edema

+4 edema

ANS: C

kt an k. c

Feedback

ba n

Edema classified as +1 indicates minimal edema of the lower extremities.

w .te

Marked edema of the lower extremities is termed +2 edema.

Edema of the extremities, face, and sacral area is classified as +3 edema.

Generalized massive edema (+4) includes accumulation of fluid in the peritoneal cavity.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 593 | Table 25-2

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

ba n

Blood pressure increase to 138/86 mm Hg

kt an k. c

15. A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?

w .te

Weight gain of 0.5 kg during the past 2 weeks

A dipstick value of 3+ for protein in her urine

Pitting pedal edema at the end of the day

ANS: C

Feedback

kt an k. c

Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or 15 mm Hg diastolic pressure.

ba n

w .te

Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week.

Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made.

Edema occurs in many normal pregnancies as well as in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 592

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

kt an k. c

16. A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate

ba n

Anxiety due to hospitalization

w .te

Worsening disease and impending convulsion

Effects of magnesium sulfate

Gastrointestinal upset

ANS: B

kt an k. c

These are danger signs and should be treated.

Feedback

ba n

w .te

Headache and visual disturbances are due to increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent.

She has not been started on magnesium sulfate as a treatment yet. Also, these are not expected effects of the medication.

These are danger signs showing increased cerebral edema and impending convulsion.

PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 599-600

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

17. Rh incompatibility can occur if the woman is Rh negative and her

kt an k. c

Fetus is Rh positive

Husband is Rh positive

ba n

w .te

Fetus is Rh negative

Husband and fetus are both Rh negative

ANS: A

Feedback

For Rh incompatibility to occur, the mother must be Rh negative and her fetus Rh positive.

kt an k. c

The husbands Rh factor is a concern only as it relates to the possible Rh factor of the fetus.

ba n

w .te

If the fetus is Rh negative, the blood types are compatible and no problems should occur.

If the fetus is Rh negative, the blood type with the mother is compatible. The husbands blood type does not enter into the problem.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 601

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. In which situation is a dilation and curettage (D&C) indicated?

Complete abortion at 8 weeks

Incomplete abortion at 16 weeks

w .te

Threatened abortion at 6 weeks

ba n

Incomplete abortion at 10 weeks

ANS: D

Feedback

kt an k. c

If all the products of conception have been passed (complete abortion), a D&C is not used.

kt an k. c

D&C is used to remove the products of conception from the uterus and can be done safely until week 14 of gestation.

ba n

If the pregnancy is still viable (threatened abortion), a D&C is not used.

w .te

D&C is used to remove the products of conception from the uterus and can be used safely until week 14 of gestation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 578

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

19. What order should the nurse expect for a patient admitted with a threatened abortion?

Bed rest

Ritodrine IV

kt an k. c

ba n

NPO

w .te

Narcotic analgesia every 3 hours, prn

ANS: A

Feedback

Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continue.

Ritodrine is not the first drug of choice for tocolytic medications.

kt an k. c

There is no reason for having the woman NPO. At times dehydration may produce contractions, so hydration is important.

ba n

Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 577

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

20. What data on a patients health history places her at risk for an ectopic pregnancy?

Use of oral contraceptives for 5 years

Recurrent pelvic infections

kt an k. c

Ovarian cyst 2 years ago

ba n

Heavy menstrual flow of 4 days duration

Feedback

w .te

ANS: B

Oral contraceptives do not increase the risk for ectopic pregnancies.

Infection and subsequent scarring of the fallopian tubes prevents normal movement of the fertilized ovum into the uterus for implantation.

Ovarian cysts do not cause scarring of the fallopian tubes.

kt an k. c

This will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnancies.

ba n

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 580 | Box 25-1

w .te

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

21. What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?

Complaint of frequent mild nausea

Blood pressure of 120/80 mm Hg

Fundal height measurement of 18 cm

kt an k. c

History of bright red spotting for 1 day, weeks ago

ba n

ANS: C

w .te

Feedback

Nausea increases in a molar pregnancy because of the increased production of hCG.

A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension.

The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy.

kt an k. c

The history of bleeding is normally described as being brownish.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 582

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

w .te

22. What routine nursing assessment is contraindicated in the patient admitted with suspected placenta previa?

Monitoring FHR and maternal vital signs

Observing vaginal bleeding or leakage of amniotic fluid

Determining frequency, duration, and intensity of contractions

Determining cervical dilation and effacement

kt an k. c

ANS: D

ba n

Feedback

w .te

Monitoring FHR and maternal vital signs is a necessary part of the assessment for this woman.

Monitoring for bleeding and rupture of membranes is not contraindicated with this woman.

Monitoring contractions is not contraindicated with this woman.

Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage.

PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 584

kt an k. c

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

ba n

23. The primary symptom present in abruptio placentae that distinguishes it from placenta previa is

w .te

Vaginal bleeding

Rupture of membranes

Presence of abdominal pain

Changes in maternal vital signs

ANS: C

ba n

Both may have vaginal bleeding.

kt an k. c

Feedback

w .te

Rupture of membranes may occur with both conditions.

Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding.

Maternal vital signs may change with both if bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 585

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

kt an k. c

24. Which laboratory marker is indicative of disseminated intravascular coagulation (DIC)?

ba n

Bleeding time of 10 minutes

w .te

Presence of fibrin split products

Thrombocytopenia

Hyperfibrinogenemia

ANS: B

Feedback

kt an k. c

Bleeding time in DIC is normal.

ba n

w .te

Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys vasculature.

Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies.

Hypofibrinogenemia occurs with DIC.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 578

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

25. A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should

Vigorously stimulate the woman.

ba n

kt an k. c

Instruct her to take deep breaths.

w .te

Administer calcium gluconate.

Increase her IV fluids.

ANS: C

Feedback

Stimulation will not increase the respirations.

kt an k. c

ba n

This will not be successful in reversing the effects of the magnesium sulfate.

w .te

Calcium gluconate reverses the effects of magnesium sulfate.

Increasing her IV fluids will not reverse the effects of the medication.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 595

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that

Bed rest and analgesics are the recommended treatment.

She will be unable to conceive in the future.

ba n

kt an k. c

w .te

A D&C will be performed to remove the products of conception.

Hemorrhage is the major concern.

ANS: D

Feedback

The recommended treatment is to remove the pregnancy before hemorrhaging.

kt an k. c

If the tube must be removed, her fertility will decrease but she will not be infertile.

ba n

A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes.

w .te

Severe bleeding occurs if the fallopian tube ruptures.

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 580

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

27. Approximately 12% to 26% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion?

Chromosomal abnormalities

kt an k. c

Infections

ba n

Endocrine imbalance

w .te

ANS: A

Immunologic factors

Feedback

At least 60% of pregnancy losses result from chromosomal abnormalities that are incompatible with life.

Maternal infection may be a cause of early miscarriage.

kt an k. c

ba n

Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss.

w .te

Women who have repeated early pregnancy losses appear to have immunologic factors the play a role in spontaneous abortion incidents.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 576

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

28. Methotrexate is recommended as part of the treatment plan for which obstetric complication?

Complete hydatidiform mole

Missed abortion

kt an k. c

w .te

Abruptio placentae

ba n

Unruptured ectopic pregnancy

ANS: C

Feedback

Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole.

Methotrexate is not indicated or recommended as a treatment option for missed abortions.

kt an k. c

Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 4 cm in diameter.

ba n

Methotrexate is not indicated or recommended as a treatment option for abruptio placentae.

w .te

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 580

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

29. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment involves

Corticosteroids to reduce inflammation

kt an k. c

An antiemetic, such as pyridoxine, to control nausea and vomiting

IV therapy to correct fluid and electrolyte imbalances

ba n

Enteral nutrition to correct nutritional deficits

Feedback

w .te

ANS: B

Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum, but they are not the expected initial treatment for this disorder.

Initially, the woman who is unable to down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances.

kt an k. c

Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed.

ba n

In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 590

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

30. A woman with preeclampsia has a seizure. The nurses primary duty during the seizure is to

Insert an oral airway.

Suction the mouth to prevent aspiration.

ba n

Stay with the patient and call for help.

kt an k. c

Administer oxygen by mask.

Feedback

w .te

ANS: D

Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patients head to the side to prevent aspiration.

Once the seizure has ended, it may be necessary to suction the patients mouth.

Oxygen would be administered after the convulsion has ended.

kt an k. c

If a patient becomes eclamptic, the nurse should stay with her and call for help. Nursing actions during a convulsion are directed towards ensuring a patent airway and patient safety.

ba n

PTS: 1 DIF: Cognitive Level: Application REF: dm. 597

w .te

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

Pelvic pain

Abdominal pain

kt an k. c

Unanticipated heavy bleeding

ba n

Vaginal spotting or light bleeding

w .te

Missed period

ANS: A, B, D, E

Feedback

Correct

A missed period or spotting can easily be mistaken by the patient as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy.

Incorrect

kt an k. c

As the fallopian tube tears open and the embryo is expelled, the patient often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about half of women, shoulder and neck pain occurs due to irritation of the diaphragm from the hemorrhage.

PTS: 1 DIF: Cognitive Level: Application REF: dm. 580

ba n

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

w w

w .te

Iron supplementation

Resumption of intercourse at 6 weeks post-procedure

kt an k. c

Expectation of heavy bleeding for at least 2 weeks

Referral to a support group if necessary

Feedback

w .te

ANS: A, C, E

Emphasizing the need for rest

ba n

Correct

The woman should be advised to consume a diet high in iron and protein. For many women, iron supplementation also is necessary. Acknowledge that the patient has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest.

Incorrect

kt an k. c

PTS: 1 DIF: Cognitive Level: Application REF: dm. 579, 583

Nothing should be placed in the vagina for 2 weeks postprocedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The patient should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur she should be instructed to contact her provider.

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

ba n

COMPLETION

habitual

ANS:

w .te

1. Recurrent spontaneous abortion refers to a condition in which a woman experiences three or more consecutive abortions or miscarriages. This is also known as ________ abortion.

PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 578

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

2. The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _____________.

kt an k. c

ANS:

placenta previa

ba n

w .te

PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 583

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. The antidote administered to reverse magnesium toxicity is ______________.

ANS:

calcium gluconate

Calcium gluconate is the antidote necessary to reverse magnesium toxicity. The nurse caring for this patient should keep calcium gluconate in the room along with secured, syringes and needles.

MULTIPLE CHOICE 1. Which are the most common sites of breast cancer metastasis? a. Kidneys Bones and liver

Heart and blood vessels

kt an k. c

Chapter 28 Infections

AIDS

Chlamydia

ba n

d. Central nervous system ANS: B Metastasis occurs when the cancer cells spread to the vascular sites, commonly the lungs, liver, and bones. Kidney metastasis is uncommon. Metastasis to the heart and blood vessels is uncommon. The brain is one of the final areas to be reached by metastasis. PTS: 1 DIF: Cognitive Level: Understanding REF: 730 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 2. Which sexually transmitted disease can be cured? a. Herpes

w .te

d. Venereal warts ANS: C The usual treatment for chlamydial bacterial infection is doxycycline hyclate or tetracycline. Concurrent treatment of all sexual partners is needed to prevent recurrence. Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections. Because no cure is known for AIDS, prevention and early detection are the main focus. Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus. PTS: 1 DIF: Cognitive Level: Understanding REF: 750 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 3. Which statement by a client diagnosed with premenstrual syndrome indicates that further health teaching is needed? a. I will not eat chips or pickles. b.

Ill eat only three meals per day.

Drinking alcohol makes me more depressed.

d. ANS: B

Coffee and chocolate can make me more irritable and nervous.

The client should be encouraged to eat six small meals a day to decrease the risk of hypoglycemia. Less intake of salty foods helps decrease fluid retention. Alcohol consumption aggravates depression. Caffeine consumption increases irritability, insomnia, anxiety, and nervousness. PTS: 1 DIF: Cognitive Level: Analysis REF: 739 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 4. A benign breast condition that includes dilation and inflammation of the collecting ducts is: a. fibroadenoma. ductal ectasia.

intraductal papilloma.

Helen, 50 years old

Mary, 16 years old

ba n

kt an k. c

d. chronic cystic disease. ANS: B Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge. Fibroadenoma is evidenced by fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules. Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts. Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated. PTS: 1 DIF: Cognitive Level: Understanding REF: 729 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. Which client is most at risk for fibroadenoma of the breast? a. Janice, 38 years old

w .te

d. Anna, 27 years old ANS: C Although it may occur at any age, fibroadenoma is most common in the teenage years. Ductal ectasia becomes more common as a client approaches menopause. Intraductal papilloma develops most often just before or during menopause. Fibrocystic breast changes are more common during the reproductive years. PTS: 1 DIF: Cognitive Level: Understanding REF: 729 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 6. Which statement is true about primary dysmenorrhea? a. Primary dysmenorrhea is experienced by all women. b.

It is unaffected by oral contraceptives.

It occurs in young multiparous women.

d. It may be caused by excessive endometrial prostaglandin. ANS: D Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping. Primary dysmenorrhea is not experienced by all women. Oral contraceptives can be a treatment choice. It occurs in young nulliparous women.

PTS: 1 DIF: Cognitive Level: Understanding REF: 737 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. A client states, Im sure that I am suffering from PMS. How can I get my doctor to take this seriously? The nurses best response is: a. Men are not usually sympathetic to PMS sufferers. b.

You are probably right. You should remind your doctor of your symptoms every time you visit.

Since you feel certain you are right, you should just treat yourself with over-the-counter medications.

kt an k. c

d. You should keep a daily record of the occurrence and severity of your symptoms for 3 months. ANS: D Symptom charting for at least 3 months is necessary to make an accurate diagnosis of PMS. Suggesting lack of sympathy from men is an inaccurate statement and will not help the client with the present problem. Reminding the physician of the symptoms will not assist in making a diagnosis. Listing symptoms for 3 months will help the physician make the diagnosis better. The client should not treat herself with over-the-counter medications. PTS: 1 DIF: Cognitive Level: Application REF: 738, 739 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. Which should the nurse stress in teaching a client to deal with the symptoms of PMS? a. Decrease her consumption of caffeine. Drink a small glass of wine with her evening meal.

Decrease her fluid intake to prevent fluid retention.

ba n

w .te

d. Eat three large meals a day to maintain glucose levels. ANS: A Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates depression and should be avoided. Fluid intake should not be decreased. Six smaller meals a day will help maintain glucose levels. PTS: 1 DIF: Cognitive Level: Application REF: 739 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. A client, age 49, confides in the nurse that she has started experiencing pain with intercourse. She asks, Is there anything I can do about this? The nurses best response is: a. No, it is part of the aging process. b.

Water-soluble vaginal lubricants may provide relief.

You need to be evaluated for a sexually transmitted disease.

d. You may have vaginal scar tissue that is producing the discomfort. ANS: B Loss of lubrication, with resulting discomfort in intercourse, is a symptom of estrogen deficiency. It is part of the aging process, but the use of lubrication will help relieve the symptoms. This is a normal occurrence with the aging process and does not indicate an STD. It is caused by loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier. PTS: 1 DIF: Cognitive Level: Application REF: 741

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Which client is most likely to have osteoporosis? a. A 50-year-old client on estrogen therapy b.

A 55-year-old client with a sedentary lifestyle

A 65-year-old client who walks 2 miles each day

constipation.

urinary frequency and burning.

kt an k. c

d. A 60-year-old client who takes supplemental calcium ANS: B Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary lifestyle, family history of the disease, and a high-fat diet. Hormone therapy may prevent bone loss. Weight-bearing exercises have been shown to increase bone density. Supplemental calcium will help prevent bone loss, especially when combined with vitamin D. PTS: 1 DIF: Cognitive Level: Understanding REF: 743 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. A client with a history of a cystocele should contact the physician if she experiences: a. backache.

Drink 8 to 10 glasses of water each day.

Void every hour while awake.

w .te

ba n

d. involuntary loss of urine when she coughs. ANS: C Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele. Back pain is a symptom of uterine prolapse. Constipation may be a problem with rectoceles. Involuntary loss of urine during coughing is stress incontinence and is not an emergency. PTS: 1 DIF: Cognitive Level: Application REF: 745 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 12. Which should the nurse teach to assist a client to regain control of her urinary sphincter? a. Do Kegel exercises.

d. Allow the bladder to become distended before voiding. ANS: A Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter. A prescribed schedule may help, but every hour is too frequent. Restricting fluids will cause bladder irritation, which exacerbates the problem. Drinking adequate fluids will not help the problem. Overdistention of the bladder will cause incontinence. PTS: 1 DIF: Cognitive Level: Application REF: 746 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 13. The physician diagnoses a 3-cm cyst in the ovary of a 28-year-old client. You expect the initial treatment to include:

beginning hormone therapy.

scheduling a laparoscopy to remove the cyst.

examining the client after her next menstrual period.

tetracycline (Achromycin).

ceftriaxone (Rocephin).

kt an k. c

d. aspirating the cyst and sending the fluid to pathology. ANS: C Most ovarian cysts regress spontaneously. Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point. It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle. A transvaginal ultrasound examination will help determine if the cyst is fluid-filled or solid. The cyst can then be removed if warranted. PTS: 1 DIF: Cognitive Level: Understanding REF: 748 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 14. The drug of choice to treat gonorrhea is: a. penicillin G (Pfizerpen).

w .te

ba n

d. acyclovir (Zovirax). ANS: C Ceftriaxone is effective for treatment of all gonococcal infections. Penicillin G is used to treat syphilis. Tetracycline is used to treat chlamydial infections. Acyclovir is used to treat herpes genitalis. PTS: 1 DIF: Cognitive Level: Understanding REF: 750 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 15. Which option could be used for the treatment and management of a client who reports mild pain associated with a clinical diagnosis of fibrocystic breast disease? a. Chamomile tea as a relaxant therapy b.

Danazol (Danocrine)

Tamoxifen (Nolvadex)

d. Over-the-counter nonsteroidal antiinflammatory drug (NSAID) therapy ANS: D Because the client is reporting mild pain, NSAIDs may provide adequate pain relief and comfort. It is recommended that tea, coffee, and/or other stimulants be limited or restricted for clients with fibrocystic breast disease. Danazol is typically used for moderate to severe pain for clients with fibrocystic breast disease because its use is associated with more serious side effects. The client reports mild pain so this would not be warranted. Tamoxifen is a selective estrogen receptor modulator (SERM) used for the treatment of breast cancers and also for moderate to severe pain in fibrocystic breast disease. The client reports mild pain, so this would not be warranted. PTS: 1 DIF: Cognitive Level: Application REF: 729 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies 16. Which treatment option minimizes the development of lymphedema in the surgical management of a client with breast cancer?

Radical mastectomy procedure

Radiation therapy

Sentinel lymph node mapping

kt an k. c

d. Ultrasound ANS: C The use of sentinel lymph node mapping identifies only those affected lymph node tissues that require surgical removal so it helps minimize the development of lymphedema in the surgical management of a client with breast cancer. Radical mastectomy is associated with lymphedema in the postsurgical breast cancer client because of the removal of lymph node tissue. Radiation therapy is not associated with a decrease in lymphedema for the breast cancer client. Ultrasound as an intervention does not affect the development of lymphedema. PTS: 1 DIF: Cognitive Level: Analysis REF: 731 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 17. You are taking care of a client who has had a colporrhaphy. Which option would indicate a priority assessment during the postoperative period? a. Documentation of a pessary in the operative procedure notes by the physician b.

Removal of vaginal packing as ordered by the physician

Use of a cell saver for transfusion therapy in the postoperative period

w .te

ba n

d. Order for removal of staples 2 to 3 days post-procedure ANS: B Vaginal packing is typically used in this type of pelvic surgery so it is a priority assessment that its removal be verified and documented. A pessary would be used as a nonsurgical intervention for a client who has had uterine prolapse and was not a surgical candidate based on medical history. A cell saver is used in orthopedic surgeries that are at risk for blood loss so that the clients own blood can be re-infused based on established protocol. There are no staples used in this type of surgical procedure, which is also known as an A & P (anterior and posterior) repair. PTS: 1 DIF: Cognitive Level: Analysis REF: 746 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities 18. In reviewing genetic testing for a female client, you note the presence of BRCA1, BRCA2, and CHEK2. How should these findings be interpreted? a. There is no increased likelihood that the client will develop breast or ovarian cancer. b.

There is an increased likelihood only for the development of breast cancer in a woman.

More information is needed to interpret these findings based on the clients family history and the clients current and past medical history.

A radical bilateral mastectomy is required immediately because the cancer may have already d. undergone sub-metastasis. ANS: C The presence of genetic markers (BRCA1, BRCA2, and CHEK2) provides strong indicators of the increased risk for the development of breast cancer in males and females and ovarian cancer. It is important to obtain additional information so that a treatment plan can be developed and

kt an k. c

implemented to improve client outcomes. There is an increased likelihood that the client will develop breast or ovarian cancer, but stating that there is an increased likelihood only for the development of breast cancer in a woman fails to include that men are also at risk of developing breast cancer. At this point, surgical intervention is speculative because the presence of biomarkers does not indicate that sub-metastasis has occurred or that the cancer has even developed. PTS: 1 DIF: Cognitive Level: Analysis REF: 748 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential MULTIPLE RESPONSE 19. A 38-year-old client presents to the clinic office complaining of increased bilateral tenderness of her breasts prior to the onset of menses. On questioning the client, this presentation has occurred off and on for several years, but the pain has increased. Physical examination reveals lumpy areas bilaterally on the upper outer quadrants of each breast tissue. The areas of concern are approximately 2 cm in size. Based on this assessment, what diagnostic testing would be required? (Select all that apply.) a. Ultrasound examination b.

Open biopsy

Fine-needle aspiration (FNA) biopsy

CBC with differential

w .te

ba n

e. Mammogram ANS: A, C, E Based on the clinical presentation, the client may have fibrocystic breast disease. Although this condition is typically benign, the fact that the client has noted a change in tenderness should be evaluated. Ultrasound, FNA, and mammography may be indicated to provide a baseline for comparison and rule out any malignancy. An open or surgical biopsy is not indicated at the present time but may be needed if the other test results indicate any pathology. Blood work is not indicated at this time relative to the diagnosis. Chapter 29 Family Planning

MULTIPLE CHOICE 1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test? a. Gloves and eye protectors b.

Speculum

Fixative agent

d. ANS: D

Lubricant Feedback

The examiner should always use Standard Precautions.

A speculum is needed to see the cervix.

A fixative agent is applied to the slide to prevent drying or disruption of the specimen.

D Lubricants interfere with the accuracy of the cytology report. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 775 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 2. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called a. Bimanual palpation Rectovaginal palpation

A Papanicolaou test

d. ANS: C

DNA testing

kt an k. c

Feedback A

Bimanual palpation is a physical examination of the vagina; the Pap test is a microscopic examinati

Rectovaginal palpation is a physical examination performed through the rectum; the Pap test is a mi examination for cancer.

The Pap test is a microscopic examination for cancer that should be performed regularly, depending

ba n

DNA testing for the various types of HPV that cause cervical cancer is now available. Samples are c D way as a Pap test. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 775 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 3. The nurse providing care in a womens health care setting must be aware that which sexually transmitted disease (STD) can be cured? a. Herpes Acquired immunodeficiency syndrome (AIDS)

Venereal warts

d. ANS: D

w .te

Chlamydia

Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infe

Feedback

Because no cure is known for AIDS, prevention and early detection are the main focus.

Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus.

The usual treatment for chlamydia bacterial infection is doxycycline or azithromycin. Concurrent tr D partners is needed to prevent recurrence. PTS: 1 DIF: Cognitive Level: Knowledge REF: pp. 797-799 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 4. Which statement by a woman diagnosed with premenstrual syndrome indicates that further health teaching is needed? a. I will not eat chips or pickles.

Coffee and chocolate can make me more irritable and nervous.

Drinking alcohol makes me more depressed.

d. ANS: D

Ill eat only three meals per day. Feedback

Less intake of salty foods helps decrease fluid retention.

Caffeine consumption increases irritability, insomnia, anxiety, and nervousness.

Alcohol consumption aggravates depression.

kt an k. c

D The woman should be encouraged to eat six small meals a day to decrease risk of hypoglycemia. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 787 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 5. Which statement by the patient indicates that she understands breast self-examination? a. I will examine both breasts in two different positions. b.

I will perform breast self-examination 1 week after my menstrual period starts.

I will examine the outer upper area of the breast only.

d. ANS: B

I will use the palm of the hand to perform the examination.

ba n

Feedback

The woman should examine her breasts when hormonal influences are at a low level.

The entire breast needs to be examined, including the outer upper area.

She should use four positions: standing with arms at her sides, standing with arms raised above her hands pressed against hips, and lying down.

w .te

D She should use the sensitive pads of the middle three fingers. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 772 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 6. A benign breast condition that includes dilation and inflammation of the collecting ducts is called a. Ductal ectasia b.

Intraductal papilloma

Chronic cystic disease

d. ANS: A

Fibroadenoma Feedback

Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular ma enlarged axillary nodes, and nipple discharge.

Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it ca erosion within the ducts.

Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and we

D Fibroadenoma is fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nod PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 777 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 7. Which patient is most at risk for fibroadenoma of the breast? a. A 38-year-old woman A 50-year-old woman

A 16-year-old woman

d. ANS: C

A 27-year-old woman

Feedback

Ductal ectasia becomes more common as a woman approaches menopause.

Intraductal papilloma develops most often just before or during menopause.

Although it may occur at any age, fibroadenoma is most common in the teenage years.

kt an k. c

ba n

D Fibrocystic breast changes are more common during the reproductive years. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 777 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 8. Adjuvant treatment with tamoxifen may be recommended for patients with breast cancer if the tumor is a. Smaller than 5 cm Located in the upper outer quadrant only

Contained only in the breast Estrogen receptive

w .te

d. ANS: D

Feedback

Tamoxifen is used depending on age, stage, and hormone receptor status, not size.

Location of the cancer does not determine the usefulness of tamoxifen. Stage of the cancer is a consideration, but more important is its sensitivity to estrogen.

D Tamoxifen is antiestrogen therapy for tumors stimulated by estrogen. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 779 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 9. Which statement is true about primary dysmenorrhea? a. It occurs in young multiparous women. b.

It is experienced by all women.

It may be due to excessive endometrial prostaglandin.

d. ANS: C

It is unaffected by oral contraceptives.

Feedback A

It occurs in young nulliparous women.

It is not experienced by all women.

Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual Prostaglandin diffuses into endometrial tissue and causes uterine cramping.

D Oral contraceptives can be a treatment choice. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 785 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 10. In helping a patient manage PMS, the nurse should a. Recommend a diet with more body-building and energy food, such as red meat and sugar. Suggest herbal therapies, and massage.

Tell the patient to push for medications from the physician as soon as symptoms occur so as to lesse

d. ANS: B

Discourage the use of diuretics. Feedback

kt an k. c

Limiting red meat, refined sugar, caffeinated beverages, and alcohol improves the diet and may miti

Herbal therapies, conscious relaxation and massage have all been reported to have a beneficial effec

Medication usually is begun only if lifestyle changes fail to provide significant relief.

ba n

w .te

D Natural diuretics may help reduce fluid retention. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 787 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 11. With regard to endometriosis, nurses should be aware that a. It is characterized by the presence and growth of endometrial tissue inside the uterus. b.

It affects 25% of all women.

It may worsen with repeated cycles or remain asymptomatic and disappear after menopause. It is unlikely to affect sexual intercourse or fertility.

d. ANS: C

Feedback

With endometriosis, the endometrial tissue is outside the uterus. Symptoms vary among women, ran nonexistent to incapacitating.

Endometriosis affects 10% of all women and is found equally in Caucasian and African-American w

Symptoms vary among women, ranging from nonexistent to incapacitating.

D Women can experience painful intercourse and impaired fertility. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 785 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. A 49-year-old patient confides to the nurse that she has started experiencing pain with intercourse and asks, Is there anything I can do about this? The nurses best response is

You need to be evaluated for a sexually transmitted disease.

Water-soluble vaginal lubricants may provide relief.

No, it is part of the aging process.

d. ANS: B

You may have vaginal scar tissue that is producing the discomfort. Feedback This is a normal occurrence with the aging process and does not indicate STDs.

Loss of lubrication with resulting discomfort in intercourse is a symptom of estrogen deficiency.

It is part of the aging process, but the use of lubrication will help relieve the symptoms.

Pain with intercourse

Breasts become smaller

d. ANS: A

Skin becomes thinner Feedback

ba n

kt an k. c

D It is due to loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurr PTS: 1 DIF: Cognitive Level: Application REF: dm. 790 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 13. A 70-year-old woman should be taught to report what condition to her health care provider? a. Vaginal bleeding

Vaginal bleeding after menopause should always be investigated. It is highly suggestive of endomet

Pain with intercourse is an expected change that occurs due to the aging process.

Breast shrinkage is an expected change that occurs due to the aging process.

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A 60-year-old woman who takes supplemental calcium

D Skin thinning is an expected change that occurs due to the aging process. PTS: 1 DIF: Cognitive Level: Application REF: dm. 789 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 14. Which woman is most likely to have osteoporosis? a. A 50-year-old woman receiving estrogen therapy c.

A 55-year-old woman with a sedentary lifestyle

d. ANS: C

A 65-year-old woman who walks 2 miles each day Feedback

Hormone therapy may prevent bone loss.

Supplemental calcium will help prevent bone loss, especially when combined with vitamin D.

Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary l history of the disease, and a high-fat diet.

D Weight-bearing exercises have been shown to increase bone density. PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 791-792 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 15. A woman with a history of a cystocele should contact the physician if she experiences a. Involuntary loss of urine when she coughs b.

Constipation

Backache Urinary frequency and burning Feedback

d. ANS: D

Involuntary loss of urine during coughing is stress incontinence and is not an emergency.

Constipation may be a problem with rectoceles.

Back pain is a symptom of uterine prolapse.

kt an k. c

ba n

D Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystoc PTS: 1 DIF: Cognitive Level: Application REF: dm. 792 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 16. To assist the woman in regaining control of the urinary sphincter, the nurse should teach her to a. Practice Kegel exercises. b.

Void every hour while awake.

Allow the bladder to become distended before voiding.

Drink 8 to 10 glasses of water each day.

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d. ANS: A

Feedback

Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urin

A prescribed schedule may help, but every hour is too frequent.

Overdistention of the bladder will cause incontinence.

Restricting fluids will cause bladder irritation that increases the problem. Drinking adequate fluids w D problem. PTS: 1 DIF: Cognitive Level: Application REF: dm. 794 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 17. The physician diagnoses a 3 cm ovarian cyst in a 28-year-old woman. The nurse expects the initial treatment to include a. Beginning hormone therapy b.

Examining the woman after her next menstrual period

Scheduling a laparoscopy as soon as possible, to remove the cyst

Aspirating the cyst as soon as possible and sending the fluid to pathology

ANS: B Feedback A

Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at

Most ovarian cysts regress spontaneously.

It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within on

Tetracycline

Ceftriaxone

d. ANS: C

Acyclovir

kt an k. c

A transvaginal ultrasound examination will help determine if the cyst is fluid filled or solid. The cys D removed if warranted. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 18. The drug of choice to treat gonorrhea is a. Penicillin G

Feedback

Penicillin is used to treat syphilis.

Tetracycline is used to treat chlamydial infections.

Ceftriaxone is effective for treatment of all gonococcal infections.

ba n

w .te

D Acyclovir is used to treat herpes genitalis. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 798 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 19. When a nurse is counseling a woman for primary dysmenorrhea, which non-pharmacologic intervention might be recommended? a. Increasing the intake of red meat and simple carbohydrates Reducing the intake of diuretic foods, such as peaches and asparagus

Temporarily substituting physical activity for a sedentary lifestyle Using a heating pad on the abdomen to relieve cramping

d. ANS: D

Feedback

Dietary changes such as eating less red meat may be recommended for women experiencing dysmen

Increasing the intake of diuretics, including natural diuretics such as asparagus, cranberry juice, pea watermelon may help ease the symptoms associated with dysmenorrhea.

Exercise has been found to help relieve menstrual discomfort through increased vasodilation and su ischemia.

D Heat minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 785

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 20. Nafarelin (Synarel) is currently used as a treatment for mild to severe endometriosis. The nurse should tell the woman taking this medication that the drug a. Stimulates the secretion of gonadotropin-releasing hormone (GnRH), thereby stimulating ovarian ac b.

Should be sprayed into one nostril every other day

Should be injected into subcutaneous tissue BID

d. ANS: D

Can cause her to experience some hot flashes and vaginal dryness

Feedback Nafarelin is a GnRH agonist that suppresses the secretion of gonadotrophin-releasing hormone.

Nafarelin is administered twice daily by nasal spray.

Nafarelin is administered intranasally.

kt an k. c

Nafarelin is a GnRH agonist, and its side effects are similar to those of menopause. The hypoestroge D in hot flashes and vaginal dryness. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 786 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 21. The nurse who is teaching a group of women about breast cancer should tell the women that a. Risk factors identify almost all women who will develop breast cancer. African-American women have a higher rate of breast cancer.

One in 10 women in the United States will develop breast cancer in her lifetime. The exact cause of breast cancer is unknown.

w .te

Feedback

d. ANS: D

ba n

Risk factors help identify a small percentage of women in whom breast cancer eventually will devel

Caucasian women have a higher incidence of breast cancer; however, African-American women ha dying of breast cancer after they are diagnosed.

One in eight women in the United States will develop breast cancer in her lifetime.

D The exact cause of breast cancer in unknown. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 778 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 22. The nurse providing education regarding breast care should explain to the woman that fibrocystic changes in breasts are a. A disease of the milk ducts and glands in the breasts b.

A pre-malignant disorder characterized by lumps found in the breast tissue

Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women cycles

d. ANS: C

Lumpiness accompanied by tenderness after menses

Feedback A

Fibrocystic changes are palpable thickenings in the breast.

Fibrocystic changes are no pre-malignant changes. This information is inaccurate.

Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderne tenderness fluctuate with the menstrual cycle.

Ultrasound

Core needle biopsy

d. ANS: C

kt an k. c

Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderne D tenderness occurs prior to menses. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 777 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 23. Which diagnostic test is used to confirm a suspected diagnosis of breast cancer? a. Mammogram

CA 15-3 Feedback

Mammography is a clinical screening tool that may aid early detection of breast cancers.

Transillumination, thermography, and ultrasound breast imaging are being explored as methods of d breast carcinoma.

When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a co needle localization biopsy.

ba n

Abnormal uterine bleeding is a common finding.

Fibroids will increase in size during the perimenopausal period.

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D CA-15 is a serum tumor marker that is used to test for the presence of breast cancer. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 777 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 24. A 36-year-old woman has been diagnosed as having uterine fibroids. When planning care for this patient, the nurse should know that a. Fibroids are malignant tumors of the uterus that require radiation or chemotherapy.

d. ANS: C

Hysterectomy should be performed. Feedback

Fibroids are benign tumors of the smooth muscle of the uterus, and their etiology is unknown.

Fibroids are estrogen-sensitive and shrink as levels of estrogen decline.

The major symptoms associated with fibroids are menorrhagia and the physical effects produced by

D A hysterectomy may be performed if the woman does not want more children and other therapies ar PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 25. When assessing a woman for menopausal discomforts, the nurse expects the woman to describe the most frequently reported discomfort, which is a. Headaches b.

Hot flashes

Mood swings

d. ANS: B

Vaginal dryness with dyspareunia

Feedback

Vasomotor instability, in the form of hat flashes or flushing, is a result of fluctuating estrogen levels common disturbance of the perimenopausal woman.

Mood swings may be associated with a decline in hormone levels; however, it is not the most freque discomfort for menopausal women.

kt an k. c

Headaches may be associated with a decline in hormone levels; however, it is not the most frequent discomfort for menopausal women.

Low protein intake

Obesity

Cigarette smoking

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d. ANS: D

ba n

Vaginal dryness and dyspareunia may be associated with a decline in hormone levels; however, it is D frequently reported discomfort for menopausal women. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 790 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 26. While evaluating a patient for osteoporosis, the nurse should be aware of what risk factor? a. African-American race

Feedback

Women at risk for osteoporosis are likely to be Caucasian or Asian.

Inadequate calcium intake is a risk factor for osteoporosis.

Women at risk for osteoporosis are likely to be small boned and thin. Obese women have higher est result of the conversion of androgens in the adipose tissue. Mechanical stress from extra weight also bone mass.

D Smoking is associated with earlier and greater bone loss and decreased estrogen production. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 791 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 27. When discussing estrogen replacement therapy (ERT) with a perimenopausal woman, the nurse should include the risks of a. Breast cancer b.

Vaginal and urinary tract atrophy

Osteoporosis

d. ANS: A

Arteriosclerosis Feedback

Women with a high risk of breast cancer should be counseled against using ERT.

Estrogen prevents atrophy of vaginal and urinary tract tissue.

Estrogen protects against the development of osteoporosis.

Dysmenorrhea

Dyspareunia PMS Feedback

ba n

d. ANS: B

kt an k. c

Estrogen has a favorable effect on circulating lipids, reducing low density lipoprotein (LDL) and tot D increasing high density lipoprotein (HDL). It also has a direct antiatherosclerotic effect on the arteri PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 790 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 28. During her annual gynecologic checkup, a 17-year-old woman states that recently she has been experiencing cramping and pain during her menstrual periods. The nurse should document this complaint as a. Amenorrhea

Amenorrhea is the absence of menstrual flow.

Dysmenorrhea is pain during or shortly before menstruation. Pain is described as sharp and crampin dull ache. It may radiate to the lower back or upper thighs.

Dyspareunia is pain during intercourse.

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PMS is a cluster of physical, psychologic, and behavioral symptoms that begin in the luteal phase of D cycle and resolve within a couple of days of the onset of menses. PTS: 1 DIF: Cognitive Level: Application REF: dm. 785 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 29. Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a patient with this condition should be aware that the optimal pharmacologic therapy for pain relief is a. Acetaminophen b.

Oral contraceptives (OCPs)

Nonsteroidal antiinflammatory drugs (NSAIDs)

d. ANS: C

Aspirin Feedback

Preparations containing acetaminophen are less effective for dysmenorrhea because they lack the an properties of NSAIDs.

OCPs are a reasonable choice for women who also want birth control. The benefit of OCPs is the re menstrual flow and irregularities. OCPs may be contradicted for some women and have a number o effects.

This pharmacologic agent has the strongest research results for pain relief. Often, if one NSAID is n one will provide relief.

kt an k. c

D NSAIDs are the drug of choice. However, if a woman is taking an NSAID, she should avoid taking PTS: 1 DIF: Cognitive Level: Application REF: dm. 785 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 30. A woman is 6 weeks pregnant and has elected to terminate her pregnancy. The nurse knows that the most common technique used for medical termination of a pregnancy in the first trimester is a. Administration of prostaglandins b.

Dilation and evacuation

Intravenous administration of Pitocin

d. ANS: A

Vacuum aspiration

ba n

Feedback

This is the most common method of surgical abortion used if medical abortion fails.

Intravenous administration of Pitocin is used to induce labor in a woman with a third trimester fetal

The most common technique for medical termination of a pregnancy within the first 7 weeks of preg administration of prostaglandins.

Uterine prolapse Rectocele

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D Vacuum aspiration is used for abortions in the first trimester. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 788 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 31. The nurse should be aware that a pessary is most effective in the treatment of what disorder? a. Cystocele

d. ANS: B

Stress urinary incontinence Feedback

A pessary is not used for the patient with a cystocele.

A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct posit

A rectocele cannot be corrected by the use of a pessary.

D It is unlikely that a pessary be the most effective treatment for stress incontinence. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 794

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 32. A postmenopausal woman who is 54 years old has been diagnosed with two leiomyomas. What assessment finding is most commonly associated with the presence of leiomyomas? a. Abnormal uterine bleeding b.

Diarrhea

Weight loss

d. ANS: A

Acute abdominal pain

Feedback

Most women are asymptomatic. Abnormal uterine bleeding is the most common symptom of leiomy

Diarrhea is not commonly associated with leiomyomas (fibroids).

Weight loss does not usually occur in the woman with leiomyomas (fibroids).

kt an k. c

ba n

D The patient with leiomyomas (fibroids) is unlikely to experience abdominal pain. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 1. While interviewing a 48-year-old patient during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this patient to begin annual screening, it is important for her to understand the reasons why women avoid testing. These reasons include (select all that apply) a. Reluctance to hear bad news Fear of x-ray exposure

Belief that lack of family history makes this test unnecessary

Expense of the procedure

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e. Having heard that the test is painful ANS: A, B, D, E Feedback

Correct

All of these are reasons for women to avoid having a mammogram done. Although the is usually covered by health insurance, and many communities offer low-cost or free sc without insurance. It is important to acknowledge that some discomfort occurs with scre the test immediately at the end of a period makes it less painful. The risk of radiation ex to none. Nurses play a vital role in providing information and reassurance to help wome fears.

Even patients with no family history should have regular screening done. The nurse sho a combination of breast self-examination and mammography needs to be performed at r Women with a family history may need to begin screening at a younger age and have ad Incorrect such as ultrasound performed. PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 775 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

2. Which medications can be taken by postmenopausal women to treat and/or prevent osteoporosis? Select all that apply. a. Calcium b.

Evista

Fosamax

Actonel

e. Vitamin C ANS: A, B, C, D

Feedback

All of these medications can be used by postmenopausal women to treat or prevent oste is another medication available for treatment of osteoporosis.

Correct

Late menarche

Early menopause

Race

ba n

kt an k. c

Vitamin D is essential for calcium to be absorbed from the intestine. Recommended sup Incorrect D Intake is 600 international units per day. PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 791-792 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 3. The exact cause of breast cancer remains undetermined. Researchers have found that there are a number of common risk factors that increase a womans chance of developing a malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? Select all that apply. a. Family history

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e. Nulliparity or first pregnancy after age 30 ANS: A, D, E Feedback

Correct

Family history, race, and nulliparity are known risk factors for the development of brea include age, personal history of cancer, high socioeconomic status, sedentary lifestyle, h replacement therapy, recent use of oral contraceptives, never having breastfed a child, a than one alcoholic beverage per day.

kt an k. c

Bleeding and cramping are normal after the procedure and will last for 1 to 2 weeks. Sanitary pads should be used rather than a tampon for the first week after an abortion to prevent infection. Other necessary health teaching that should be done includes the following: no intercourse for the first week; no douching for the first week, or perhaps not at all; temperature evaluation twice per day to identify infection; follow-up appointment in 2 weeks; and no strenuous work for a few days. PTS: 1 DIF: Cognitive Level: Application REF: dm. 788 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 2. Women in the U.S. are now more likely to die of cardiac disease than all cancers combined. Is this statement true or false? ANS: T Heart disease is now the leading cause of death for women in the United States, killing 26% of women who died in 2006. Almost twice as many American women die of heart disease or stroke than any form of cancer including breast cancer.

MULTIPLE CHOICE 1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test? a. Gloves and eye protectors Speculum

Fixative agent

d. ANS: D

Lubricant Feedback

ba n

The examiner should always use Standard Precautions.

A speculum is needed to see the cervix.

A fixative agent is applied to the slide to prevent drying or disruption of the specimen.

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Rectovaginal palpation

A Papanicolaou test

d. ANS: C

DNA testing Feedback

Bimanual palpation is a physical examination of the vagina; the Pap test is a microscopic examinati

Rectovaginal palpation is a physical examination performed through the rectum; the Pap test is a mi examination for cancer.

The Pap test is a microscopic examination for cancer that should be performed regularly, depending

Acquired immunodeficiency syndrome (AIDS)

Venereal warts

d. ANS: D

kt an k. c

Chlamydia Feedback

Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infe

Because no cure is known for AIDS, prevention and early detection are the main focus.

Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus.

ba n

w .te

Coffee and chocolate can make me more irritable and nervous.

Drinking alcohol makes me more depressed.

Ill eat only three meals per day.

d. ANS: D

Feedback

Less intake of salty foods helps decrease fluid retention.

Caffeine consumption increases irritability, insomnia, anxiety, and nervousness.

Alcohol consumption aggravates depression.

I will perform breast self-examination 1 week after my menstrual period starts.

I will examine the outer upper area of the breast only.

d. ANS: B

I will use the palm of the hand to perform the examination. Feedback She should use four positions: standing with arms at her sides, standing with arms raised above her hands pressed against hips, and lying down.

The woman should examine her breasts when hormonal influences are at a low level.

The entire breast needs to be examined, including the outer upper area.

Intraductal papilloma

Chronic cystic disease Fibroadenoma Feedback

ba n

d. ANS: A

kt an k. c

Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it ca erosion within the ducts.

Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and we

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Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular ma enlarged axillary nodes, and nipple discharge.

A 50-year-old woman

A 16-year-old woman

d. ANS: C

A 27-year-old woman Feedback

Ductal ectasia becomes more common as a woman approaches menopause.

Intraductal papilloma develops most often just before or during menopause.

Although it may occur at any age, fibroadenoma is most common in the teenage years.

Contained only in the breast

d. ANS: D

Estrogen receptive

kt an k. c

Feedback A

Tamoxifen is used depending on age, stage, and hormone receptor status, not size.

Location of the cancer does not determine the usefulness of tamoxifen.

Stage of the cancer is a consideration, but more important is its sensitivity to estrogen.

ba n

It may be due to excessive endometrial prostaglandin. It is unaffected by oral contraceptives.

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d. ANS: C

Feedback

It occurs in young nulliparous women.

It is not experienced by all women.

Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual Prostaglandin diffuses into endometrial tissue and causes uterine cramping.

Suggest herbal therapies, and massage.

Tell the patient to push for medications from the physician as soon as symptoms occur so as to lesse

Discourage the use of diuretics.

ANS: B Feedback A

Limiting red meat, refined sugar, caffeinated beverages, and alcohol improves the diet and may miti

Herbal therapies, conscious relaxation and massage have all been reported to have a beneficial effec

Medication usually is begun only if lifestyle changes fail to provide significant relief.

It may worsen with repeated cycles or remain asymptomatic and disappear after menopause.

d. ANS: C

kt an k. c

It is unlikely to affect sexual intercourse or fertility. Feedback

With endometriosis, the endometrial tissue is outside the uterus. Symptoms vary among women, ran nonexistent to incapacitating.

Endometriosis affects 10% of all women and is found equally in Caucasian and African-American w

Symptoms vary among women, ranging from nonexistent to incapacitating.

ba n

w .te

No, it is part of the aging process. You may have vaginal scar tissue that is producing the discomfort.

d. ANS: B

Feedback

This is a normal occurrence with the aging process and does not indicate STDs.

Loss of lubrication with resulting discomfort in intercourse is a symptom of estrogen deficiency.

It is part of the aging process, but the use of lubrication will help relieve the symptoms.

Vaginal bleeding

Pain with intercourse

Breasts become smaller

d. ANS: A

Skin becomes thinner Feedback

Vaginal bleeding after menopause should always be investigated. It is highly suggestive of endomet

Pain with intercourse is an expected change that occurs due to the aging process.

Breast shrinkage is an expected change that occurs due to the aging process.

kt an k. c

A 55-year-old woman with a sedentary lifestyle

d. ANS: C

A 65-year-old woman who walks 2 miles each day Feedback

ba n

Hormone therapy may prevent bone loss.

Supplemental calcium will help prevent bone loss, especially when combined with vitamin D.

Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary l history of the disease, and a high-fat diet.

w .te

Constipation

Backache

d. ANS: D

Urinary frequency and burning Feedback

Involuntary loss of urine during coughing is stress incontinence and is not an emergency.

Constipation may be a problem with rectoceles.

Back pain is a symptom of uterine prolapse.

Void every hour while awake.

Allow the bladder to become distended before voiding. Drink 8 to 10 glasses of water each day.

d. ANS: A

Feedback

Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urin

A prescribed schedule may help, but every hour is too frequent.

Overdistention of the bladder will cause incontinence.

kt an k. c

ba n

Scheduling a laparoscopy as soon as possible, to remove the cyst Aspirating the cyst as soon as possible and sending the fluid to pathology

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d. ANS: B

Feedback B

Most ovarian cysts regress spontaneously.

It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within on

Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at

Tetracycline

Ceftriaxone

d. ANS: C

Acyclovir Feedback

Penicillin is used to treat syphilis.

Tetracycline is used to treat chlamydial infections.

Ceftriaxone is effective for treatment of all gonococcal infections.

kt an k. c

Reducing the intake of diuretic foods, such as peaches and asparagus

Temporarily substituting physical activity for a sedentary lifestyle

d. ANS: D

Using a heating pad on the abdomen to relieve cramping Feedback

Dietary changes such as eating less red meat may be recommended for women experiencing dysmen

Increasing the intake of diuretics, including natural diuretics such as asparagus, cranberry juice, pea watermelon may help ease the symptoms associated with dysmenorrhea.

Exercise has been found to help relieve menstrual discomfort through increased vasodilation and su ischemia.

ba n

Should be sprayed into one nostril every other day

w .te

D Heat minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine PTS: 1 DIF: Cognitive Level: Analysis REF: dm. 785 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 20. Nafarelin (Synarel) is currently used as a treatment for mild to severe endometriosis. The nurse should tell the woman taking this medication that the drug a. Stimulates the secretion of gonadotropin-releasing hormone (GnRH), thereby stimulating ovarian ac c.

d. ANS: D

Should be injected into subcutaneous tissue BID Can cause her to experience some hot flashes and vaginal dryness Feedback

Nafarelin is a GnRH agonist that suppresses the secretion of gonadotrophin-releasing hormone.

Nafarelin is administered twice daily by nasal spray.

Nafarelin is administered intranasally.

African-American women have a higher rate of breast cancer.

One in 10 women in the United States will develop breast cancer in her lifetime. The exact cause of breast cancer is unknown.

d. ANS: D

Feedback

Risk factors help identify a small percentage of women in whom breast cancer eventually will devel

Caucasian women have a higher incidence of breast cancer; however, African-American women ha dying of breast cancer after they are diagnosed.

One in eight women in the United States will develop breast cancer in her lifetime.

kt an k. c

ba n

Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women cycles

w .te

d. ANS: C

Lumpiness accompanied by tenderness after menses Feedback

Fibrocystic changes are no pre-malignant changes. This information is inaccurate.

Fibrocystic changes are palpable thickenings in the breast.

Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderne tenderness fluctuate with the menstrual cycle.

Ultrasound

c. d. ANS: C

Core needle biopsy CA 15-3 Feedback Mammography is a clinical screening tool that may aid early detection of breast cancers.

Transillumination, thermography, and ultrasound breast imaging are being explored as methods of d breast carcinoma.

When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a co needle localization biopsy.

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Fibroids will increase in size during the perimenopausal period.

Abnormal uterine bleeding is a common finding. Hysterectomy should be performed. Feedback

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d. ANS: C

Fibroids are benign tumors of the smooth muscle of the uterus, and their etiology is unknown.

Fibroids are estrogen-sensitive and shrink as levels of estrogen decline.

The major symptoms associated with fibroids are menorrhagia and the physical effects produced by

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D A hysterectomy may be performed if the woman does not want more children and other therapies ar PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 795 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 25. When assessing a woman for menopausal discomforts, the nurse expects the woman to describe the most frequently reported discomfort, which is a. Headaches b.

Hot flashes

Mood swings

d. ANS: B

Vaginal dryness with dyspareunia Feedback

Headaches may be associated with a decline in hormone levels; however, it is not the most frequent discomfort for menopausal women.

Vasomotor instability, in the form of hat flashes or flushing, is a result of fluctuating estrogen levels common disturbance of the perimenopausal woman.

Mood swings may be associated with a decline in hormone levels; however, it is not the most freque discomfort for menopausal women.

Low protein intake

Obesity

d. ANS: D

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Cigarette smoking Feedback

Women at risk for osteoporosis are likely to be Caucasian or Asian.

Inadequate calcium intake is a risk factor for osteoporosis.

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Osteoporosis

Arteriosclerosis

d. ANS: A

Feedback

Women with a high risk of breast cancer should be counseled against using ERT.

Estrogen prevents atrophy of vaginal and urinary tract tissue.

Estrogen protects against the development of osteoporosis.

Dysmenorrhea

Dyspareunia

d. ANS: B

PMS

Feedback Amenorrhea is the absence of menstrual flow.

Dysmenorrhea is pain during or shortly before menstruation. Pain is described as sharp and crampin dull ache. It may radiate to the lower back or upper thighs.

Dyspareunia is pain during intercourse.

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Nonsteroidal antiinflammatory drugs (NSAIDs) Aspirin

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d. ANS: C

Feedback

Preparations containing acetaminophen are less effective for dysmenorrhea because they lack the an properties of NSAIDs.

This pharmacologic agent has the strongest research results for pain relief. Often, if one NSAID is n one will provide relief.

Administration of prostaglandins

Dilation and evacuation

Intravenous administration of Pitocin

d. ANS: A

Vacuum aspiration Feedback

The most common technique for medical termination of a pregnancy within the first 7 weeks of preg administration of prostaglandins.

This is the most common method of surgical abortion used if medical abortion fails.

Intravenous administration of Pitocin is used to induce labor in a woman with a third trimester fetal

Uterine prolapse

Rectocele Stress urinary incontinence Feedback

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d. ANS: B

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A pessary is not used for the patient with a cystocele.

A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct posit

A rectocele cannot be corrected by the use of a pessary.

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D It is unlikely that a pessary be the most effective treatment for stress incontinence. PTS: 1 DIF: Cognitive Level: Knowledge REF: dm. 794 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 32. A postmenopausal woman who is 54 years old has been diagnosed with two leiomyomas. What assessment finding is most commonly associated with the presence of leiomyomas? a. Abnormal uterine bleeding b.

Diarrhea

Weight loss

d. ANS: A

Acute abdominal pain Feedback

Most women are asymptomatic. Abnormal uterine bleeding is the most common symptom of leiomy

Diarrhea is not commonly associated with leiomyomas (fibroids).

Weight loss does not usually occur in the woman with leiomyomas (fibroids).

Belief that lack of family history makes this test unnecessary

Expense of the procedure

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e. Having heard that the test is painful ANS: A, B, D, E Feedback

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Correct

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Evista

Fosamax

Actonel

e. Vitamin C ANS: A, B, C, D Feedback Correct

All of these medications can be used by postmenopausal women to treat or prevent oste is another medication available for treatment of osteoporosis.

Late menarche

Early menopause

Race

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e. Nulliparity or first pregnancy after age 30 ANS: A, D, E Feedback

Correct

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Early menarche and late menopause are risk factors for breast malignancy, not late men Incorrect menopause. PTS: 1 DIF: Cognitive Level: Comprehension REF: dm. 774 | Box 32-2 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance TRUE/FALSE 1. The nurse understands that further health teaching is necessary when her young patient who has just had an abortion states, I guess Ill have to wear a tampon for the next week. Is this statement true or false? ANS: T Bleeding and cramping are normal after the procedure and will last for 1 to 2 weeks. Sanitary pads should be used rather than a tampon for the first week after an abortion to prevent infection. Other necessary health teaching that should be done includes the following: no intercourse for the first week; no douching for the first week, or perhaps not at all; temperature evaluation twice per day to identify infection; follow-up appointment in 2 weeks; and no strenuous work for a few days. PTS: 1 DIF: Cognitive Level: Application REF: dm. 788 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 2. Women in the U.S. are now more likely to die of cardiac disease than all cancers combined. Is this statement true or false? ANS: T Heart disease is now the leading cause of death for women in the United States, killing 26% of women who died in 2006. Almost twice as many American women die of heart disease or stroke than any form of cancer including breast cancer.

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3) The culturally sensitive nurse will assess cultural attitudes and beliefs about contraception, which can include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Gender inequities 2. Religion 3. Deference to authority figures 4. Devaluation of large families 5. Attitudes about bleeding Answer: 1, 2, 3, 5 Explanation: 1. Gender inequities may prohibit some Arab, Latina, and Eastern Indian women from seeking out or using a contraceptive method unless their husbands do not object. 2. The Roman Catholic Church considers all artificial methods of contraception unacceptable. 3. Deference to authority figures is not uncommon in traditional Chinese, Arab, Latina, and East Indian women, especially if the nurse is male. 5. Attitudes toward bleeding affect a womans duties to her family and partner. Vaginal bleeding may be seen as unclean by Muslim and Orthodox Jewish women. Any contraceptive method that involves irregular bleeding might not be acceptable. Among women who feel a monthly period is necessary, any method that ultimately causes amenorrhea would not be acceptable.

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4. What the clients partner prefers 5. Whether the client is in a monogamous relationship Answer: 2, 3, 5 Explanation: 2. A factor to consider when choosing a method of contraception is how frequently the client has intercourse. 3. A factor to consider when choosing a method of contraception is whether the client has a history of thrombophlebitis or any other condition that would contraindicate its use. 5. A factor to consider when choosing a method of contraception is whether the client is in a monogamous relationship. 5) A client asks the nurse, Can you explain to us how to use the basal body temperature method to detect ovulation and prevent pregnancy? What response by the nurse is best? 1. Take your temperature every evening at the same time and keep a record for a period of several weeks. A noticeable drop in temperature indicates that ovulation has occurred. 2. Take your temperature every day at the same time and keep a record of the findings. A noticeable rise in temperature indicates ovulation. 3. Take your temperature each day, immediately upon awakening, and keep a record of each finding. A noticeable rise in temperature indicates that ovulation is about to occur. 4. This is an unscientific and unproven method of determining ovulation, and is not recognized as a means of birth control. Answer: 3 Explanation: 3. The basal body temperature method is used to detect ovulation by an increase in the basal temperature during the menstrual cycle. It requires that the woman take her temperature every morning upon awakening (before any activity) and record the findings on a temperature graph, and is based on the fact that the temperature almost always rises and remains elevated after ovulation because of the production of progesterone, a thermogenic (heat-producing) hormone. 6) During a counseling session on natural family planning techniques, the nurse explains that cervical mucus at the time of ovulation should be of what consistency? 1. Egg white appearance and stretchable 2. Opaque and acidic 3. High in leukocytes 4. Lacking in quantity Answer: 1 Explanation: 1. Cervical mucus at the time of ovulation has an egg white appearance and is known as fertile mucus; it is friendly to sperm because it assists passage through the cervix and uterus up into the fallopian tubes. 7) A woman is asking the nurse about using the calendar method of contraception. She reports that her last six menstrual cycles were 28, 32, 29, 36, 30, and 27 days long, respectively. Based on this information, when should the nurse tell the client to abstain from intercourse? 1. Days 9-25 2. Days 9-15 3. Days 10-21 4. Days 10-16 Answer: 1 Explanation: 1. To calculate the period of abstinence, the nurse must subtract 18 from the shortest cycle length and 11 from the longest cycle length.

8) A nurse is teaching a group of college students at a Catholic university about natural family planning (NFP). Teaching was successful if the students say natural family planning is which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. It is free, safe, and acceptable according to our religion. 2. It includes breastfeeding for 1 year. 3. It is useful in helping us plan pregnancies. 4. It allows us to safely have intercourse during our fertile days. 5. It does not involve the use of artificial substances or devices.

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9) The nurse educator is planning a class about contraception, and includes information about the effects of various contraceptive methods on sexually transmitted diseases. Which statement will the nurse include concerning spermicides? 1. Spermicides are effective against gonorrhea and chlamydia, but not against HIV. 2. Spermicides are not effective against sexually transmitted diseases, and can increase a womans susceptibility to HIV. 3. Spermicides are effective against HIV, but are not effective against the other sexually transmitted diseases. 4. Whether or not spermicides are effective against sexually transmitted diseases depends on where the woman is in her cycle. Answer: 2 Explanation: 2. Spermicides are not effective against any sexually transmitted disease. Spermicides have a negative effect on the integrity of vaginal cells, making them more susceptible. 10) The OB-GYN nurse is teaching a client at the clinic that use of a spermicide has an increased effectiveness if used with which other items? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. A non-water-based lubricant 2. A diaphragm 3. A contraceptive sponge 4. Prophylactic antibiotics 5. A condom Answer: 2, 3, 5 Explanation: 2. Barrier contraceptives such as a diaphragm act by blocking the transport of sperm and are often used in conjunction with a spermicide. 3. Barrier contraceptives such as the contraceptive sponge act by blocking the transport of sperm and are often used in conjunction with a spermicide. 5. Barrier contraceptives such as the condom act by blocking the transport of sperm and are often used in conjunction with a spermicide. 11) The nurse in the clinic instructs a client using the natural method of contraception to begin counting the first day of her cycle as which day? 1. The day her menstrual period ceases 2. The first day after her menstrual period ceases 3. The first day of her menstrual period

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4. The day of ovulation Answer: 3 Explanation: 3. The first day of menstruation is the first day of the cycle. 12) A client in the womens clinic asks the nurse, How is the cervical mucus method of contraception different from the rhythm method? The appropriate response by the nurse is that the cervical mucus method is which of the following? 1. More effective for women with irregular cycles 2. Not acceptable to women of many different religions 3. Harder to work with than is the rhythm method 4. Requires an artificial substance or device Answer: 1 Explanation: 1. The cervical mucus method (Billings Ovulation Method) can be used by women with irregular cycles. 13) A client who wants to use the vaginal sponge method of contraception shows that she understands the appropriate usage when she makes which statement? 1. I need to use a lubricant prior to insertion. 2. I need to add spermicidal cream prior to intercourse. 3. I need to moisten it with water prior to use. 4. I need to leave it in no longer than 6 hours. Answer: 3 Explanation: 3. To activate the spermicide in the vaginal sponge, it must be moistened thoroughly with water. 14) A female client who is 36 years old, weighs 200 pounds, is monogamous, and does not smoke desires birth control. The nurse understands that which contraceptive method is inappropriate for this client? 1. Intrauterine device 2. Vaginal sponge 3. Combined oral contraceptives 4. Transdermal hormonal contraception Answer: 4 Explanation: 4. Transdermal hormonal contraception is contraindicated because of the clients obesity.

Chapter 30 Vulnerable Populations

The nurse is presenting a class at a local community health center on violence during pregnancy. Which of the following would the nurse include as a possible complication?

Hypertension of pregnancy

Chorioamnionitis

Placenta previa

Postterm labor

Which approach would be most appropriate when counseling a woman who is a suspected victim of violence?

Offer her a pamphlet about the local battered womens shelter.

Call her at home to ask her some questions about her marriage.

Wait until she comes in a few more times to make a better assessment.

Ask, Have you ever been physically hurt by your partner?

When describing an episode, the victim reports that she attempted to calm her partner down to keep things from escalating. This behavior reflects which phase of the cycle of violence?

Battering

Honeymoon

Tension-building

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Reconciliation

A battered pregnant woman reports to the nurse that her husband has stopped hitting her and promises never to hurt her again. Which of the following is an appropriate response?

Thats great. I wish you both the best.

The cycle of violence often repeats itself.

He probably didnt mean to hurt you.

You need to consider leaving him.

Which of the following nursing actions would be least helpful for a client who is a victim of violence?

Assist the client to project her anger.

Provide information about a safe home and crisis line.

Teach her about the cycle of violence.

Discuss her legal and personal rights.

When describing the cycle of violence to a community group, the nurse explains that the first phase usually is:

Somehow triggered by the victims behavior

Characterized by tension-building and minor battery

Associated with loss of physical and emotional control

Like a honeymoon that lulls the victim

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Which of the following statements would be most appropriate to empower victims of violence to take action?

Give your partner more time to come around.

Rememberchildren do best in two-parent families.

Change your behavior so as not to trigger the violence.

You are a good person and you deserve better than this.

When a nurse suspects that a client may have been abused, the first action should be to:

Ask the client about the injuries and if they are related to abuse.

Encourage the client to leave the batterer immediately.

Set up an appointment with a domestic violence counselor.

Ask the suspected abuser about the victims injuries.

Which of the following would the nurse describe as a characteristic of the second phase of the cycle of violence?

The batterer is contrite and attempts to apologize for the behavior.

The physical battery is abrupt and unpredictable.

Verbal assaults begin to escalate toward the victim.

The victim accepts the anger as legitimately directed at her.

10.

In addition to providing privacy, which of the following would be most appropriate initially in situations involving suspected abuse?

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Allow the client to have a good cry over the situation.

Tell the client, Injuries like these dont usually happen by accident.

Call the police immediately so they can question the victim.

Ask the abuser to describe his side of the story first.

It is not your fault. No one deserves to be hurt.

What else did you do to make him so angry with you?

You need to start to clean the house early in the day.

Remember, he works hard and you need to meet his needs.

12.

When developing a presentation for a local community organization on violence, the nurse is planning to include statistics on intimate partner abuse and its effects on children. In what percentage of the cases in which a parent is abused are the children battered also?

50% to 75%

25% to 50%

10% to 25%

Less than 5%

13.

The primary goal when working with victims of intimate partner violence is to:

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11.

When the nurse is alone with a client, the client says, It was all my fault. The house was so messy when he got home and I know he hates that. Which response would be most appropriate?

Convince them to leave the abuser soon

Help them cope with their life as it is

Empower them to regain control of their life

Arrest the abuser so he or she cant abuse again

Teaching for victims who are recovering from abusive situations must focus on ways to:

Enhance their personal appearance and hairstyle

Develop their creativity and work ethic

Improve their communication skills and assertiveness

Plan more nutritious meals to improve their own health

15.

During a follow-up visit to the clinic, a victim of sexual assault reports that she has changed her job and moved to another town. She tells the nurse, I pretty much stay to myself at work and at home. The nurse interprets these findings to indicate that the client is in which phase of rape recovery?

Disorganization

Denial

Reorganization

Integration

16.

A nurse is assessing a rape survivor for post-traumatic stress disorder. The nurse asks the woman, Do you feel as though you are reliving the trauma? The nurse is assessing for which of the following?

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14.

Physical symptoms

Intrusive thoughts

Avoidance

Hyperarousal

Most victims of rape tell someone about it.

Few women falsely cry rape.

Women have rape fantasies desiring to be raped.

A rape victim feels vulnerable and betrayed afterwards.

Medication and counseling can help a rape victim cope.

18.

After teaching a class on date rape, the instructor determines that the teaching was successful when the class identifies which of the following as the most common date rape drug?

Gamma hydroxybutyrate

Liquid ecstasy

Ketamine

Rohypnol

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17.

A group of students are preparing a class discussion about rape and sexual assault. Which of the following would the students include as being most accurate? (Select all that apply.)

A nurse is caring for a woman who was recently raped. The nurse would expect this woman to experience which of the following first?

Denial

Disorganization

Reorganization

19.

Integration

20.

A group of nurses are researching information about risk factors for intimate partner violence in men. Which of the following would the nurses expect to find related to the individual person? (Select all that apply.)

Dysfunctional family system

Low academic achievement

Victim of childhood violence

Heavy alcohol consumption

Economic stress

21.

A nurse is working with a victim of intimate partner violence and helping her develop a safety plan. Which of the following would the nurse suggest that the woman take with her? (Select all that apply.)

Drivers license

Social security number

Cash

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Phone cards

Health insurance cards

22.

A nurse is presenting a discussion on sexual violence at a local community college. When describing the incidence of sexual violence, the nurse would identify that a woman has which chance of experiencing a sexual assault in her lifetime?

One in three

One in six

Two in 15

Three in 20

23.

After teaching a class on sexual violence, the instructor determines that the teaching was successful when the class identifies which of the following as a type of sexual violence. (Select all that apply.)

Female genital cutting

Bondage

Infanticide

Human trafficking

Rape

24.

A nurse is reading a journal article about sexual abuse. Which age range would the nurse expect to find as the peak age for such abuse?

710 years

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812 years

1418 years

1822 years

25.

After teaching a group of students about sexual abuse and violence, the instructor determines that the teaching was successful when the students describe incest as involving which of the following?

Sexual exploitation by blood or surrogate relatives

Sexual abuse of individuals over age 18

Violent aggressive assault on a person

Consent between perpetrator and victim.

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6. 7.

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Answer Key

10.

11.

12.

15.

16.

17.

B, D, E

18.

19.

20.

B, C, D

21.

A, B, C, E B

22.

25.

A, B, C, D, E

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23. 24.

14.

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13.