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Maternal Newborn Nursing The Critical

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Maternal Newborn Nursing The Critical Components Of Nursing Care 2nd Edition by
Roberta Durham – Test Bank

Sample Questions

Chapter 5: Psycho-Social-Cultural Aspects of the Antepartum Period


Multiple Choice

1. Sally is in her third trimester and has begun to sing and talk to the fetus. Sally is probably
exhibiting signs of:a. Mental illnessb. Delusionsc. Attachmentd. Crisis

ANS: c

Feedback

a. This is normal maternal–fetal adaptation.

b. Delusions are not real, and the fetus is real.

Correct, because talking to the fetus is a sign of


c. positive maternal adaptation. All other answers
indicate pathology.

Interacting with the fetus in utero represents


d.
normal development of attachment to the fetus.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

2. What is the most common expected emotional reaction of a woman to the news that she is
pregnant? a. Jealousyb. Acceptancec. Ambivalenced. Depression

ANS: c

Feedback
Others in the family may be jealous of the fetus,
a.
but that is not a common maternal response.

Acceptance of the pregnancy typically occurs


b.
later in the pregnancy.

Ambivalence is a normal expected reaction to the


c. news of pregnancy, whether or not the
pregnancy is planned or wanted.

This would represent an abnormal emotional


d.
response to pregnancy.

KEY: Integrated Process: Teaching and Learning | Nursing Process: Analysis | Cognitive Level:
Knowledge | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level:
Easy

3. Which of the following information regarding sexual activity would the nurse give a pregnant
woman who is 35 weeks’ gestation? a. Sexual activity should be avoided from now until 6 weeks
postpartum.b. Sexual desire may be affected by nausea and fatigue. c. Sexual desire may be
increased due to increased pelvic congestion.d. Sexual activity may require different positions to
accommodate the woman’s comfort.

ANS: d

Feedback

There are no contraindications to sexual activity


a. during this time for a normally progressing
pregnancy.

Nausea and fatigue affect sexual desire during


b.
the first trimester, not the third.

c. Increased sexual desire r/t increased pelvic


congestion is a characteristic of the second
trimester, not the third.

Correct. An enlarging abdomen creates feelings


of awkwardness and bulkiness and may require
d.
couples to modify intercourse positions for the
pregnant woman’s comfort.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

4. Which statement best exemplifies adaptation to pregnancy in relation to the adolescent?a.


Adolescents adapt to motherhood in a similar way to other childbearing women.b. Social
support has very little effect on adolescent adaptation to pregnancy. c. The pregnant adolescent
faces the challenge of multiple developmental tasks.d. Pregnant adolescents of all ages can be
capable and active participants in health-care decisions.

ANS: c

Feedback

Adolescents must cope with the conflicting


a. developmental tasks of pregnancy and
adolescence at the same time.

Social support has been associated with a more


b.
positive adaptation to mothering for adolescents.

Correct. Pregnant adolescents face conflicting


c. and multiple developmental tasks of pregnancy
and adolescence at the same time.

By late adolescence (ages 17 to 20) this can occur,


but early adolescents are oriented toward the
d. present and are self-centered, and often
pregnancy at this age is a result of abuse or
coercion.
KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension
| Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult

5. Jane’s husband Brian has begun to put on weight. What is this a possible sign of? a. Culturalism
syndromeb. Couvade syndromec. Moratorium phased. Attachment

ANS: b

Feedback

a. This is not related to culture.

Correct. Couvade syndrome has symptoms that


b.
mimic changes of pregnancy.

Moratorium phase represents one of the phases


c.
of the father’s responses to pregnancy.

d. Attachment is reflected in behaviors.

KEY: Integrated Process: Caring | Cognitive Level: Knowledge | Content Area: Maternity |
Client Need: Psychosocial Integrity | Difficulty Level: Easy

6. Cathy is pregnant for the second time. Her son, Steven, has just turned 2 years old. She asks you
what she should do to help him get ready for the expected birth. What is the nurse’s most
appropriate response?a. Steven will probably not understand any explanations about the arrival
of the new baby, so Cathy should do nothing.b. If Steven’s sleeping arrangements need to be
changed, it should be done well in advance of the birth.c. Steven should come to the next
prenatal visit and listen to the fetal heartbeat to encourage sibling attachment. d. Steven should
be encouraged to plan an elaborate welcome for the newborn.

ANS: b

Feedback
This applies to very young children under the age
a.
of 2.

Children still sleeping in a crib should be moved


to a bed at least 2 months before the baby is due,
b.
as this age group is particularly sensitive to
disruptions of the physical environment.

This is not appropriate for a 2-year-old but may


c.
be appropriate for older age groups.

This is not appropriate for a 2-year-old but may


d.
be appropriate for older age groups.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult

7. The nurse is interviewing a pregnant client who states she plans to drink chamomile tea to
ensure an effective labor. The nurse knows that this is an example of:a. Cultural prescriptionb.
Cultural tabooc. Cultural restrictiond. Cultural demonstration

ANS: a

Feedback

Correct. Cultural prescription is an expected


a. behavior of the pregnant woman during the
childbearing period.

Taboos are cultural restrictions believed to have


b. serious supernatural consequences. Drinking
chamomile tea would not be in this category.

Restrictions are activities during the childbearing


period which are limited for the pregnant
c.
woman. Drinking chamomile tea would not be in
this category.

d. Demonstration is not a term that is used in


relation to cultural behaviors.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Basic Care and Comfort | Difficulty Level: Easy

8. Which of the following would be a priority for the nurse when caring for a pregnant woman who
has recently emigrated from another country?a. Help her develop a realistic, detailed birth
plan.b. Identify her support system.c. Teach her about expected emotional changes of
pregnancy.d. Refer her to a doula for labor support.

ANS: b

Feedback

A detailed birth plan may not be culturally


a.
appropriate and is not first priority.

Correct, because lack of social support has been


correlated with an increased risk of pregnancy
complications and difficult adaptation to
pregnancy. Pregnant women who are recent
b.
immigrants face many challenges in obtaining
needed social support, and the nurse should first
identify her support system to plan further
interventions and referrals.

There may be cultural variations in emotional


c.
changes of pregnancy.

The nurse should first identify her support system


d. before planning further interventions and
referrals.

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity |
Client Need: Psychosocial Integrity | Difficulty Level: Moderate
9. A pregnant client at 20 weeks’ gestation comes to the clinic for her prenatal visit. Which of the
following client statements would indicate a need for further assessment? a. “I hate it when the
baby moves.”b. “I’ve started calling my mom every day.”c. “My partner and I can’t stop talking
about the baby.”d. “I still don’t know much time I’m going to take off work after the baby
comes.”

ANS: a

Feedback

Experiencing quickening as unpleasant may be a


a. sign of maladaptation to pregnancy and needs
further assessment by the nurse.

This is an expected finding in maternal


b. adaptation and development of the maternal
role.

This is an expected finding in maternal


c. adaptation and development of the maternal
role.

At 20 weeks’ gestation, the client still has plenty


d.
of time to process this decision.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Moderate

10. A pregnant client asks the nurse why she should attend childbirth classes. The nurse’s response
would be based on which of the following information? a. Attending childbirth class is a good
way to make new friends.b. Childbirth classes will help new families develop skills to meet the
challenges of childbirth and parenting.c. Attending childbirth classes will help a pregnant woman
have a shorter labor.d. Childbirth classes will help a pregnant woman decrease her chance of
having a cesarean delivery.
ANS: b

Feedback

There may be a beneficial effect of childbirth


a. classes, but this is not the primary goal of
childbirth education.

Correct. These are the stated goals of childbirth


b.
education (ICEA, Lamaze).

Evidence remains inconclusive regarding linking


c. attendance at childbirth classes with a decreased
incidence of cesarean section and shorter labors.

Evidence remains inconclusive regarding linking


d. attendance at childbirth classes with a decreased
incidence of cesarean section and shorter labors.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Easy

11. A woman presents for prenatal care at 6 weeks’ gestation by LMP. Which of the following
findings would the nurse expect to see?

12. Multiple pillow orthopnea

13. Maternal ambivalence

14. Fundus at the umbilicus

15. Pedal and ankle edema

ANS: b

Feedback

Orthopnea is a common complaint of women


a.
during the third trimester.

b. Ambivalence is a common feeling of women


during the first trimester.

The fundus should be at the umbilicus at 20


c.
weeks’ gestation.

Dependent edema is a common complaint of


d.
women during the third trimester.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension |


Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty
Level: Moderate

12. A first-time father is experiencing couvade syndrome. He is likely to exhibit which of the
following symptoms or behaviors?

13. Urinary frequency

14. Hypotension

15. Bradycardia

16. Prostatic hypertrophy

ANS: a

Feedback

Urinary frequency is a common symptom of


a.
couvade.

The father’s blood pressure is not usually


b.
affected.

c. The father’s heart rate is not usually affected.

d. Prostatic changes are not related to couvade.


KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension |
Content Area: Family Dynamics | Client Need: Psychosocial Integrity | Difficulty Level:
Moderate

13. When providing a psychosocial assessment on a pregnant woman at 21 weeks’ gestation, the
nurse would expect to observe which of the following signs?

14. Ambivalence

15. Depression

16. Anxiety

17. Happiness

ANS: d

Feedback

Ambivalence is often seen during the first


a.
trimester.

The nurse would not expect to see depression at


b.
any time during the pregnancy.

The patient may express some anxiety near the


c.
time of delivery.

The nurse would expect the patient to exhibit


d.
signs of happiness at this time.

KEY: Integrated Process: Communication and Documentation; Nursing Process: Assessment |


Cognitive Level: Application | Content Area: Antepartum Care | Client Need: Health Promotion
and Maintenance | Difficulty Level: Easy
14. An example of a cultural prescriptive belief during pregnancy is:

15. Remain active during pregnancy

16. Coldness in any form should be avoided

17. Do not have your picture taken

18. Avoid sexual intercourse during the third trimester

ANS: a

The belief that the patient should remain active during pregnancy is the only example of a
cultural prescriptive belief. All of the other answers are examples of cultural restrictive beliefs.

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area:


Maternity | Client Need: Cultural Respect | Difficulty Level: Easy

15. Taboos are cultural restrictions that:

16. Have serious supernatural consequences

17. Have serious clinical consequences

18. Have superstitious consequences

19. Are functional and neutral practices


ANS: a

Taboos are believed to have serious supernatural consequences. Taboos are not known to have
clinical or superstitious consequences and are not functional or neutral practices.

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area: Cultural
Competence | Client Need: Cultural Respect | Difficulty Level: Moderate

16. Jenny, a 21-year-old single woman, comes for her first prenatal appointment at 31 weeks’
gestation with her first pregnancy. The clinic nurse’s most appropriate statement is:

17. “Jenny, it is late in your pregnancy to be having your first appointment, but it is nice to meet you
and I will try to help you get caught up in your care.”

18. “Jenny, have you had care in another clinic? I can’t believe this is your first appointment!”

19. “Jenny, by the date of your last menstrual period, you are 31 weeks and now that you are finally
here, we need you to come monthly for the next two visits and then weekly.”

20. “Jenny, by your information, you are 31 weeks’ gestation in this pregnancy. Do you have
questions for me before I begin your prenatal history and information sharing?”

ANS: d

Feedback

The initial interview time with the patient should


be used to build a positive, nonthreatening
a. relationship and to gain her confidence by
respecting her choices and advocating for
continued prenatal care that is woman centered.

b. The initial interview time with the patient should


be used to build a positive, nonthreatening
relationship and to gain her confidence by
respecting her choices and advocating for
continued prenatal care and not making
assumptions about prior care. The prenatal
nurse’s objective is to provide a user-friendly
service that is efficient, effective, caring, and
patient centered.

The initial interview time with the patient should


be used to build a positive, nonthreatening, and
c. nonjudgmental relationship and to gain her
confidence by respecting her choices and
advocating for continued prenatal care.

The initial interview time with the patient should


be used to build a positive, nonthreatening
relationship and to gain her confidence by
respecting her choices and advocating for
d.
continued prenatal care. The prenatal nurse’s
objective is to provide a user-friendly service that
is efficient, effective, caring, and patient
centered.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate

17. The clinic nurse visits with Wayne, a 32-year-old man whose partner is pregnant for the first time
and is at 12 weeks. Wayne describes nausea and vomiting, fatigue, and weight gain. His
symptoms are best described as:

18. Influenza

19. Couvade syndrome

20. Acid reflux

21. Cholelithiasis

ANS: b
Feedback

This cluster of symptoms is indicative of couvade


a. syndrome, the experience of maternal signs and
symptoms of pregnancy.

In preparation for parenthood, the male partner


moves through a series of developmental tasks.
During the first trimester, the father begins to
deal with the reality of the pregnancy and may
worry about financial strain and his ability to be a
b.
good father. Feelings of confusion and guilt often
surface with the recognition that he is not as
excited about the pregnancy as his partner, and
couvade syndrome, the experience of maternal
signs and symptoms, may develop.

This cluster of symptoms is indicative of couvade


c. syndrome, the experience of maternal signs and
symptoms of pregnancy.

This cluster of symptoms is indicative of couvade


d. syndrome, the experience of maternal signs and
symptoms of pregnancy.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate

Multiple Response

18. The clinic nurse encourages paternal attachment during pregnancy by including the father in
(select all that apply):
19. Prenatal visits

20. Ultrasound appointments

21. Prenatal class information

22. History taking and obtaining prenatal screening information

ANS: b, c, d

Pregnancy is psychologically stressful for men; some enjoy the role of nurturer, but others feel
alienated and begin to stray from the relationship. The nurse can be instrumental in promoting
early paternal attachment. Involvement of the father during examinations and tests and prenatal
classes, along with thorough explanations of the need for them, can minimize the father’s
feelings of being left out. A history and prenatal screening should be conducted at the first
prenatal visit with the woman alone to ensure confidentiality and an open discussion of any
problems or concerns she may have. The history should include information about the current
pregnancy; the obstetric and gynecologic history; and a cultural assessment, and a medical,
nutritional, social, and family (including the father’s) medical history.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate

19. The perinatal nurse screens all pregnant women early in pregnancy for maternal attachment risk
factors, which include (select all that apply):

20. Adolescence

21. Low educational level

22. History of depression

23. A strong support system for the pregnancy


ANS: a, b, c

Maternal attachment to the fetus is an important area to assess and can be useful in identifying
families at risk for maladaptive behaviors. The nurse should assess for indicators such as
unintended pregnancy, domestic violence, difficulties in the partner relationship, sexually
transmitted infections, limited financial resources, substance use, adolescence, poor social
support systems, low educational level, the presence of mental conditions, or adolescence that
might interfere with the patient’s ability to bond with and care for the infant. A strong support
system can facilitate the patient’s ability to bond with and care for the infant.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:
Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Moderate

20. Strategies for culturally responsive care include (select all that apply):

21. Practicing ethnocentrism

22. Applying stereotyping

23. Examining one’s own biases

24. Learning another language

ANS: c, d

The only actions among the choices that are culturally responsive are examining one’s own
biases and learning another language. Ethnocentrism and stereotyping are not culturally
responsive actions.

KEY: Integrated Process: Safe and Effective Care Environment | Cognitive Level: Application |
Content Area: Cultural Competence | Client Need: Cultural Respect | Difficulty Level: Moderate
Fill-in-the-Blank

21. The clinic nurse talks with Becky, a 16-year-old woman who is now 28 weeks’ gestation. Today’s
visit is only the second prenatal appointment that Becky has kept. The nurse wonders if Becky’s
failure to come for routine prenatal checks is, in part, related to an adolescent’s orientation to
the __________, rather than to the __________.

ANS: present; future

The adolescent may not seek prenatal care unless pressured by authority figures or peers to do
so. By nature, adolescents are not future oriented. Hence, the pregnant adolescent may not be
able to readily accept the reality of the unborn child.

KEY: Integrated Process: Teaching/Learning | Cognitive Level: Analysis | Content Area:


Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Difficult

22. According to Rubin, the mother-to-be needs to accept the pregnancy and incorporate it into her
own reality and __________. This process is known as “__________.”

ANS: self-concept; binding in

The mother-to-be needs to accept the pregnancy and incorporate it into her own reality and self-
concept. This process is known as “binding in.” Acceptance of the child is critical to a successful
adjustment to the pregnancy. Acceptance must come from the expectant woman as well as from
others.

KEY: Integrated Process: Nursing Process: Clinical Problem Solving | Cognitive Level:
Knowledge Content Area: Maternity | Client Need: Health Promotion and Maintenance |
Difficulty Level: Easy

23. The clinic nurse asks pregnant women about their acceptance and planning for this pregnancy as
a component of domestic violence screening. The nurse is aware that a(n) __________
pregnancy __________ the risk for domestic violence.

ANS: unplanned; increases

Intimate partner violence (IPV) may occur for the first time during pregnancy, or the nurse may
identify evidence during the physical examination that is suspicious of ongoing physical abuse.
Acceptance of pregnancy may be delayed if it was unplanned or unwanted. As a women’s
advocate, nurses have a duty to be observant, to actively listen, and to use communication skills
to gain clarification and understanding.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

Chapter 7: High-Risk Antepartum Nursing Care

Multiple Choice
1. A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the
priority nursing assessment to ensure client safety.a. Assess uterine contractions continuously.b.
Assess fetal heart rate continuously.c. Assess urinary output.d. Assess respiratory rate.

ANS: d

Feedback

Monitoring contractions does not indicate


a.
magnesium toxicity.

Magnesium sulfate will decrease fetal variability and


b. not provide an accurate assessment of magnesium
toxicity.

Urinary output does not correlate to decreased


c.
deep tendon reflexes.

Correct. Respiratory effort and deep tendon reflexes


(DTRs) are involuntary, and a decrease in DTRs could
d.
indicate the risk of magnesium sulfate toxicity and
the risk for decreased respiratory effort.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Moderate

2. A pregnant client with a history of multiple sexual partners is at highest risk for which of the
following complications:a. Premature rupture of membranesb. Gestational diabetesc. Ectopic
pregnancyd. Pregnancy-induced hypertension

ANS: c
Feedback

Multiple partners do not increase a woman’s risk of


a.
premature rupture of membranes.

Genetics and client diet and weight are contributing


b.
factors to gestational diabetes.

Correct. A history of multiple sexual partners places


the client at a higher risk of having contracted a
sexually transmitted disease that could have
c.
ascended the uterus to the fallopian tubes and
caused fallopian tube blockage, placing the client at
high risk for an ectopic pregnancy.

Multiple sexual partners are not a risk factor for


d.
pregnancy-induced hypertension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

3. Identify the hallmark of placenta previa that differentiates it from abruptio placenta.a. Sudden
onset of painless vaginal bleedingb. Board-like abdomen with severe painc. Sudden onset of
bright red vaginal bleedingd. Severe vaginal pain with bright red bleeding

ANS: a

Feedback

Correct. When the placenta attaches to the lower


uterine segment near or over the cervical os,
a.
bleeding may occur without the onset of
contractions or pain.

The hallmark for abruptio placenta is pain and a


b.
board-like abdomen.

c. Bright red bleeding could be related to abruptio


placenta, placenta previa, or other complications of
pregnancy.

d. Pain is not a hallmark of placenta previa.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

4. Which of the following assessments would indicate instability in the client hospitalized for
placenta previa?a. BP <90/60 mm/Hg, Pulse <60 BPM or >120 BPMb. FHR moderate variability
without accelerationsc. Dark brown vaginal discharge when voidingd. Oral temperature of 99.9°F

ANS: a

Feedback

A decrease in BP accompanied by bradycardia or


a.
tachycardia is an indication of hypovolemic shock.

FHR with moderate variability can be absent of


b. accelerations during fetal sleep cycles or after
maternal sedation.

Bright red vaginal bleeding is an indication of


c.
current bleeding.

Oral temperature may fluctuate based on the


client’s hydration status. It should be reassessed.
d.
Cause for concern is a temperature of 100.4°F or
more.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate
5. During pregnancy, poorly controlled asthma can place the fetus at risk for:a. Hyperglycemiab.
IUGRc. Hypoglycemiad. Macrosomia

ANS: b

Feedback

Maternal asthma does not place the fetus at risk for


a.
hyperglycemia.

Compromised pulmonary function can lead to


decompensation and hypoxia that decrease oxygen
b.
flow to the fetus and can cause intrauterine growth
restriction (IUGR).

c. Asthma does not directly affect glycemic control.

A fetus experiencing hypoxia would be small for


gestational age, not large for gestational age.
d.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: AnalysisContent Area:
Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

6. Which of the following nursing diagnoses is of highest priority for a client with an ectopic
pregnancy who has developed disseminated intravascular coagulation (DIC)?a. Risk for deficient
fluid volumeb. Risk for family process interruptedc. Risk for disturbed identityd. High risk for
injury

ANS: a

Feedback

a. Correct. The client is at high risk for hypovolemia


which is life threatening and takes precedence over
any psychosocial or less pressing diagnoses.

This is a psychosocial diagnosis and is not life


b.
threatening.

This is a psychosocial diagnosis and is not life


c.
threatening.

The client is at risk for injury; however, the diagnosis


d. of deficient fluid volume is more descriptive and has
clearly defined goals and interventions.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult

7. Which of the following laboratory values is most concerning in a client with pregnancy-induced
hypertension?a. Total urine protein of 200 mg/dLb. Total platelet count of 40,000 mm c. Uric
acid level of 8 mg/dLd. Blood urea nitrogen 24 mg/dL

ANS: b

Feedback

The client’s urine protein is elevated. A urine


a. protein of ≥300 mg/dL in a 24-hour collection is
considered concerning.

Correct. A platelet count of £50,000 is a critical


value and should be reported to the health-care
b.
provider immediately. This client is at increased risk
of hemorrhage.

c. The uric acid level is only slightly elevated.

d. The BUN is only slightly elevated.


KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Difficult

8. Which of the following medications administered to the pregnant client with GDM and
experiencing preterm labor requires close monitoring of the client’s blood glucose levels?a.
Nifedipineb. Betamethasone c. Magnesium sulfated. Indomethacin

ANS: b

Feedback

Nifedipine does not affect maternal blood glucose


a.
levels.

Beta-sympathomimetics may stimulate


b. hyperglycemia which will require an increased need
for insulin.

Magnesium sulfate does not affect blood glucose


c.
levels.

d. Indomethacin does not affect blood glucose levels.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Pharmacological/Parenteral Therapies | Difficulty Level: Difficult

9. While educating the client with class II cardiac disease, at 28 weeks’ gestation, the nurse
instructs the client to notify the physician if she experiences which of the following conditions?
a. Emotional stress at workb. Increased dyspnea while restingc. Mild pedal and ankle edemad.
Weight gain of 1 pound in 1 week

ANS: b
Feedback

Emotional stress increases cardiac workload;


however, without symptoms of cardiac
a.
decompensation, this is not immediately
concerning.

Increasing dyspnea, at rest, can be a sign of cardiac


b. decompensation leading to increased congestive
heart failure.

Mild edema during the third trimester is normal.


However, increasing edema and pitting edema
c.
should be reported as they can be a sign of
increasing CHF.

A weight gain of 1 pound per week is expected


d.
during the third trimester.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

10. The nurse working in a prenatal clinic is providing care to three primigravida patients. Which of
the patient findings would the nurse highlight for the physician?

11. 15 weeks, denies feeling fetal movement

12. 20 weeks, fundal height at the umbilicus

13. 25 weeks, complains of excess salivation

14. 30 weeks, states that her vision is blurry

ANS: d

Feedback

a. This finding is normal. Quickening is usually felt


between 16 and 20 weeks’ gestation.

This finding is normal. The fundal height at 20


b. weeks’ gestation is usually at the level of the
umbilicus.

Excess salivation is a normal, albeit annoying,


c.
finding.

Blurred vision is a sign of pregnancy-induced


d. hypertension (PIH). This finding should be reported
to the woman’s health-care practitioner.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application |


Content Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body
Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of
Risk Potential | Difficulty Level: Difficult

11. The perinatal nurse is assessing a woman in triage who is 34 + 3 weeks’ gestation in her first
pregnancy. She is worried about having her baby “too soon,” and she is experiencing uterine
contractions every 10 to 15 minutes. The fetal heart rate is 136 beats per minute. A vaginal
examination performed by the health-care provider reveals that the cervix is closed, long, and
posterior. The most likely diagnosis would be:

12. Preterm labor

13. Term labor

14. Back labor

15. Braxton-Hicks contractions

ANS: d

Feedback

a. Preterm labor (PTL) is defined as regular uterine


contractions and cervical dilation before the end of
the 36th week of gestation. Many patients present
with preterm contractions, but only those who
demonstrate changes in the cervix are diagnosed
with preterm labor.

b. Term labor occurs after 37 weeks’ gestation.

There is no indication in this scenario that this is


c.
back labor.

Braxton-Hicks contractions are regular contractions


occurring after the third month of pregnancy. They
may be mistaken for regular labor, but unlike true
labor, the contractions do not grow consistently
d. longer, stronger, and closer together, and the cervix
is not dilated. Some patients present with preterm
contractions, but only those who demonstrate
changes in the cervix are diagnosed with preterm
labor.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

12. The perinatal nurse knows that the term to describe a woman at 26 weeks’ gestation with a
history of elevated blood pressure who presents with a urine showing 2+ protein (by dipstick) is:

13. Preeclampsia

14. Chronic hypertension

15. Gestational hypertension

16. Chronic hypertension with superimposed preeclampsia

ANS: d
Feedback

Preeclampsia is a multisystem, vasopressive disease


process that targets the cardiovascular,
a.
hematologic, hepatic, and renal and central nervous
systems.

Chronic hypertension is hypertension that is present


b. and observable prior to pregnancy or hypertension
that is diagnosed before the 20th week of gestation.

Gestational hypertension is a nonspecific term used


to describe the woman who has a blood pressure
c.
elevation detected for the first time during
pregnancy, without proteinuria.

The following criteria are necessary to establish a


diagnosis of superimposed preeclampsia:
hypertension and no proteinuria early in pregnancy
(prior to 20 weeks’ gestation) and new-onset
proteinuria, a sudden increase in protein—urinary
excretion of 0.3 g protein or more in a 24-hour
specimen, or two dipstick test results of 2+ (100
d. mg/dL), with the values recorded at least 4 hours
apart, with no evidence of urinary tract infection; a
sudden increase in blood pressure in a woman
whose blood pressure has been well controlled;
thrombocytopenia (platelet count lower than
100,000/mmC); and an increase in the liver enzymes
alanine transaminase (ALT) or aspartate
transaminase (AST) to abnormal levels.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level:
Moderate

13. A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the
attending physician immediately of which of the following findings?
14. Patellar and biceps reflexes of +4

15. Urinary output of 50 mL/hr

16. Respiratory rate of 10 rpm

17. Serum magnesium level of 5 mg/dL

ANS: c

Feedback

The magnesium sulfate has been ordered because


the patient has severe pregnancy-induced
a.
hypertension. Patellar and biceps reflexes of +4 are
symptoms of the disease.

b. The urinary output must be above 25 mL/hr.

The drop in respiratory rate may indicate that the


c. patient is suffering from magnesium toxicity. The
nurse should report the finding to the physician.

The therapeutic range of magnesium is 4 to 7


d.
mg/dL.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation |


Cognitive Level: Application | Content Area: Adverse Effects/Contraindications; Antepartum
Care; Potential for Alterations in Body Systems; Reduction of Risk Potential: Diagnostic Tests |
Client Need: Health Promotion and Maintenance; Pharmacological and Parenteral Therapies;
Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

14. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which
of the following common medication effects would the nurse expect to see in the mother?

15. Serum potassium level increases


16. Diarrhea

17. Urticaria

18. Complaints of nervousness

ANS: d

Feedback

The nurse would not expect to see a rise in the


a.
mother’s serum potassium levels.

b. The beta agonists are not associated with diarrhea.

c. The beta agonists are not associated with urticaria.

Complaints of nervousness are commonly made by


d.
women receiving subcutaneous beta agonists.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content
Area: Intrapartum Care; Pharmacological and Parenteral Therapies: Adverse
Effects/Contraindications and Side Effects | Client Need: Health Promotion and Maintenance;
Physiological Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate

15. Which of the following signs or symptoms would the nurse expect to see in a woman with
concealed abruptio placentae?

16. Increasing abdominal girth measurements

17. Profuse vaginal bleeding

18. Bradycardia with an aortic thrill

19. Hypothermia with chills


ANS: a

Feedback

The nurse would expect to see increasing abdominal


a.
girth measurements.

Profuse vaginal bleeding is rarely seen in placental


b. abruption and is never seen when the abruption is
concealed.

With excessive blood loss, the nurse would expect


c.
to see tachycardia.

The nurse would expect to see a stable


d.
temperature.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content
Area: Antepartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems |
Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk
Potential | Difficulty Level: Moderate

16. A woman who has had no prenatal care was assessed and found to have hydramnios on
admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the
following complications of pregnancy likely contributed to these findings?

17. Pyelonephritis

18. Pregnancy-induced hypertension

19. Gestational diabetes

20. Abruptio placentae

ANS: c

Feedback
Pyelonephritis does not lead to the development of
a.
hydramnios or macrosomia.

Pregnancy-induced hypertension does not lead to


b.
the development of hydramnios or macrosomia.

Untreated gestational diabetics often have


c.
hydramnios and often deliver macrosomic babies.

Abruptio placentae does not lead to the


d.
development of hydramnios or macrosomia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content
Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need:
Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation |
Difficulty Level: Difficult

17. For the patient with which of the following medical problems should the nurse question a
physician’s order for beta agonist tocolytics?

18. Type 1 diabetes mellitus

19. Cerebral palsy

20. Myelomeningocele

21. Positive group B streptococci culture

ANS: a

Feedback

Beta agonists often elevate serum glucose levels.


a.
The nurse should question the order.

b. Beta agonists are not contraindicated for patients


with cerebral palsy.

Beta agonists are not contraindicated for patients


c.
with myelomeningocele.

Beta agonists are not contraindicated for patients


d.
with group B streptococci.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation |


Cognitive Level: Application | Content Area: Intrapartum Care; Reduction of Risk Potential:
Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance;
Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

18. The nurse is caring for two laboring women. Which of the patients should be monitored most
carefully for signs of placental abruption?

19. The patient with placenta previa

20. The patient whose vagina is colonized with group B streptococci

21. The patient who is hepatitis B surface antigen positive

22. The patient with eclampsia

ANS: d

Feedback

Patients with placenta previa are not especially high


a.
risk for placental abruption.

Patients colonized with group B streptococci are not


b.
especially high risk for placental abruption.

Patients who are hepatitis B surface antigen positive


c.
are not especially high risk for placental abruption.

d. Patients with eclampsia are high risk for placental


abruption.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application |


Content Area: Intrapartum Care; Reduction of Risk Potential: Potential for Complications |
Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk
Potential | Difficulty Level: Difficult

19. The nurse is caring for a woman at 28 weeks’ gestation with a history of preterm delivery. Which
of the following laboratory data should the nurse carefully assess in relation to this diagnosis?

20. Human relaxin levels

21. Amniotic fluid levels

22. Alpha-fetoprotein levels

23. Fetal fibronectin levels

ANS: d

Feedback

Relaxin levels are rarely assessed. In addition, they


a.
are unrelated to the incidence of preterm labor.

Amniotic fluid levels are not directly related to the


b.
incidence of preterm labor.

Alpha-fetoprotein levels are not related to the


c.
incidence of preterm labor.

A rise in the fetal fibronectin levels in cervical


d.
secretions has been associated with preterm labor.
KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content
Area: Antepartum Care; Reduction of Risk Potential: Laboratory Values | Client Need: Health
Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty
Level: Moderate

20. Which of the following statements is most appropriate for the nurse to say to a patient with a
complete placenta previa?

21. “During the second stage of labor you will need to bear down.”

22. “You should ambulate in the halls at least twice each day.”

23. “The doctor will likely induce your labor with oxytocin.”

24. “Please promptly report if you experience any bleeding or feel any back discomfort.”

ANS: d

Feedback

This response is inappropriate. This patient will be


a.
delivered by cesarean section.

This response is inappropriate. Patients with


b.
placenta previa are usually on bed rest.

This response is inappropriate. This patient will be


c.
delivered by cesarean section.

Labor often begins with back pain. Labor is


d. contraindicated for a patient with complete
placenta previa.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application |


Content Area: Antepartum Care | Client Need: Health Promotion and Maintenance | Difficulty
Level: Easy
21. A woman at 32 weeks’ gestation is diagnosed with severe preeclampsia with HELLP syndrome.
The nurse will identify which of the following as a positive patient care outcome?

22. Rise in serum creatinine

23. Drop in serum protein

24. Resolution of thrombocytopenia

25. Resolution of polycythemia

ANS: c

Feedback

A rise in serum creatinine indicates that the kidneys


a. are not effectively excreting creatinine. It is a
negative outcome.

A drop in serum protein indicates that the kidneys


b. are allowing protein to be excreted. This is a
negative outcome.

Resolution of thrombocytopenia is a positive sign. It


c. indicates that the platelet count is returning to
normal.

Polycythemia is not related to HELLP syndrome.


Rather one sees a drop in red cell and platelet
d.
counts with HELLP. A positive sign, therefore, would
be a rise in the RBC count.

KEY: Integrated Process: Nursing Process: Evaluation | Cognitive Level: Application | Content
Area: Antepartum Care; Physiological Adaptation: Illness Management | Client Need: Health
Promotion and Maintenance; Physiological Integrity: Physiological Adaptation | Difficulty
Level: Difficult
22. A 16-year-old patient is admitted to the hospital with a diagnosis of severe preeclampsia. The
nurse must closely monitor the woman for which of the following?

23. High leukocyte count

24. Explosive diarrhea

25. Fractured pelvis

26. Low platelet count

ANS: d

Feedback

High leukocyte count is not associated with severe


pregnancy-induced hypertension (PIH) or HELLP
a.
(hemolysis, elevated liver enzymes, and low
platelets) syndrome.

Explosive diarrhea is not associated with severe PIH


b.
or HELLP syndrome.

A fractured pelvis is not associated with severe PIH


c.
or HELLP syndrome.

Low platelet count is one of the signs associated


d. with HELLP (hemolysis, elevated liver enzymes, and
low platelets) syndrome.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content
Area: Antepartum Care; Diagnostic Tests; Reduction of Risk Potential: Laboratory Data | Client
Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential |
Difficulty Level: Difficult
23. A woman at 10 weeks’ gestation is diagnosed with gestational trophoblastic disease (hydatiform
mole). Which of the following findings would the nurse expect to see?

24. Platelet count of 550,000/ mm3

25. Dark brown vaginal bleeding

26. White blood cell count 17,000/ mm3

27. Macular papular rash

ANS: b

Feedback

The nurse would not expect to see an elevated


a.
platelet count.

The nurse would expect to see dark brown vaginal


b.
discharge

The nurse would not expect to see an elevated


c.
white blood cell count.

d. The nurse would not expect to see a rash.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content
Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need:
Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation |
Difficulty Level: Difficult
24. After an education class, the nurse overhears an adolescent woman discussing safe sex practices.
Which of the following comments by the young woman indicates that additional teaching about
sexually transmitted infection (STI) control issues is needed?

25. “I could get an STI even if I just have oral sex.”

26. “Girls over 16 are less likely to get STDs than younger girls.”

27. “The best way to prevent an STI is to use a diaphragm.”

28. “Girls get human immunodeficiency virus (HIV) easier than boys do.”

ANS: c

Feedback

This statement is true. Organisms that cause


a. sexually transmitted infections can invade the
respiratory and gastrointestinal tracts.

This statement is true. Young women are especially


b. high risk for becoming infected with sexually
transmitted diseases.

This statement is untrue. The young woman needs


further teaching. Condoms protect against STDs and
pregnancy. In addition, condoms can be kept in
readiness for whenever sex may occur
c.
spontaneously. Using condoms does not require the
teen to plan to have sex. A diaphragm is not an
effective infection-control method. Plus, it would
require the teen to plan for intercourse.

This statement is true. Young women are higher risk


d.
for becoming infected with HIV than are young men.

KEY: Integrated Process: Nursing Process: Evaluation; Teaching and Learning | Cognitive Level:
Application | Content Area: Disease Prevention; High Risk Behaviors; Human Sexuality | Client
Need: Health Promotion and Maintenance: High Risk Behaviors; Human Sexuality | Difficulty
Level: Moderate
25. A woman who is admitted to labor and delivery at 30 weeks’ gestation, is 1 cm dilated, and is
contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following
maternal vital signs is most important for the nurse to assess each hour?

26. Temperature

27. Pulse

28. Respiratory rate

29. Blood pressure

ANS: c

Feedback

The temperature should be monitored, but it is not


a.
the most important vital sign.

The pulse rate should be monitored, but it is not the


b.
most important vital sign.

The respiratory rate is the most important vital sign.


c. Respiratory depression is a sign of magnesium
toxicity.

The blood pressure should be monitored, but it is


d.
not the most important vital sign.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content
Area: Intrapartum Care; Potential for Complications from Pharmacological Therapies: Adverse
Effects/Contraindications | Client Need: Health Promotion and Maintenance; Physiological
Integrity: Pharmacological and Parenteral Therapies | Difficulty Level: Moderate
26. You are caring for a patient who was admitted to labor and delivery at 32 weeks’ gestation and
diagnosed with preterm labor. She is currently on magnesium sulfate, 2 gm per hour. Upon your
initial assessment you note that she has a respiratory rate of 8 with absent deep tendon reflexes.
What will be your first nursing intervention?

27. Elevate head of the bed

28. Notify the MD

29. Discontinue magnesium sulfate

30. Draw a serum magnesium level

ANS: c

Initial nursing intervention needs to be discontinuing magnesium sulfate because the patient is
exhibiting signs of magnesium toxicity with absent deep tendon reflexes and decreased
respiratory rate.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application and
Comprehension | Content Area: Maternity | Client Need: Safe and Effective Care Environment |
Difficulty Level: Hard

27. A 34-weeks’ gestation multigravida, G3 P1 is admitted to the labor suite. She is contracting every
7 minutes and 40 seconds. The woman has several medical problems. Which of the following of
her comorbidities is most consistent with the clinical picture?

28. Kyphosis

29. Urinary tract infection

30. Congestive heart failure

31. Cerebral palsy


ANS: b

Feedback

a. Kyphosis is unrelated to preterm labor.

Urinary tract infections often precipitate preterm


b.
labor.

It is unlikely that the congestive heart failure


c.
precipitated the preterm labor.

d. Cerebral palsy is unrelated to preterm labor.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content
Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need:
Health Promotion and Maintenance: Antepartum Care; Physiological Integrity: Physiological
Adaptation | Difficulty Level: Difficult

28. A primiparous woman has been admitted at 35 weeks’ gestation and diagnosed with HELLP
syndrome. Which of the following laboratory changes is consistent with this diagnosis?

29. Hematocrit dropped to 28%.

30. Platelets increased to 300,000 cells/mm3.

31. Red blood cells increased to 5.1 million cells/mm 3.

32. Sodium dropped to 132 mEq/dL.

ANS: a

Feedback

The nurse would expect to see a drop in the


a.
hematocrit: The H in HELLP stands for hemolysis.

b. The nurse would expect to see low platelets.


c. The nurse would expect to see hemolysis.

The sodium is usually unaffected in HELLP


d.
syndrome.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content
Area: Intrapartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need:
Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation |
Difficulty Level: Moderate

29. A labor nurse is caring for a patient, 39 weeks’ gestation, who has been diagnosed with placenta
previa. Which of the following physician orders should the nurse question?

30. Type and cross-match her blood.

31. Insert an internal fetal monitor electrode.

32. Administer an oral stool softener.

33. Assess her complete blood count.

ANS: b

Feedback

It would be appropriate to type and cross-match the


a.
patient for a blood transfusion.

This action is inappropriate. When a patient has a


b. placenta previa, nothing should be inserted into the
vagina.

To prevent constipation, it is appropriate for a


c.
patient to take a stool softener.

d. It is appropriate to monitor the patient for signs of


anemia.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application |


Content Area: Antepartum Care; Patient Advocacy; Potential for Alterations in Body Systems |
Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk
Potential; Safe and Effective Care Environment: Management of Care | Difficulty Level:
Moderate

30. A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout
her pregnancy. Which of the following complications of pregnancy would the nurse expect to
see?

31. Postpartum hemorrhage

32. Neonatal hyperglycemia

33. Postpartum oliguria

34. Neonatal macrosomia

ANS: d

Feedback

The patient is not especially high risk for a


a.
postpartum hemorrhage.

The nurse would expect to see neonatal


b.
hypoglycemia, not hyperglycemia.

c. The nurse would expect to see postpartum polyuria.

The nurse would expect to see neonatal


d.
macrosomia.
KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content
Area: Antepartum Care; Physiological Adaptation: Alterations in Body Systems | Client Need:
Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation |
Difficulty Level: Difficult

31. According to agency policy, the perinatal nurse provides the following intrapartal nursing care for
the patient with preeclampsia:

32. Take the patient’s blood pressure every 6 hours

33. Encourage the patient to rest on her back

34. Notify the physician of a urine output greater than 30 mL/hr

35. Administer magnesium sulfate according to agency policy

ANS: d

Feedback

The nurse is the manager of care for the woman


with preeclampsia during the intrapartal period.
a. Careful assessments are critical. The blood pressure
is taken every 1 hour or more frequently according
to physician orders or institutional protocol.

The nurse is the manager of care for the woman


with preeclampsia during the intrapartal period.
b. Careful assessments are critical. The patient should
be encouraged to assume a side-lying position to
enhance uterine perfusion.

The nurse is the manager of care for the woman


with preeclampsia during the intrapartal period.
c. Careful assessments are critical. A urine output less
than 30 mL/hr is indicative of oliguria and the
physician must be notified.

d. The nurse is the manager of care for the woman


with preeclampsia during the intrapartal period.
Careful assessments are critical. The nurse
administers medications as ordered and should
adhere to hospital protocol for a magnesium sulfate
infusion.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

32. The perinatal nurse is providing care to Marilyn, a 25-year-old G1 TPAL 0000 woman hospitalized
with severe hypertension at 33 weeks’ gestation. The nurse is preparing to administer the
second dose of beta-methasone prescribed by the physician. Marilyn asks: “What is this
injection for again?” The nurse’s best response is:

33. “This is to help your baby’s lungs to mature.”

34. “This is to prepare your body to begin the labor process.”

35. “This is to help stabilize your blood pressure.”

36. “This is to help your baby grow and develop in preparation for birth.”

ANS: a

Feedback

Antenatal glucocorticoids such as beta-methasone


may be given (12 mg IM 24 hours apart) to promote
a. fetal lung maturity if the gestational age is less than
34 weeks and childbirth can be delayed for 48
hours.

b. Antenatal glucocorticoids such as beta-methasone


may be given (12 mg IM 24 hours apart) to promote
fetal lung maturity if the gestational age is less than
34 weeks and childbirth can be delayed for 48
hours.

Antenatal glucocorticoids such as beta-methasone


may be given (12 mg IM 24 hours apart) to promote
c. fetal lung maturity if the gestational age is less than
34 weeks and childbirth can be delayed for 48
hours.

Antenatal glucocorticoids such as beta-methasone


may be given (12 mg IM 24 hours apart) to promote
d. fetal lung maturity if the gestational age is less than
34 weeks and childbirth can be delayed for 48
hours.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

33. A woman who is 36 weeks pregnant presents to the labor and delivery unit with a history of
congestive heart disease. Which of the following findings should the nurse report to the primary
health-care practitioner?

34. Presence of chloasma

35. Presence of severe heartburn

36. 10-pound weight gain in a month

37. Patellar reflexes +1

ANS: c

Feedback

a. Chloasma is a normal pregnancy finding.

b. Heartburn is an expected finding during the third


trimester.

The weight gain may be due to fluid retention. Fluid


retention may occur in patients with pregnancy-
c. induced hypertension and in patients with
congestive heart failure. The physician should be
notified.

Although slightly hyporeflexic, patellar reflexes of +1


d.
are within normal limits.

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation |


Cognitive Level: Application | Content Area: Antepartum Care; Reduction of Risk Potential:
Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance;
Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

34. The single most important risk factor for preterm birth includes:

35. Uterine and cervical anomalies

36. Infection

37. Increased BMI

38. Prior preterm birth

ANS: d

The single most important factor is prior preterm birth with a reoccurrence rate of up to 40%.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate
35. Your antepartal patient is 38 weeks’ gestation, has a history of thrombosis, and has been on
strict bed rest for the last 12 hours. She is now experiencing shortness of breath. What about the
patient may be a contributing factor for her shortness of breath?

36. Physiologic changes in pregnancy result in vasodilation, which increases the tendency to form
blood clots.

37. Physiologic changes in pregnancy result in vasoconstriction, which increases the tendency to
form blood clots.

38. Physiologic changes in pregnancy result in anemia, which increases the tendency to form blood
clots.

39. Physiologic changes in pregnancy result in decreased perfusion to the lungs, which increases
the tendency to form blood clots.

ANS: a

The patient’s shortness of breath, bed rest, and history of thrombosis indicate possible pulmonary
embolism. Her pregnant state also increases the potential for thrombosis resulting from increased
levels of coagulation factors and decreased fibrinolysis, venous dilation, and obstruction of the
venous system by the gravid uterus. Thromboembolitic diseases occurring most frequently in
pregnancy include deep vein thrombosis and pulmonary embolism.

KEY: Integrated Process: Critical Thinking | Cognitive Level: Complication | Content Area:
Physiologic Adaptation: Alteration in Body Systems | Client Need: Physiologic Adaptation |
Difficulty Level: Hard

36. Metabolic changes during pregnancy __________ glucose tolerance.

37. lower

38. increase
39. maintain

40. alter

ANS: a

Metabolic changes during pregnancy lower glucose tolerance.

KEY: Integrated Process: Knowledge | Cognitive Level: Synthesis | Content Area: Maternity

| Client Need: Physiologic Adaptation | Difficulty Level: Hard

True/False

37. Immediately postpartum, the insulin needs in diabetic women increase dramatically.

ANS: FalseThere is a significant decrease in the need for insulin immediately after delivery
related to the loss of antagonistic placental hormones and suppression of the anterior pituitary
growth hormone.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Easy
38. The perinatal nurse observes the placental inspection by the health-care provider after birth.
This examination may help to determine whether an abruption has occurred prior to or during
labor.

ANS: True

Fifty percent of abruptions occur before labor and after the 30th week, 15% occur during labor,
and 30% are identified only upon inspection of the placenta after delivery.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

39. It is critical for the perinatal nurse to learn, as part of the facility’s policies and procedures, to
immediately perform a vaginal examination on a woman who presents with vaginal bleeding
after 24 weeks’ gestation.

ANS: False

Placenta previa should be suspected in all patients who present with bleeding after 24 completed
weeks of gestation. Because of the risk of placental perforation, vaginal examinations are not
performed.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate
40. The perinatal nurse knows that the survival rate for infants born at or greater than 28 to 29
gestational weeks is greater than 90%.

ANS: True

With appropriate medical care, neonatal survival dramatically improves as the gestational age
increases, with over 50% of neonates surviving at 25 weeks’ gestation, and over 90% surviving
at 28 to 29 weeks of gestation.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

41. A patient with hypertension who is receiving intravenous magnesium sulfate therapy has
requested an epidural anesthetic. The perinatal nurse should first review the patient’s complete
blood count results for evidence of a decreased platelet count.

ANS: True

Baseline information, including complete blood count (CBC), clotting studies, serum
electrolytes, and renal function tests, is used to alert the care providers to changes in the patient’s
condition as additional laboratory tests are obtained.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Physiological Integrity | Difficulty Level: Difficult
42. The perinatal nurse knows that the laboring diabetic patient’s blood glucose level should always
be less than 120 mg/dL.

ANS: True

Blood glucose levels are assessed every hour, and fluid/insulin adjustments are made as needed
to maintain maternal blood glucose levels between 80 and 120 mg/dL.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

Multiple Response

43. The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta
previa risk factors include (select all that apply):

44. Cocaine use

45. Tobacco use

46. Previous caesarean birth

47. Previous use of medroxyprogesterone (Depo-Provera)

ANS: a, b, c

Feedback

a. Placenta previa may be associated with risk factors


including smoking, cocaine use, a prior history of
placenta previa, closely spaced pregnancies, African
or Asian ethnicity, and maternal age greater than 35
years.

Placenta previa may be associated with risk factors


including smoking, cocaine use, a prior history of
b. placenta previa, closely spaced pregnancies, African
or Asian ethnicity, and maternal age greater than 35
years.

Placenta previa may be associated with conditions


that cause scarring of the uterus such as a prior
c.
cesarean section, multiparity, or increased maternal
age.

Previous use of medroxyprogesterone (Depo-


d.
Provera) is not a risk factor for placenta previa.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

44. Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of
lower abdominal cramping and urinary frequency at 30 weeks’ gestation. An appropriate nursing
action would be to (select all that apply):

45. Assess the fetal heart rate

46. Obtain urine for culture and sensitivity

47. Assess Kerry’s blood pressure and pulse

48. Palpate Kerry’s abdomen for contractions

ANS: a, b, d
Feedback

Women experiencing preterm labor may complain


of backache, pelvic aching, menstrual-like cramps,
increased vaginal discharge, pelvic pressure, urinary
a. frequency, and intestinal cramping with or without
diarrhea. The patient’s abdomen should be
palpated to assess for contractions, and the fetus’s
heart rate should be monitored.

Women experiencing preterm labor may complain


of backache, pelvic aching, menstrual-like cramps,
increased vaginal discharge, pelvic pressure, urinary
frequency, and intestinal cramping with or without
diarrhea. A urinalysis and urine culture and
sensitivity (C & S) should be obtained on all patients
b.
who present with signs of preterm labor, and the
nurse must remember that signs of UTI often mimic
normal pregnancy complaints (i.e., urgency,
frequency). The patient’s abdomen should be
palpated to assess for contractions, and the fetus’s
heart rate should be monitored.

Assessment of blood pressure and pulse is not an


c.
important nursing action in this scenario.

Women experiencing preterm labor may complain


of backache, pelvic aching, menstrual-like cramps,
increased vaginal discharge, pelvic pressure, urinary
d. frequency, and intestinal cramping with or without
diarrhea. The patient’s abdomen should be
palpated to assess for contractions and the fetus’s
heart rate should be monitored.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

45. The perinatal nurse knows that tocolytic agents are most often used to (select all that apply):
46. Prevent maternal infection

47. Prolong pregnancy to 40 weeks’ gestation

48. Prolong pregnancy to facilitate administration of antenatal corticosteroids

49. Allow for transport of the woman to a tertiary care facility

ANS: c, d

Feedback

a. Tocolytics are not used to treat maternal infection.

Tocolytics are generally only effective in delaying


b.
delivery for several days.

Presently, it is believed that the best reason to use


tocolytic drugs is to allow an opportunity to begin
c.
the administration of antenatal corticosteroids to
accelerate fetal lung maturity.

Delaying the birth provides time for maternal


d. transport to a facility equipped with a neonatal
intensive care unit.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Peds/Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level:
Easy

46. The perinatal nurse provides a hospital tour for couples and families preparing for labor and
birth in the future. Teaching is an important component of the tour. Information provided about
preterm labor and birth prevention includes (select all that apply):

47. Encouraging regular, ongoing prenatal care

48. Reporting symptoms of urinary frequency and burning to the health-care provider
49. Coming to the labor triage unit if back pain or cramping persist or become regular

50. Lying on the right side, withholding fluids, and counting fetal movements if contractions occur
every 5 minutes

ANS: a, b, c

Feedback

The nurse should encourage all pregnant women to


obtain prenatal care and screen for vaginal and
a. urogenital infections and treat appropriately, and
remind pregnant women to call their provider
repeatedly if symptoms of preterm labor occur.

Educating all women of childbearing age about


preterm labor is a crucial component of prevention.
The nurse should encourage all pregnant women to
b. obtain prenatal care and screen for vaginal and
urogenital infections and treat appropriately, and
remind pregnant women to call their provider
repeatedly if symptoms of preterm labor occur.

Educating all women of childbearing age about


preterm labor is a crucial component of prevention.
The nurse should encourage all pregnant women to
c. obtain prenatal care and screen for vaginal and
urogenital infections and treat appropriately, and
remind pregnant women to call their provider if
symptoms of preterm labor occur.

Lying on the right side; drinking fluids, not


withholding fluids; and counting fetal movements if
d.
contractions occur every 5 minutes are
recommended if a woman thinks she is contracting.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate
47. The perinatal nurse describes for the new nurse the various risks associated with prolonged
premature preterm rupture of membranes. These risks include (select all that apply):

48. Chorioamnionitis

49. Abruptio placentae

50. Operative birth

51. Cord prolapse

ANS: a, b, d

Even though maintaining the pregnancy to gain further fetal maturity can be beneficial,
prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental
abruption, and cord prolapse.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

48. Betamethasone is a steroid that is given to a pregnant woman with signs of preterm labor. The
purpose of giving steroids is to (select all that apply):

49. Stimulate the production of surfactant in the preterm infant

50. Be given between 24 and 34 weeks’ gestation

51. Increase the severity of respiratory distress

52. Accelerate fetal lung maturity

ANS: a, b, d
Betamethasone is a steroid that is given to pregnant women with signs of preterm labor between
24 and 34 weeks’ gestation. It stimulates the production of surfactant in the preterm infant and
accelerates fetal lung maturity.

KEY: Integrated Process: Knowledge | Cognitive Level: Comprehension | Content Area:


Pharmacological and Parenteral Therapies: Expected Effects/Outcomes | Client Need:
Pharmacologic and Parenteral Therapies | Difficulty Level: Hard

49. Marked hemodynamic changes in pregnancy can impact the pregnant woman with cardiac
disease. Signs and symptoms of deteriorating cardiac status include (select all that apply):

50. Orthopnea

51. Nocturnal dyspnea

52. Palpitations

53. Irritation

ANS: a, b, c

Signs and symptoms of deteriorating cardiac status with cardiac disease include orthopnea,
nocturnal dyspnea, and palpitations, but do not include irritation.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Synthesis | Content
Area: Reduction of Risk Potential-Potential for Complications | Client Need: Physiologic
Adaptation | Difficulty Level: Hard
Short Answer

50. A condition where the placenta attaches to the lower uterine segment of the uterus

ANS: Placenta previa

KEY: Integrated Process: Teaching/Learning | Cognitive Level: Knowledge | Content Area:


Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

51. A pregnancy that ends before 20 weeks’ gestation

ANS: Miscarriage

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

52. Birth prior to 37 completed weeks of pregnancy

ANS: Preterm birth


KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

53. Specks or spots in the vision where the patient cannot see; “blind spots”

ANS: Scotoma

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

54. A disease characterized by an abnormal placental development that results in the production of
fluid-filled grapelike clusters and a vast proliferation of trophoblastic tissue

ANS: Hydatidiform mole/Gestational trophoblastic disease

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Peds/Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy
55. No expulsion of the products of conception, but bleeding and dilation of the cervix such that a
pregnancy is unlikely

ANS: Inevitable abortion

KEY: Integrated Processes: Teaching and Learning | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

56. Placement of suture to mechanically close a weak cervix

ANS: Cervical cerclage

KEY: Integrated Process: Teaching and Learning | | Cognitive Level: Knowledge | Content Area:
Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

Fill-in-the-Blank

57. The perinatal nurse knows that an early pregnancy loss occurs before __________ weeks, and a
late pregnancy loss is one that occurs between 12 and __________ weeks.
ANS: 12; 20

Not all conceptions result in a live-born infant. Of all clinically recognized pregnancies, 10% to
20% are lost, and approximately 22% of pregnancies detected on the basis of hCG assays are lost
before the appearance of any clinical signs or symptoms. By definition, an early pregnancy loss
occurs before 12 weeks of gestation; a late pregnancy loss is one that occurs between

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

58. Mary, a G3 TPAL 0020 woman at 20 weeks’ gestation, has had a transvaginal ultrasound. Mary
has been informed that she has cervical incompetence. The perinatal nurse explains that this
diagnosis means that her cervix has __________ without __________ contractions.

ANS: dilated; regular

Patients with cervical incompetence usually present with painless dilation and effacement of the
cervix, often during the second trimester of pregnancy. The patient frequently gives a history of
repeated second trimester losses with no apparent etiology. Incompetent cervix is estimated to
cause approximately 15% of all second trimester losses.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

59. The perinatal nurse knows that nausea and vomiting are common in pregnancy and usually
resolve by __________ weeks’ gestation. The severe form of this condition is __________.
ANS: 16; hyperemesis gravidarum

Feedback 1: Nausea and vomiting are a common condition of pregnancy which affect 70% to
85% of pregnant women and usually resolve by the 16th week of gestation.

Feedback 2: Hyperemesis gravidarum represents the extreme end of the nausea/vomiting


spectrum in terms of severity. Criteria for the diagnosis of hyperemesis gravidarum include
persistent vomiting unrelated to other causes, a measure of acute starvation (usually large
ketonuria), and some discrete weight loss, most often 5% of the prepregnancy weight.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Health Promotion and Maintenance | Difficulty Level: Easy

60. The perinatal nurse explains to the student nurse who is assessing the abdomen of a 32-week
pregnant woman with placenta previa that it would not be unusual to find the fetus in a
__________ or __________ position.

ANS: breech; transverse

Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the
internal cervical os. This condition accounts for 20% of all antepartal hemorrhages. Leopold
maneuvers often reveal the fetus to be in a breech or oblique position or transverse lie because of
the abnormal location of the placenta.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate
61. The perinatal nurse knows that a __________ hemorrhage is limited to the uterus, and a
__________ hemorrhage moves blood toward and through the cervix.

ANS: concealed; revealed

Feedback 1: A concealed hemorrhage occurs in 20% of cases and describes an abruption in


which the bleeding is confined within the uterine cavity. The most common abruption is
associated with a revealed or external hemorrhage, where the blood dissects downward toward
the cervix.

Feedback 2: The most common abruption is associated with a revealed or external hemorrhage,
where the blood dissects downward toward the cervix.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

62. The perinatal nurse encourages Colleen, who has just been discharged from the hospital for
intravenous therapy for severe nausea and vomiting, to ensure that she __________ often, eats
frequent, __________ meals and avoids __________ odors.

ANS: rests; small; cooking

The nurse should counsel the woman with nausea and vomiting to avoid foods and sensory
stimuli that provoke symptoms (i.e., some women become nauseous when they smell certain
foods being prepared) and also to eat small, frequent meals of dry, bland foods and include high-
protein snacks in their diet.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate

Chapter 11: Intrapartum and Postpartum Care of Cesarean Birth Families


Multiple Response

1. Which of the following is a medical indication for a cesarean birth? (Select all that apply.)

2. Maternal blood pressure of 130/90b. Cervical dilation of 1.5 cm per hour during the active phase
of laborc. Late deceleration of the fetal heart rate with minimal variabilityd. Complete placenta
previae. Arrest of fetal descent

ANS: c, d, eA maternal blood pressure of 130/90 may be an indication of mild PHI which is not
a medical indication for cesarean birth. Cervical dilation of 1.5 cm/minutes is within normal
limits for cervical changes during the active phase. Late decelerations combined with minimal
variability in the fetal heart rate reflect fetal intolerance of labor and are an indication for
cesarean birth. A complete placenta previa covers the internal os necessitating a cesarean birth.
Arrest of fetal descent indicates cephalopelvic disproportion.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

2. A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor
and operative records indicate that she had premature rupture of membranes followed by 36
hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is
1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that
apply.)

3. Fluid volume deficitb. Infectionc. Impaired mother–infant attachmentd. Falls


ANS: a, b, c, dThe woman is at risk for fluid volume deficit related to blood loss and risk for
postpartum hemorrhage due to risk of uterine atony. She is at risk for infection related to
premature and prolonged rupture of membranes. The woman is at risk for impaired mother–
infant attachment related to maternal pain and exhaustion. She is at risk for falls related to
anesthesia and orthostatic hypotension.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Reduction of Risk Potential | Difficulty Level: Difficult

3. The perinatal nurse teaches the student nurse that deep breathing exercises following a
cesarean birth are critical to the prevention of (select all that apply):

4. Pneumonia

5. Atelectasis

6. Abdominal distension

7. Increased tidal volume

ANS: a, b

Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns
that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung
functions, patients should be taught how to perform pulmonary exercises. Expectoration of
secretions and deep breathing help prevent common complications including atelectasis and
pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result
from delayed peristalsis.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Application | Content Area:
Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate
Multiple Choice

4. A nurse is admitting a woman for a scheduled cesarean section. Which of the following
assessment data should be immediately reported to the physician?a. White cell count of
11,000b. Hemoglobin of 11 g/dLc. Hematocrit of 33%d. Platelet count of 97,000

ANS: d

Feedback

This laboratory value is within normal limits for a


a.
pregnant woman.

This laboratory value is within normal limits for a


b.
pregnant woman.

This laboratory value is within normal limits for a


c.
pregnant woman.

Normal range of platelets is 150,000 to 400,000. A


d. low platelet count places the woman at risk for
increased bleeding.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension


| Content Area: Maternity | Client Need: Reduction of Risk Potential

Difficulty Level: Moderate


5. A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech
presentation. Select the best nursing action for reducing the couple’s anxiety levels.a. Explain the
reason for the need for a cesarean section.b. Inform parents that their baby is in distress.c. Ask
the couple to share their concerns.d. Reassure the couple that both the woman and baby are in
no danger.

ANS: c

Feedback

Explaining the reason she is having a cesarean birth


a.
is helpful but may not address their concerns.

It is important to acknowledge that the baby is


stable, but this response does not allow the couple
b.
to share their concerns that may be causing an
increase in anxiety.

By asking the couple to share their concerns, the


c.
nurse can address these concerns.

Reassuring the couple that the woman and baby are


in no danger is correct, but it is not the best answer
d.
because it does not allow the couple to verbalize
their concerns.

KEY: Integrated Process: Caring | Cognitive Level: Application | Content Area: Maternity |
Client Need: Psychosocial Integrity | Difficulty Level: Moderate

6. A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal
morphine at the time of the birth. Which of the following assessment data would require
immediate intervention?a. Itching of the palms and feetb. Nauseac. Urinary output of 300 mL in
the past 4 hoursd. Respiratory rate of 10 breaths/minute

ANS: d

Feedback
This is a side effect of intrathecal morphine which is
a.
not life threatening.

This is a side effect of intrathecal morphine which is


b.
not life threatening.

A urinary output of 300 mL in 4 hours is within


c.
normal limits.

Correct. An adverse effect of intrathecal morphine


d. that requires immediate intervention is respiratory
distress.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:
Maternity | Client Need: Reduction of Risk Potential |Difficulty Level: Moderate

7. A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural
anesthesia. Which of the following interventions should the nurse perform on the mother at this
time?

8. Maintain the client flat in bed.

9. Assess the client’s patellar reflexes.

10. Monitor hourly urinary outputs.

11. Assess the client’s respiratory rate.

ANS: d

Feedback

The client should be assisted to a position of


a.
comfort.

b. There is no indication in the scenario that the client


must have her reflexes assessed.

The client’s hydration should be monitored


c. postsurgery, but hourly assessments are
unnecessary.

The client has undergone major abdominal surgery.


d. Her respiratory function should be assessed
regularly.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application |


Content Area: Postpartum Care; Reduction of Risk Potential: Potential for Alterations in Body
Systems | Client Need: Health Promotion and Maintenance; Physiological Integrity: Reduction of
Risk Potential | Difficulty Level: Moderate

8. A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following
symptoms would the nurse expect to see?

9. Abdominal distension

10. Polyuria

11. Diastasis recti

12. Dependent edema

ANS: a

Feedback

The nurse would expect to see a distended


a.
abdomen in a client with a paralytic ileus.

b. Polyuria is unrelated to a paralytic ileus.

c. Diastasis recti is unrelated to a paralytic ileus.

d. Dependent edema is unrelated to a paralytic ileus.


KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Comprehension |
Content Area: Physiological Adaptation: Alterations in Body Systems; Postpartum Care | Client
Need: Health Promotion and Maintenance; Physiological Integrity: Physiological Adaptation |
Difficulty Level: Moderate

9. The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be
receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse:

10. Assists the woman to lie down in a supine position.

11. Administers a rapid intravenous infusion of 500 mL of normal saline.

12. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion.

13. Encourages frequent cleansing breaths after the patient has been placed in the correct position
for the anesthesia administration.

ANS: b

Complications that may occur with spinal anesthesia block include maternal hypotension,
decreased placental perfusion, and an ineffective breathing pattern. Prior to administration, the
patient’s fluid balance is assessed, and IV fluids are administered to reduce the potential for
sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of
blood in the lower extremities). Following administration of the anesthetic, the patient’s blood
pressure, pulse, and respirations and fetal heart rate must be taken and documented every 5 to 10
minutes.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult
10. The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic
agent in an epidural is primarily to:

11. Increase the total anesthetic volume

12. Preserve a greater amount of maternal motor function

13. Increase the intensity of the motor and sensory block

14. Decrease the number of side effects

ANS: b

Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic
required and helps to preserve a greater amount of maternal motor function.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Comprehension | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Difficult

11. Tanya, a 30-year-old woman, is being prepared for an elective cesarean birth. The perinatal nurse
assists the anesthesiologist with the spinal block and then positions Tanya in a supine position.
Tanya’s blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm.
The perinatal nurse’s best response is to:

12. Place a wedge under Tanya’s left hip.

13. Discontinue Tanya’s intravenous administration.

14. Have naloxone (Narcan) ready for administration.

15. Have epinephrine ready for administration.


ANS: a

In the event of severe maternal hypotension, the nurse should place the patient in a lateral
position or use a wedge under the hip to displace the uterus, elevate the legs, maintain or increase
the IV infusion rate, and administer oxygen by face mask at 10 to 12 L/min, or according to
institution protocol.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content
Area: Maternity | Client Need: Physiological Integrity | Difficulty Level: Difficult

12. The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth.
Providing an opportunity to review this experience may assist Chantal in:

13. Her role development in the “letting go” stage

14. Decreasing her ambivalence about her labor and birth

15. Understanding her guilt involved in her labor and birth

16. Developing more positive feelings about her labor and birth

ANS: d

After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of
potential psychological issues that may arise. Research suggests that women may perceive
cesarean birth to be a less positive experience than a vaginal birth. Unplanned or emergent
cesarean deliveries and the experience of cesarean birth may be associated with more negative
perceptions of the birthing experience. Allowing Chantal to talk about the experience can help
her develop a more positive attitude about her own experience.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy
13. The best time to give prophylactic antibiotics to the women undergoing cesarean section is:

14. One hour before the surgery

15. Two hours before the surgery

16. Not indicated unless she has an active infection

17. At the time the cord is clamped

ANS: a
Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes prior
to the skin incision.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension


| Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level:
Easy

14. During a cesarean section, which action by the nurse is done to prevent compression of the
descending aorta and vena cava?

15. Right lateral tilt

16. Left lateral tilt

17. Elevate head of gurney at 30 degrees

18. Administration of IV fluid preload of 500 to 1000 mL

ANS: b

Positioning of the patient with a left tilt maintains a left uterine displacement to decrease the risk
of aortocaval compression related to compression on the aorta and inferior vena cava due to
weight of the gravid uterus.
KEY: Integrated Process: Nursing Process: Intervention | Cognitive Level: Application and
Comprehension | Content Area: Reduction of Risk Potential: Potential for Alterations in Body
Systems | Client Need: Safe and Effective Care Environment | Difficulty: Hard

Fill-in-the-Blank

15. A post-cesarean section client has been ordered to receive 500 mL of 5% dextrose in water every
4 hours. The drop factor of the macrodrip tubing is 10 gtt/mL. To what drip rate should the nurse
regulate the IV? __________ gtt/min

ANS: 21

Feedback: 21 gtt/min

The formula for calculating drip rates is:

volume multiplied by drop factor = drip rate

time in minutes

500 mL = 10 gtt/cc = 21 gtt/min

4 hours = 60 min/hr

KEY: Integrated Process: Nursing Process: Analysis; Nursing Process: Implementation |


Cognitive Level: Synthesis | Content Area: Pharmacological and Parenteral Therapies:
Medication Administration | Client Need: Physiological Integrity: Pharmacological and
Parenteral Therapies | Difficulty Level: Moderate

16. The perinatal nurse knows that the presence of abdominal distension and gas in the post-
cesarean birth mother is due to __________.

ANS: delayed peristalsis

Delayed peristalsis and constipation commonly occur because of slowed peristalsis associated
with pregnancy hormones and childbirth anesthesia. In addition, incisional pain may contribute
to a decrease in ambulation which contributes to delayed peristalsis.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content
Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

17. The Joint Commission Standard states that the __________, __________, and __________ are
accurately identified and clearly communicated during the final verification process before the
start of any surgical or invasive procedure.

ANS: site; procedure; patient

To decrease the risk of surgery or invasive procedure being done on the wrong patient or in the
wrong site, a “time-out” is called, and active communication to verify correct procedure, site,
and patient is done just prior to the beginning of surgery or invasive procedure.
KEY: Integrated Process: Communication and Documentation | Cognitive Level: Knowledge |
Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level:
Moderate

True/False

18. During an emergency cesarean birth the “time-out” procedure may be omitted based on the
obstetrical emergency.

ANS: False

Joint commission guidelines for patient safety necessitate there always be a time-out to prevent
wrong patient, wrong site, wrong procedure, and medical errors.

KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension


| Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level:
Easy