Chapter 31: Mental Health Disorders and Substance Abuse

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

MULTIPLE CHOICE

1. A client with a history of bipolar disorder is called by the postpartum support nurse for
follow-up. Which symptoms would reassure the nurse that the client is not experiencing a
manic episode?
a. Psychomotor agitation and lack of sleep
b. Increased appetite and lack of interest in activities
c. Hyperactivity and distractibility
d. Pressured speech and grandiosity
ANS: B
An increased appetite and a lack of interest would reassure the nurse that the client is not
experiencing an episode of mania. Clinical manifestations of a manic episode include at least
three of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas,
distractibility, psychomotor agitation, and excessive involvement in pleasurable activities. The
pregnant woman exhibiting symptoms of a manic episode will likely have a decreased interest
in eating and an increased level of interest in pleasurable activities without regard for negative
consequences. Psychomotor agitation and a lack of sleep, hyperactivity and distractibility, and
pressured speech and grandiosity are all clinical manifestations of a manic episode.

DIF: Cognitive Level: Apply REF: p. 746

TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what
is the nurse’s primary concern in planning the client’s care?
a. Displaying outbursts of anger
b. Neglecting her hygiene
c. Harming her infant
d. Losing interest in her husband
ANS: C
Thoughts of harm to herself or to the infant are among the most serious symptoms of PPD and
require immediate assessment and intervention. Although outbursts of anger and neglecting
personal hygiene are symptoms attributable to PPD, the major concern remains the potential
of harm to herself or her infant. Although this client is likely to lose interest in her spouse, it is
not the nurse’s primary concern.

DIF: Cognitive Level: Understand REF: p. 748 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity

3. During an inpatient psychiatric hospitalization, what is the most important nursing

intervention?
a. Contacting the client’s significant other
b. Supervising and guiding visits with her infant
c. Allowing no contact with anyone who annoys her
d. Having the infant with the mother at all times
 ANS: B
In the hospital setting, the reintroduction of the infant to the mother can and should occur at
the mother’s own pace. A schedule is set that increases the number of hours the mother cares
for her infant over several days, culminating in the infant staying overnight in the mother’s
room. These supervised and guided visits allow the mother to experience meeting the infant’s
needs and giving up sleep for the infant. Reintroducing the mother to her infant while in a
supervised setting is essential. Another important task for a mother under psychiatric care is to
reestablish positive interactions with others.

DIF: Cognitive Level: Understand REF: pp. 749-750 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity

4. Despite warnings, prenatal exposure to alcohol continues to far exceed exposure to illicit
drugs. Which condition is rarely associated with fetal alcohol syndrome (FAS)?
a. Respiratory conditions
b. Intellectual impairment
c. Neural development disorder
d. Alcohol-related birth defects (ARBDs)
ANS: A
Respiratory difficulties are not attributed to exposure to alcohol in utero. Other abnormalities
related to FAS include mental retardation, neurodevelopment disorders, and ARBDs.

DIF: Cognitive Level: Understand REF: p. 752

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. As a powerful central nervous system (CNS) stimulant, which of these substances can lead to
miscarriage, preterm labor, placental separation (abruption), and stillbirth?
a. Heroin
b. Alcohol
c. Phencyclidine (1-phenylcyclohexylpiperidine; PCP)
d. Cocaine
ANS: D
Cocaine is a powerful CNS stimulant. Effects on pregnancy associated with cocaine use
include abruptio placentae, preterm labor, precipitous birth, and stillbirth. Heroin is an opiate;
its use in pregnancy is associated with preeclampsia, intrauterine growth restriction,
miscarriage, premature rupture of membranes, infections, breech presentation, and preterm
labor. The most serious effect of alcohol use in pregnancy is FAS. The major concern
regarding PCP use in pregnant women is its association with polydrug abuse and its
neurobehavioral effects on the neonate.

DIF: Cognitive Level: Understand REF: pp. 752-753

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

6. According to research, which risk factor for PPD is likely to have the greatest effect on the
client postpartum?
a. Prenatal depression
b. Single-mother status
c. Low socioeconomic status
d. Unplanned or unwanted pregnancy
 ANS: A
Prenatal depression has been found to be a major risk factor for PPD. Single-mother status
and low socioeconomic status are both small-relationship predictors for PPD. Although an
unwanted pregnancy may contribute to the risk for PPD, it does not pose as great an effect as
prenatal depression.

DIF: Cognitive Level: Understand REF: p. 744

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

7. Which is the most accurate description of PPD without psychotic features?

a. Postpartum baby blues requiring the woman to visit with a counselor or
psychologist
b. Condition that is more common among older Caucasian women because they have
higher expectations
c. Distinguishable by pervasive sadness along with mood swings
d. Condition that disappears without outside help
ANS: C
PPD is characterized by an intense pervasive sadness along with labile mood swings and is
more persistent than postpartum baby blues. PPD, even without psychotic features, is more
serious and persistent than postpartum baby blues. PPD is more common among younger
mothers and African-American mothers. Most women need professional help to get through
PPD, including pharmacologic intervention.

DIF: Cognitive Level: Understand REF: p. 745

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. While providing care to the maternity client, the nurse should be aware that one of these
anxiety disorders is likely to be triggered by the process of labor and birth. Which disorder fits
this criterion?
a. Phobias
b. Panic disorder
c. Posttraumatic stress disorder (PTSD)
d. Obsessive-compulsive disorder (OCD)
ANS: C
PTSD can occur as the result of a past trauma such as rape. Symptoms of PTSD include re-
experiencing the event, numbing, irritability, angry outbursts, and exaggerated startle reflex.
With the increased bodily touch and vaginal examinations that occur during labor, the client
may have memories of the original trauma. The process of giving birth may result in her
feeling out of control. The nurse should verbalize an understanding and reassure the client as
necessary. Phobias are irrational fears that may lead a person to avoid certain events or
situations. Panic disorders may occur in as many as 3% to 5% of women in the postpartum
period and are described as episodes of intense apprehension, fear, and terror. Symptoms of a
panic disorder may include palpitations, chest pain, choking, or smothering. OCD symptoms
include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and
recheck her infant once he or she is born, although she realizes that this behavior is irrational.
OCD is optimally treated with medications.

DIF: Cognitive Level: Understand REF: p. 742

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
 9. Which substance used during pregnancy causes vasoconstriction and decreased placental
perfusion, resulting in maternal and neonatal complications?
a. Alcohol
b. Caffeine
c. Tobacco
d. Chocolate
ANS: C
Smoking in pregnancy is known to cause a decrease in placental perfusion and is the cause of
low-birth-weight infants. Prenatal alcohol exposure is the single greatest preventable cause of
mental retardation. Alcohol use during pregnancy can cause high blood pressure, miscarriage,
premature birth, stillbirth, and anemia. Caffeine may interfere with certain medications and
worsen arrhythmias. Chocolate, particularly dark chocolate, contains caffeine that may
interfere with certain medications.

DIF: Cognitive Level: Remember REF: p. 752

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. As part of the discharge teaching, the nurse can prepare the mother for her upcoming
adjustment to her new role by instructing her regarding self-care activities to help prevent
PPD. Which statement regarding this condition is most helpful for the client?
a. Stay home, and avoid outside activities to ensure adequate rest.
b. Be certain that you are the only caregiver for your baby to facilitate infant
attachment.
c. Keep your feelings of sadness and adjustment to your new role to yourself.
d. Realize that PPD is a common occurrence that affects many women.
ANS: D
Should the new mother experience symptoms of the baby blues, it is important that she be
aware that these symptoms are nothing to be ashamed of. As many as 10% to 15% of new
mothers experience similar symptoms. Although obtaining enough rest is important for the
mother, she should not distance herself from her family and friends. Her spouse or partner can
communicate the best visiting times to enable the new mother to obtain adequate rest. It is
also important that she not isolate herself at home by herself during this time of role
adjustment. Even if breastfeeding, other family members can participate in the infant’s care. If
depression occurs, then the symptoms will often interfere with mothering functions; therefore,
family support is essential. The new mother should share her feelings with someone else and
avoid overcommitting herself or feel as though she has to be superwoman. A telephone call to
the hospital “warm line” may provide reassurance with lactation issues and other infant care
questions. Should symptoms continue, a referral to a professional therapist may be necessary.

DIF: Cognitive Level: Apply REF: p. 748

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

11. A woman at 24 weeks of gestation states that she has a glass of wine with dinner every
evening. Why would the nurse counsel the client to eliminate all alcohol?
a. Daily consumption of alcohol indicates a risk for alcoholism.
b. She will be at risk for abusing other substances as well.
c. The fetus is placed at risk for altered brain growth.
d. The fetus is at risk for multiple organ anomalies.
 ANS: C
No period exists when consuming alcohol during pregnancy is safe. The documented effects
of alcohol consumption during pregnancy include mental retardation, learning disabilities,
high activity level, and short attention span. The brain grows most rapidly in the third
trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has
not been linked to alcohol use.

DIF: Cognitive Level: Apply REF: p. 752

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. A pregnant woman who abuses cocaine admits to exchanging sex to finance her drug habit.
This behavior places the client at the greatest risk for what?
a. Depression of the CNS
b. Hypotension and vasodilation
c. Sexually transmitted infections (STIs)
d. Postmature birth
ANS: C
Exchanging sex acts for drugs places the woman at increased risk for STIs because of multiple
partners and the lack of protection. Cocaine is a CNS stimulant that causes hypertension and
vasoconstriction. Premature delivery of the infant is one of the more common problems
associated with cocaine use during pregnancy.

DIF: Cognitive Level: Understand REF: p. 754

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. What is the most dangerous effect on the fetus of a mother who smokes cigarettes while
pregnant?
a. Genetic changes and anomalies
b. Extensive CNS damage
c. Fetal addiction to the substance inhaled
d. Intrauterine growth restriction
ANS: D
The major consequences of smoking tobacco during pregnancy are low-birth-weight infants,
prematurity, and increased perinatal loss. Cigarettes will not normally cause genetic changes
or extensive CNS damage. Addiction to tobacco is not a usual concern related to the neonate.

DIF: Cognitive Level: Understand REF: p. 752

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

14. The use of methamphetamine (meth) has been described as a significant drug problem in the
United States. The nurse who provides care to this client population should be cognizant of
what regarding methamphetamine use?
a. Methamphetamines are similar to opiates.
b. Methamphetamines are stimulants with vasoconstrictive characteristics.
c. Methamphetamines should not be discontinued during pregnancy.
d. Methamphetamines are associated with a low rate of relapse.
ANS: B
 Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and
are similarly used. As is the case with cocaine users, methamphetamine users are urged to
immediately stop all use during pregnancy. Unfortunately, because methamphetamine users
are extremely psychologically addicted, the rate of relapse is extremely high.

DIF: Cognitive Level: Understand REF: p. 753

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

15. With one exception, the safest pregnancy is one during which the woman is drug and alcohol
free. What is the optimal treatment for women addicted to opioids?
a. Methadone maintenance treatment (MMT)
b. Detoxification
c. Smoking cessation
d. 4 Ps Plus
ANS: A
MMT is currently considered the standard of care for pregnant women who are dependent on
heroin or other narcotics. Buprenorphine is another medication approved for the treatment of
opioid addiction that is increasingly being used during pregnancy. Opioid replacement therapy
has been shown to decrease opioid and other drug use, reduce criminal activity, improve
individual functioning, and decrease the rates of infections such as hepatitis B and C, human
immunodeficiency virus (HIV), and other STIs. Detoxification is the treatment used for
alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for
inpatient management. Women are more likely to stop smoking during pregnancy than at any
other time in their lives. A smoking cessation program can assist in achieving this goal. The 4
Ps Plus is a screening tool specifically designed to identify pregnant women who need in-
depth assessment related to substance abuse.

DIF: Cognitive Level: Apply REF: p. 755 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1. Reports have linked third trimester use of selective serotonin uptake inhibitors (SSRIs) with a
constellation of neonatal signs. The nurse is about to perform an assessment on the infant of a
mother with a history of a mood disorder. Which signs and symptoms in the neonate may be
the result of maternal SSRI use? (Select all that apply.)
a. Hypotonia
b. Hyperglycemia
c. Shivering
d. Fever
e. Irritability
ANS: C, D, E
Neonatal signs of maternal SSRI use include continuous crying, irritability, jitteriness,
shivering, fever, hypertonia, respiratory distress, feeding difficulty, hypoglycemia, and
seizures. The onset of signs and symptoms ranges from several hours to several days after
birth, but the signs generally resolve within 2 weeks.

DIF: Cognitive Level: Apply REF: p. 742

TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. Screening questions for alcohol and drug abuse should be included in the overall assessment
during the first prenatal visit for all women. The 4 Ps Plus is a screening tool specifically
designed to identify the need for a more in-depth assessment. Which are the correct
components of the 4 Ps Plus? (Select all that apply.)
a. Parents
b. Partner
c. Present
d. Past
e. Pregnancy
ANS: A, B, D, E
The nurse who is screening the client using the 4 Ps Plus would use the following format:
Parents: “Did either of your parents have a problem with alcohol or drugs?” Partner: “Does
your partner have a problem with alcohol or drugs?” Past: “Have you ever had any beer, wine,
or liquor?” Pregnancy: “In the month before you knew you were pregnant, how many
cigarettes did you smoke? How much beer, wine, or liquor did you drink?” Present: Is not a
component of the 4 Ps Plus.

DIF: Cognitive Level: Apply REF: p. 753

TOP: Nursing Process: Assessment MSC: Client Needs: Psychologic Integrity