Answers and Rationales 603
1. cannot use shivering to produce heat. 324. What is the most common complication for which a nurse
2. cannot break down glycogen to glucose.
3. has a limited supply of brown fat available to provide
heat.
4. has a limited amount of pituitary hormones to control
internal heat.
323. A nurse must meet the hydration needs of a preterm infant.
What should the nurse consider about the preterm infant’s
kidney function?
1. Large amounts of urine are excreted.
2. It is the same as in a full-term newborn.
3. Urine is concentrated with an elevated specific gravity.
4. Acid-base and electrolyte balance are adequately
maintained.
ANSWERS AND RATIONALES
Nursing Care to Promote Childbearing and
Women’s Health
1.  2  Nurses who counsel clients about abortion should
know what services are available and the various
methods that are used to induce abortion. Nurses
who cannot control their negative feelings toward
abortion should not counsel women who are
thinking of undergoing the procedure.
1  Nursing practice necessitates knowledge of research
results; statements must be based on fact, not personal
feelings or beliefs.  3  The nurse should give the client
only the information requested and should not state
personal feelings.  4  The nurse is responsible for giving
information about abortion and need not defer to the
health care provider.
Client Need: Management of Care; Cognitive Level: Application;
Nursing Process: Evaluation/Outcomes; Reference: Ch 23,
Induced Abortion, Nursing Care
2.  3  This response is a positive negotiation to be
reassigned to an area where the nurse’s personal
values will not pose a problem.
1  This is an ineffective way to resolve value conflict;
undoubtedly, a client would sense this conflict.  2  The
nurse may not have the legal, ethical, or professional
right to refuse this assignment if employed by the
facility.  4  Imposing this kind of advice is unethical and
unprofessional.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Nursing Care
3.  4  The client must feel comfortable enough to
verbalize her feelings; this helps to complete
the grieving process.
1  This is a false assumption.  2  Induced abortion is a
sterile procedure and should not predispose the client to
postoperative infection.  3  Studies show that
contraceptive counseling at this time is most important,
because the client may not return after the abortion.
CHILDBEARING AND WOMEN’S HEALTH NURSING
must monitor preterm infants?
1. Hemorrhage
2. Brain damage
3. Respiratory distress
4. Aspiration of mucus
325.  A nurse is caring for preterm infants with respiratory distress
in the neonatal intensive care unit (NICU). What is the
priority nursing action?
1. Limit caloric intake to decrease metabolic rate.
2. Maintain the prone position to prevent aspiration.
3. Limit oxygen concentration to prevent eye damage.
4. Maintain a high-humidity environment to promote gas
exchange.
ANSWERS AND RATIONALES
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis; Reference: Ch 23, Induced
Abortion, Nursing Care
4.  2  Because mothering is not an inborn instinct in
humans, almost all mothers, including multiparas,
report some ambivalence and anxiety about their
mothering ability.
1  Frequently maternal feelings are nurtured by the sight
of the infant.  3  The length of time it takes to develop
these feelings is specific for each individual. With some
mothers it may take a much longer time.  4  Ambivalent
feelings are universal in response to a neonate.
Client Need: Psychosocial Integrity; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
5.  3  Although support may help minimize guilt, it will
not eliminate it; however, support will sustain
family cohesion and unity.
1  Support may help, but it does not completely alleviate
guilt feelings.  2  Support does not affect the legal
responsibility of the parents.  4  This may help, but it
cannot completely relieve pressure.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 23, Induced Abortion, Nursing
Care
6.  2  Some type of a barrier contraceptive (condom
with foam or jelly or a diaphragm) is usually
recommended for the client with diabetes and
heart disease.
1  Oral contraceptives are not recommended for this
client because of their tendency to alter glucose
tolerance.  3  An IUD is not recommended because it
may predispose this client to infection.  4  Clients with
heart disease can become pregnant again in the future.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Nursing Care
 604 CHAPTER 28  Childbearing and Women’s Health Nursing
7.  4  Subsequent to IUD insertion there may be an
CHILDBEARING AND WOMEN’S HEALTH NURSING
excessive menstrual flow for several cycles; because
the IUD is a foreign body, there is an increase in the
blood supply as a result of the inflammatory
process.
1  There is no documentation of this.  2  This may occur
on insertion but is uncommon.  3  This may occur, but it
is not classified as a side effect.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Data Base
8.  2  The IUD may cause irritability of the myometrium,
inducing contraction of the uterus and expulsion of
the device.
1  This is a rare, rather than a common,
occurrence.  3  Clients do not report discomfort during
coitus when an IUD is in place.  4  Increased vaginal
ANSWERS AND RATIONALES
infections are not reported with the use of an IUD.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Data Base
9.  4  Intrauterine devices produce a spermicidal
intrauterine environment; a copper IUD (ParaGard
T380A) inflames the endometrium, damaging or
killing sperm and preventing fertilization and/or
implantation; a Mirena IUD (LNG-IUS) releases
levonorgestrel, damaging sperm and causing the
endometrium to atrophy, thus preventing
fertilization and/implantation.
1  A diaphragm blocks the cervical os.  2  This is not the
action of an IUD.  3  This is the function of a condom.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Data Base
10.  3  The ovum is capable of being fertilized for 24 to 36
hours following ovulation; after this time it travels a
variable distance between the fallopian tube and
uterus, and if not fertilized, disintegrates and is
phagocytized by leukocytes.
1, 2  The ovum is viable a longer time.  4  The ovum is
not fertilizable after 36 hours.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Menstrual Cycle
11.  1  As ovulation approaches there may be a drop in
the basal temperature because of an increased
production of estrogen; when ovulation occurs there
will be a rise in the basal temperature because of an
increased production of progesterone.
2  At ovulation the temperature rises after a slight
drop.  3  At ovulation the temperature drop is slight, not
marked.  4  At ovulation the temperature drops slightly
and then rises.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Data Base
12.  3  Breakthrough bleeding commonly occurs when
clients begin taking oral contraceptives; it is
midcycle bleeding, and if it persists, the dosage
should be changed.
1  Cervicitis is unrelated to oral contraceptive use.  2  At
this time there is no evidence that ovarian cysts are
related to oral contraceptive use.  4  Fibrocystic breast
disease is unrelated to oral contraceptive use.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Data Base
13.  4  Some spermatozoa will remain viable in the vas
deferens for a variable time after vasectomy.
1  There has been some success in reversing this
procedure.  2  Precautions must be taken to prevent
fertilization until absence of sperm in the semen has
been verified.  3  The procedure does not affect sexual
functioning.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Nursing Care
14.  1  Although unusual, conception can occur during
menses.
2  The pill prevents ovulation and therefore conception.
However, the pill does not protect a female from being
exposed to a sexually transmitted microorganism. 
3  Sperm do not survive in a large body of water. 
4  Condoms provide the lowest risk of developing an
STI. The risk of pregnancy when using a male condom is
about 14%, and when used correctly and consistently it
is 3%; the risk of pregnancy if a female condom is used
is 21%.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 23, Family
Planning, Contraceptive Methods
15.  Answer: 1, 5, 6.
1  Oral agents have a hormonal component. 
2  Diaphragms act as a barrier.  3  Cervical caps act as
a barrier.  4  Female condoms act as a barrier.  5  Foam
spermicides kill the sperm; there is no hormonal
effect.  6  Transdermal agents have a hormonal
component.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 23, Contraceptive Methods, Data Base
16.  1  Stress or infection can alter the body’s metabolism,
causing an elevation in temperature; a rise in
temperature from these causes may be
misinterpreted as ovulation.
2  This may increase sperm volume but does not affect
the female’s basal temperature.  3  Age is not a factor
concerning efficiency of the basal body temperature
method of contraception in premenopausal
woman.  4  Frequency of intercourse may affect the

volume of sperm but does not alter the female’s basal
temperature.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Data Base
17.  1  Antiovulatory drugs suppress menstruation.
Breakthrough bleeding is not expected with
biphasic drugs. The drug is given for 21 days, and a
menstrual flow does not occur during this time.
2  Sexual activity is not restricted when one is taking oral
contraceptives.  3  There is no indication for increased
Pap smears; once a year is sufficient.  4  Increasing
calcium intake is not relevant to the administration of
oral contraceptives.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Contraceptive Methods, Nursing Care
18.  4  Excessive bleeding should be reported because it is
an indication that all of the products of conception
have not been evacuated.
1  The client may shower daily.  2  Tampons should be
avoided for at least 3 days, although some protocols stress
avoidance of tampons for 3 weeks.  3  Depending on the
protocol, sexual intercourse should be avoided for at least
1 week and up to 2 weeks.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 23, Induced
Abortion, Nursing Care
19.  3  A follow-up visit  4  to 8 days later should confirm
that the abortion has occurred.
1, 4  This is too soon.  2  This is too late.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 23, Induced Abortion,
Data Base
20.  3  A laparoscopic tubal ligation takes about 20
minutes to perform. The client is admitted as an
outpatient and goes home the same day after she
recovers from the anesthesia.
1  Menstruation will continue because there is no trauma
to the ovaries or the endocrine glands involved with
reproduction.  2  Sterility is immediate; a waiting period
is not required as with a vasectomy.  4  Microsurgery to
reverse the procedure is not guaranteed or easily
accomplished.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 23, Contraceptive
Methods, Data Base
21.  3  Ovulation occurs 14 days before the onset of menses.
1  Midway between cycles is appropriate only if the client
has a 28-day cycle.  2  This means that ovulation occurs
on approximately day 5 of the menstrual cycle, which is
not factual.  4  Variations in the cycle occur in the
preovulation period; it is not as accurate as counting 14
days before the next expected menses.
Answers and Rationales 605
Client Need: Health Promotion and Maintenance; Cognitive
CHILDBEARING AND WOMEN’S HEALTH NURSING
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Menstrual Cycle
22.  4  At this time, because of increased estrogen levels,
the cervical mucus is abundant, and its quality
changes in such a way as to optimize sperm survival
time.
1  Cervical mucus at this time is no longer receptive to
spermatozoa.  2  Cervical mucus is destructive to
spermatozoa and sperm penetration at this time.  3  The
cervical mucus at this time is not yet receptive to
spermatozoa.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Menstrual Cycle
23.  2  Past pelvic infections may result in tubal occlusions,
ANSWERS AND RATIONALES
most of which are caused by postinfection
adhesions.
1  Although a tubal injury is possible, tubal infections are
more common.  3  This is a benign tumor of the uterus
and does not affect the tube.  4  Tubal congenital
anomalies are rare; uterine anomalies are more common.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 23, Infertility and Sterility
24.  1  A strategy for increasing the chances of conceiving
requires the couple to plan intercourse only while
the woman is ovulating; this removes spontaneity
and is often stressful.
2  Obtaining and delivering the necessary specimens may
be inconvenient but should not be stressful.  3  The
number of office visits and examinations that are required
may be cumbersome but should not be stressful. 
4  Although taking daily temperatures may be annoying,
it should not be stressful.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 23, Infertility and Sterility
25.  2  This is an accurate, objective statement that should
be included in a discussion of genetic factors that
influence fertility.
1  This is not the role of the nurse; based on the
objective data imparted by the nurse, the couple should
make the decision whether or not to be tested. 3, 4  This
information is not relevant at this time and might cause
unnecessary concern.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 23, Infertility
and Sterility
26.  2  When the testes are twisted, a decrease in their
blood supply occurs. This can result in gangrene.
1  Medication can be given to relieve pain.  3  The testes
do not rupture if edema occurs.  4  Sperm are continually
produced, so their destruction is not the concern.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
 606 CHAPTER 28  Childbearing and Women’s Health Nursing
Process: Planning/Implementation; Reference: Ch 23, Infertility
CHILDBEARING AND WOMEN’S HEALTH NURSING
and Sterility
27.  4  This test enables the examiner to visualize the
uterus and fallopian tubes and the pelvic organs of
reproduction.
1  A biopsy is the surgical excision of tissue for
diagnostic purposes.  2  A cystogram is used to
visualize the urinary bladder.  3  A culdoscopy is the
direct examination of female pelvic viscera using an
endoscope introduced through a perforation in the
vagina.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 23, Infertility and Sterility
28.  1  Providing factual information decreases fear and
fosters further communication.
2  Cervical cancer is asymptomatic in the early
stages.  3  This offers false reassurance.  4  At this time
ANSWERS AND RATIONALES
the client may not be able to focus on written
instructions; also, the anxiety may be related to the
potential implications of the results of the test rather
than the actual procedure.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 23, Related
Procedures, Pelvic Examination
29.  2  January 16. The time between ovulation and the
next menstruation is relatively constant. Within a
30-day cycle the first 15 days are preovulatory,
ovulation occurs on day 16, and the next 14 days
are postovulatory.
1, 3, 4  This answer reflects an inaccurate calculation of
the date of ovulation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process; Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 23,
Menstrual Cycle
Nursing Care Related to Major Disorders
Affecting Women’s Health
30.  2  Leuprolide (Lupron) is administered once a month
via IM injection; it decreases LH and FSH levels, as
well as hormone-dependent tissue. One of its side
effects is hot flashes.
1  Estrogen (Premarin) affects the release of pituitary
gonadotropins and inhibits ovulation; it is
contraindicated because the goal of treatment is to
suppress the action of estrogen on the endometrial
tissue.  3  Diclofenac (Voltaren) is used for primary
dysmenorrhea; it is an NSAID that inhibits prostaglandin
synthesis.  4  Ergonovine (Ergotrate) is used to contract
the postpartum uterus.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 24, Endometriosis, Data Base
31.  1  Ceftriaxone (Rocephin) is a broad-spectrum
antibiotic and is preferred during pregnancy.
2  Levofloxacin (Levaquin), although listed as an
unlabeled use for gonococcal infection, should not be
prescribed during pregnancy.  3  Sulfonamides may cause
hemolysis in the fetus.  4  Trimethoprim/
sulfamethoxazole (Bactrim) contains a sulfonamide and is
contraindicated during pregnancy.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 24, Vaginitis, Data Base
32.  2  Persistent pain of any kind during menstruation
(dysmenorrhea) usually indicates a problem, and
the client should seek medical attention.
1  Although diversion is a method to alter pain
perception, the presence of pain requires investigation of
possible causes.  3  Although a nutritious diet is
beneficial, iron does not prevent the pain of
dysmenorrhea.  4  Voluntary relaxation of the abdominal
muscles does not result in cessation of dysmenorrhea.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 24,
Endometriosis, Data Base
33.  Answer: 3, 4.
1  This is not related to endometriosis.  2  This is not
related to endometriosis.  3  Endometriosis is the
presence of aberrant endometrial tissue outside the
uterus. The tissue responds to ovarian stimulation and
bleeds during menstruation, which causes rectal
pressure.  4  Endometriosis is the presence of aberrant
endometrial tissue outside the uterus. The tissue responds
to ovarian stimulation and bleeds during menstruation,
which causes abdominal pain. 5 This is not related to
endometriosis. 6 Pelvic infections are not caused by
endometriosis; they most frequently are sexually
transmitted.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 24,
Endometriosis, Data Base
34.  4  The nurse must determine the client’s feelings
concerning loss of fertility; if she is childless, the
client must cope with the knowledge that unless
ova are removed and frozen before the surgery, her
genes will not be passed to the next generation,
even with in vitro fertilization.
1  Laparoscopic surgery is relatively painless.  2  Since the
abdominal cavity is not entered, there is minimal risk of
hemorrhage.  3  There is no evidence to indicate that a
chronic illness is related to the need for the surgery.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis; Reference: Ch 24,
Endometriosis, Nursing Care
35.  Answer: 1, 3.
1  The posterior vaginal wall is pushed forward by the
herniation of the rectum; this protrusion causes painful
intercourse.  2  A rectocele is not accompanied by
abdominal pain.  3  The posterior vaginal wall is pushed
forward by the herniation of the rectum; this protrusion
increases rectal pressure and causes the bearing-down
sensation.  4  This is the primary sign of a cystocele. 5 A

cystocele, not a rectocele, is associated with urinary tract
infections.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 24,
Cystocele and/or Rectocele, Data Base
36.  4  As the uterus drops, the vaginal wall relaxes. When
the bladder herniates into the vagina (cystocele)
and the rectal wall herniates into the vagina
(rectocele), the individual feels pressure or pain in
the lower back and/or pelvis. When there is an
increase in intraabdominal pressure in the presence
of a cystocele, incontinence results.
1  A white vaginal discharge (leukorrhea) and vaginal
itching (pruritus) do not indicate cystocele and rectocele;
they are common with a vaginal infection.  2  Sporadic
bleeding is not expected with cystocele and
rectocele.  3  These are not expected with cystocele and
rectocele; a fever would indicate an infection;
constipation, not diarrhea, is more likely to occur.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
24, Cystocele and/or Rectocele, Data Base
37.  Answer: 1, 3, 4.
1  Distention causes discomfort; this is avoided because
the catheter prevents retention.  2  Because the bladder is
continually empty when an indwelling catheter is in
place, it loses tone; this is an expected side effect.  3  The
effects of anesthesia and the inflammatory process may
impede voiding, leading to urinary retention; an
indwelling catheter empties the bladder.  4  Distention
places pressure on the suture line; this is avoided because
the indwelling catheter prevents retention. 5 This is not
necessary; hourly urine outputs reflect kidney function.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 24,
Cystocele and/or Rectocele, Nursing Care
38.  1  Immediately after this type of surgery, pain is
associated with bearing down; the client should be
instructed to increase fluid, fiber, and activity to
prevent constipation.
2  Exercise is encouraged.  3  The anterior colporrhaphy
is expected to reduce incontinence; urinary retention is
not expected.  4  The colporrhaphy involves only the
vaginal wall; the rectum should not be involved.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 24, Cystocele and/
or Rectocele, Nursing Care
39.  4  Ulcerations may occur when the vagina and uterus
are displaced and exposed.
1  Edema is not usually the problem.  2  Fistulas are not
associated with procidentia.  3  Exudate is not present
with procidentia.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
24, Prolapsed Uterus, Nursing Care
40.  3  Moist compresses may be ordered to prevent
ulcerations.
Answers and Rationales 607
1  Ambulation is contraindicated; it will predispose to
CHILDBEARING AND WOMEN’S HEALTH NURSING
the development of ulcerations.  2  This is ineffective
because gravity alone does not correct the
prolapse.  4  This may cause irritation and should be
avoided.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 24, Prolapsed Uterus, Nursing Care
41.  2  The Fowler position facilitates localization of the
infection by pooling exudate in the lower pelvis.
1, 3  This position does not use gravity to promote
pooling of exudate in the lower pelvis.  4  This position
does not use gravity to promote pelvic drainage despite
an elevated head.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 24, Pelvic Inflammatory Disease, Nursing Care
42.  1  Erosion of the cervix frequently occurs at the
ANSWERS AND RATIONALES
columnosquamous junction, the most common site
for carcinoma of the cervix.
2  Treatment of cervical erosions does not prevent pelvic
inflammatory disease; early onset of sexual intercourse
(before 16 years of age), multiple sexual partners, and
history of human papillomavirus (HPV) infection are
risk factors for cancer of the cervix rather than
consequences of precervical cancer.  3  Metrorrhagia,
abnormal bleeding from the uterus, may be present as
erosion develops into carcinoma; however, spotting may
be the earliest sign and will be eliminated when the
cancer is treated.  4  The goal of treatment of the erosion
is to prevent cancer.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 24, Cancer of
the Cervix, Data Base
43.  3  Polyps are usually benign, but a biopsy should be
done because epidermoid cancer occasionally arises
from cervical polyps.
1  Polyps usually are benign.  2  Polyps rarely are the
precursors of uterine cancer.  4  Bleeding may occur
whether they are benign or malignant.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Assessment/Analysis; Reference: Ch 24, Uterine
Neoplasms, Data Base
44.  4  Any sign of abnormal vaginal bleeding may indicate
cervical cancer and must be investigated.
1  Discomfort is a late sign of cervical cancer because
there are few nerve endings in this area.  2  The cancer
must be extensive to cause pressure.  3  Discharge
becomes foul-smelling after there is necrosis and
infection; it is not an early sign.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Assessment/Analysis; Reference: Ch 24, Cancer of the
Cervix, Data Base
45.  1  According to the International Federation of
Gynecology and Obstetrics, stage 0 is indicative of
preinvasive cancer. When the cancerous cells are
 608 CHAPTER 28  Childbearing and Women’s Health Nursing
completely confined within the epithelium of the
CHILDBEARING AND WOMEN’S HEALTH NURSING
cervix without stromal invasion, it is stage 0 and
called carcinoma in situ.
2  This is stage IA; there is minimal stromal invasion.  Neoplasms, Data Base
3  This is stage II and involves the area around the broad
ligaments but not the pelvic wall; there is extension to
the corpus of the uterus.  4  This is stage I.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
24, Cancer of the Cervix, Data Base
46.  4  Rare cell adenoma of daughters is associated with
mothers who took DES or DES-type drugs during
pregnancy.
1  Although DES was prescribed between 1941 and 1971
to reduce the risk for spontaneous abortion in high-risk
women, this question will not elicit specific information
about DES.  2  Use of oral contraceptives is not
associated with DES exposure.  3  The client with
ANSWERS AND RATIONALES
DES-related problems may exhibit abnormal bleeding or
a heavy mucoid vaginal discharge, not lesions on the
perineum.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Assessment/Analysis; Reference:
Ch 24, Cancer of the Cervix, Data Base
47.  2  The physical trauma of the procedure will result in a
blood-tinged vaginal discharge for several days.
1  Vaginal packing will be in place for 2 to 3 days;
intercourse and tampon use should be delayed until total
healing occurs.  3  Conization does not involve an
external incision or dressing.  4  Conization affects only
the cervix and does not alter reproductive ability.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 24, Cancer of the
Cervix, Nursing Care
48.  3  Aprons do not protect the posterior side of the
caregiver; therefore, the nurse should always keep
the front of the apron facing the source of
radiation.
1  This is unnecessary. Body fluids of clients with
unsealed, not sealed, implants may be contained in a
specially marked container, while others are allowed to
use a toilet followed by several flushes.  2  Client
receiving radioactive sealed or unsealed therapy should be
in a private room with a private bath. This protects other
clients receiving internal radiation from excessive
exposure.  4  Visiting should be limited to those
individuals who are 16 years of age and older. Visits
should last no longer than 30 minutes daily. Visitors
should be taught to maintain a 6-foot distance from the
source of the radiation.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 24, Cancer of the Cervix, Nursing Care
49.  1  An panhysterectomy in the premenopausal woman
produces artificial onset of menopause.
2, 3, 4  Because the uterus is removed, there will be no
uterine endometrial proliferation and no desquamation.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 24, Uterine
50.  4  A hysterectomy involves only removal of the uterus.
The ovaries, which secrete estrogen and
progesterone, are not removed. Therefore,
menopause will not be precipitated but will occur
naturally.
1  Surgical menopause is precipitated by the removal of
the ovaries, not the uterus.  2  When the ovaries are
removed, older women might have less severe symptoms
than younger women; however, in this instance the
ovaries are not removed.  3  This does not answer the
question. The nurse should serve as a resource person.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 24, Uterine
Neoplasms, Data Base
51.  4  The nurse cannot prescribe medication. In addition,
the use of hormones is controversial and depends
on the health care provider’s beliefs and the client’s
needs.
1, 3  This is advice the nurse is not legally licensed to
provide.  2  This is an evasive response; it does not
answer the client’s question.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 24, Uterine
Neoplasms, Data Base
52.  1  During an abdominal hysterectomy the urinary
bladder may be nicked accidently.
2  The client is not likely to develop an infection with
bleeding so soon.  3  Bleeding would be present from
other sites, such as the incision, as well as in the urinary
bag.  4  The uterus is removed with a hysterectomy;
therefore, there is no uterine bleeding.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 24, Uterine Neoplasms, Nursing Care
53.  4  Estrogen receptor protein (ERP)–positive tumors
have a more dramatic response to hormonal
therapies that reduce estrogen.
1  Estrogen contributes to tumor growth; supplements are
not indicated.  2  This does not influence breast
reconstruction.  3  ERP-positive is unrelated to metastasis.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 24, Cancer of the Breast, Data Base
54.  3  Postoperatively the arm on the operated side is
elevated on pillows, with the hand higher than the
arm to prevent muscle strain and edema.
1  Total immobilization should be avoided, and
adduction may put undue pressure on the operative
site.  2  Although the arm is slightly abducted, sandbags
are not used because complete immobility should be
prevented.  4  This will impair venous return and increase
edema.

Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 24, Cancer of the Breast, Nursing Care
55.  1  Deep breathing aids in expanding lung tissue and
prevents stasis of pulmonary secretions.
2  Although empathetic, delay could compromise
the client’s respiratory status.  3  This may result in
atelectasis and retained respiratory secretions.  the client’s bones.  2  Increased, not decreased, urine
4  This only states a fact and provides no option
to meet the need to limit pain or the need to prevent
atelectasis.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Caring; Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 24,
Cancer of the Breast, Nursing Care
56.  4  This defect in bone matrix formation weakens the
bones, making them unable to withstand usual
functional stresses.
1  Avascular necrosis is death of bone tissue that results
from reduced circulation to bone.  2  Pathologic fractures
can result from osteoporosis.  3  Hyperplasia of
osteoblasts is not related to osteoporosis. This occurs
during bone healing.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 24,
Osteoporosis, Data Base
57.  1  This regimen limits bone demineralization and
reduces bone pain, which promote increased
activity.
2  This is unrelated to osteoporosis; it would be an
expected outcome if the client were receiving calcium for
hypocalcemia.  3  This is unrelated to osteoporosis or its
therapy.  4  This is unrelated to osteoporosis; it would be
expected if the client were receiving vitamin C for
capillary fragility.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 24, Osteoporosis, Nursing Care
58.  3  Prolonged immobility results in bone
demineralization because there is decreased bone
production by osteoblasts and increased resorption
by osteoclasts.
1  Estrogen helps prevent bone demineralization.  bone density.  3  Sunscreen should be avoided to promote
2  Hypoparathyroidism decreases mobilization of calcium
from the bones, and thus serum calcium level is lowered.  in the skin; vitamin D helps the body absorb calcium.
4  Decreased calcium intake or absorption may
precipitate osteoporosis.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
24, Osteoporosis, Data Base
59.  3  Turnip greens are high in calcium and vitamins.
1  High levels of nitrogen from protein breakdown may
increase the release of calcium from bone to serve as a
buffer of the nitrogen.  2  Soft drinks that are high in
phosphorus may interfere with calcium absorption from
the gastrointestinal (GI) tract.  4  Enriched grains that are
high in phosphorus may interfere with calcium
absorption from the GI tract.
Answers and Rationales 609
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
CHILDBEARING AND WOMEN’S HEALTH NURSING
Integrated Process: Teaching/Learning; Nursing Process:
Evaluation/Outcomes; Reference: Ch 24, Osteoporosis, Nursing Care
60.  3  A diet high in calcium and exercise, which helps
deposit calcium into bone, are the most important
factors in limiting the extent of osteoporosis.
1  Weight gain should be discouraged to limit stress on
calcium should be monitored because it reflects
demineralization of bone.  4  Opioids usually are not
prescribed; other analgesics are used for pain.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 24,
Osteoporosis, Nursing Care
61.  Answer: 3, 5.
1  Weight loss should be slow and reasonable; restricting
calories promotes production of the hormone leptin,
ANSWERS AND RATIONALES
which stimulates bone loss.  2  Eight hundred or more
(up to 2,000), international units (IU), not 400 IU, of
vitamin D are the recommended daily intake for a
postmenopausal woman.  3  This is the recommended
daily intake of calcium for a postmenopausal woman. 
4  These activities may promote overall health and vigor;
they will not increase the strength or mass of bone. 
5  Weight-bearing activities (e.g., walking, dancing,
weight lifting, and aerobic exercise) are best for building
bone mass.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 24, Osteoporosis,
Nursing Care
62.  4  Teriparatide (Forteo) is a 34–amino acid
polypeptide that represents the biologically active
part of human parathyroid hormone; it enhances
bone microarchitecture and increases bone mass
and strength.
1  Supplemental intake of vitamin A should not exceed
recommended daily requirements; too much vitamin A
has been associated with bone loss and an elevated rate of
fractures.  2  Alendronate sodium (Fosamax), a regulator
of bone metabolism, not teriparatide (Forteo), inhibits
osteoclast-mediated bone resorption, minimizing loss of
exposure to the sun so that vitamin D can be converted
Sunscreen should be used after 5 to 20 minutes of
exposure to prevent the negative effects of prolonged
exposure to ultraviolet rays.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 24, Osteoporosis, Data Base
63.  3  Although not 100% effective, a condom is the best
protection against gonorrhea in a sexually active
person.
1  Douching has no proven protective effect against
sexually transmitted infections; excessive douching can
alter the natural environment of the vagina and may even
promote an ascending infection.  2  Although this is the
 610 CHAPTER 28  Childbearing and Women’s Health Nursing
best way to prevent a sexually transmitted infection, it is
CHILDBEARING AND WOMEN’S HEALTH NURSING
not the most realistic response for a sexually active
person. Once people become sexually active, they usually
remain sexually active.  4  Spermicidal creams do not
have a protective effect against sexually transmitted
infections; spermicides kill sperm and limit the risk for
pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 24,
Vaginitis, Nursing Care
64.  4  Metronidazole (Flagyl) is a potent amebicide. It is
effective in eradicating the protozoan Trichomonas
vaginalis.
1  Penicillin is administered for its effect on bacterial, not
protozoal, infections.  2  Gentian violet is a local
antiinfective that is applied topically; it may cause
discoloration of the skin. Gentian violet is effective
ANSWERS AND RATIONALES
against Candida albicans.  3  This is an antifungal for
infections caused by C. albicans.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 24, Vaginitis, Data Base
65.  3  This is the anatomic direction of the vaginal tract in
the back-lying position.
1, 2, 4  The vaginal tract may be injured when the
douche nozzle is directed without considering the vagina’s
anatomy.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 24,
Vaginitis, Nursing Care
Nursing Care of Women during Uncomplicated
Pregnancy, Labor, Childbirth, and the
Postpartum Period
66.  2  Expected periods of marked change and
adjustment are called developmental crises.
1  These are transient; they are similar to previous mood
changes and should not affect the client’s ability to
cope.  3  These occur throughout the life cycle of a
mature woman and should not now be classified as a
crisis.  4  Pregnancy becomes a crisis if the client’s partner
withdraws support.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Nursing Process: Assessment/Analysis; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
67.  3  Nonsteroidal antiinflammatory drugs (NSAIDs), as
well as other over-the-counter (OCT) drugs taken
during pregnancy, may cause problems in the
newborn during the neonatal period.
1  This is not a cause for concern; if the membranes
ruptured more than 24 hours before birth, infection may
be a concern.  2  Hemophilia affects males; this fetus is
known to be a female. A female may be a carrier but will
not have hemophilia.  4  A history of a placenta previa in
an earlier pregnancy will not have implications for this
newborn.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference: Ch
25, Prenatal Period, Nursing Care During the Prenatal Period
68.  4  This is a genetic disorder transmitted as an
autosomal recessive trait that occurs primarily
among Ashkenazi Jews.
1, 2, 3  This disease does not have a higher prevalence in
the Jewish population.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
69.  1  During the eighth week of pregnancy the organ
systems and other structures are developed to the
extent that they take the human form; at this time
the embryo becomes a fetus and remains so until
birth.
2  At this time the developing cells are called an
embryo.  3  At the time of implantation the group of
developing cells is called a blastocyst.  4  The embryo can
be visualized on a sonogram before it becomes a fetus.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period, Development of the Embryo/Fetus
70.  2  The pressure of the enlarging fetus causes upward
displacement of the diaphragm, which results in
thoracic breathing; this limits the descent of the
diaphragm on inspiration.
1  The lower rib cage expands.  3  There is no change in
the size of the lung during pregnancy.  4  The thoracic
cage enlarges; it does not rise.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
71.  3  By this time the fetus and placenta have grown,
expanding the size of the uterus. The enlarged
uterus extends into the abdominal cavity.
1, 2  At this time the uterus is still within the pelvic
area.  4  At this time the uterus has already risen out of
the pelvis and is extending farther into the abdominal
area.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
72.  Answer: 2, 5, 4, 1, 3.
2  Sickle cell screening, particularly for black women,
should be done on the initial visit. 5 Alpha-fetoprotein
(AFP) testing for neural tube defects should be done
between 14 and 16 weeks.  4  Serum glucose testing for
gestational diabetes should be done between 26 and 28
weeks.  1 Fetal movement tests can begin at 28 weeks
gestation because the fetus’ pattern of movement

becomes stabilized at this time.  3  Group B streptococcus
culture should be done between 36 and 38 weeks.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference: Ch
25, Prenatal Period; Physical, Physiologic, and Emotional Changes
During Pregnancy
73.  Answer: 1, 2, 5.
1  Understanding risks of transmission along with
treatment options if the client is HIV positive will help
her make appropriate decisions regarding
testing.  2  Some women are confused about what
positive or negative means when receiving test results.
Explaining this in pretest counseling and again when
results are given decreases unnecessary stress and
misunderstanding.  3  Although it may be helpful for
health care providers to know if a client is at risk for
HIV, the client is not required to disclose this
information.  4  HIV testing of pregnant women is not
required; however, it is recommended by health care
providers.  5  Because of the stigma of the disease and
possible effects on insurance and medical care, clients
should receive adequate counseling regarding
implications.
Client Need: Reduction of Risk Potential; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 25, Prenatal Period; Physical,
Physiologic, and Emotional Changes During Pregnancy
74.  1  This is the period in which the fetus stores deposits
of fat.
2  There is growth, but fat deposition does not occur in
this period.  3  The first 8 weeks is the period of
organogenesis, when cells differentiate into major organ
systems.  4  This is the period of the blastocyst, when
initial cell division takes place.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period, Development of the Embryo/
Fetus
75.  2  April 29, 2011. The Nägele rule is an indirect,
noninvasive method for estimating the date of
birth: EDB = last menstrual period +  1  year
–  3  months + 7 days.
1  This is beyond the expected date of birth. 3, 4  This is
before the expected date of birth.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
76.  4  Increasing the client’s knowledge of physical and
psychologic changes resulting from pregnancy
prepares the client for expected changes as
pregnancy continues; it is most effective when
taught during the first trimester.
1  This is too early; this should be done in the last
trimester.  2  The client should be alerted to danger signs
and symptoms; however, primary teaching is directed
toward increasing her knowledge of expected physiologic
changes.  3  Concerns about role transition to parenthood
should be addressed in the third trimester.
Answers and Rationales 611
Client Need: Health Promotion and Maintenance; Cognitive
CHILDBEARING AND WOMEN’S HEALTH NURSING
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
77.  2  Crown to rump measurement is used to determine
the age of the embryo until 11 weeks.
1  Occipital frontal diameter is not an ultrasound
measurement used at term.  3  Biparietal diameter at
term will be approximately 9.8 cm.  4  Diagonal
conjugate is not used as an ultrasound measurement; it is
the estimated size of the maternal pelvic outlet. The
actual size of the pelvis, as it relates to fetal size, is best
determined with ultrasonography.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
ANSWERS AND RATIONALES
78.  2  The blood volume increases by approximately 50%
during pregnancy. Peak blood volume occurs
between 30 and 34 weeks’ gestation.
1  The hematocrit decreases as a result of hemodilution. 
3  The sedimentation rate increases because of a decrease
in plasma proteins.  4  WBC values remain stable during
the antepartum period.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
79.  3  A purplish color results from the increased
vascularity and blood vessel engorgement of the
vagina.
1  This is softening of the lower uterine segment.  2  This
is softening of the cervix.  4  After the fourth month of
pregnancy, uterine contractions can be felt through the
abdominal wall. They are irregular and painless, and they
increase blood flow to the placenta.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Integrated Process: Communication/
Documentation; Nursing Process: Assessment/Analysis; Reference:
Ch 25, Prenatal Period; Physical, Physiologic, and Emotional Changes
During Pregnancy
80.  2  There is a 30% to 50% increase in maternal plasma
volume at the end of the first trimester, leading to a
decrease in the concentrations of hemoglobin and
erythrocytes.
1  Erythropoiesis increases after the first trimester. 
3  Iron utilization is unrelated to the development of
physiologic anemia of pregnancy.  4  Detoxification
demands are unchanged during pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
81.  2  The hemoglobin level of a healthy individual is
12 to 16 g/dL. During pregnancy it may decrease as
a result of an increased blood volume, especially
during the second trimester. The hemodilution is
greater than a concomitant increase in RBC
 612 CHAPTER 28  Childbearing and Women’s Health Nursing
production, causing physiologic anemia. If the
CHILDBEARING AND WOMEN’S HEALTH NURSING
hemoglobin decreases to less than 11 g/dL, the
client is diagnosed with anemia, probably due
to a deficiency of iron or folic acid. Iron
supplementation may need to be increased.
1  The expected platelet level is 150,000 to 400,000
mm3. There should be no significant change in this level
throughout pregnancy.  3  The expected fasting blood
glucose is 70 to 105 mg/dL; there should be no
significant change in this level throughout pregnancy.  after the first trimester.
4  The expected WBC count is 5,000 to 10,000 mm3
and during pregnancy it is 5,000 to 15,000 mm3; it
begins to rise in the second trimester and peaks in the
third trimester.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 25, Prenatal Period; Physical, Physiologic, and Emotional Changes
During Pregnancy
ANSWERS AND RATIONALES
82.  3  Before health teaching is instituted, the nurse
should ascertain the client’s past experiences; they
will influence the teaching plan.
1  This does not give the client a chance to discuss her
feelings about the examination.  2  This presupposes that
the client is fearful and does not address the client’s
question.  4  This does not give the client a chance to
discuss her feelings about the examination; the nurse is
assuming that the client’s concerns are related to
discomfort.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 25, Prenatal Period, Nursing Care During the Prenatal
Period
83.  3  The acronym GTPAL reflects G, gravidity; T, term
birth; P, preterm births; A, abortions; and L, living
children; G5 T2 P1 A1 L4 indicates that there were
5 pregnancies, twins count as 1 pregnancy and
the present pregnancy counts as 1;  2  term
births; twins count as 1 preterm birth;  muscles and applies gentle pressure to the veins,
1  abortion;  4  living children.
1  G4 T3 P2 A1 L4: this indicates that there were 4, not
5, pregnancies; 3, not 2, term births; twins count as 1,
not 2, preterm birth; 1 abortion; 4 living children. legs can be elevated while sitting at her desk.  3  If the
  2  G5 T2 P2 A1 L4: this indicates that there were 5
pregnancies; 2 term births; twins count as 1, not 2,
preterm birth; 1 abortion; 4 living children.  4  G4 T3
P1 A1 L4: this indicates that there were 4, not 5,
pregnancies; 3, not 2, term births; twins count as 1
preterm birth; 1 abortion; 4 living children.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Communication/
Documentation; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period, Nursing Care During the
Prenatal Period
84.  4  This is an expected cardiopulmonary adaptation
during pregnancy caused by an increased
ventricular rate and elevated diaphragm.
1, 2, 3  This is pathologic, a sign of impending cardiac
decompensation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
85.  4  Chorionic gonadotropin, secreted in large amounts
by the placenta during gestation, and the metabolic
changes associated with pregnancy can precipitate
nausea and vomiting in early pregnancy; usually
the manifestations of morning sickness disappear
1  Estrogen is elevated throughout pregnancy, but it is
not the instigator of the nausea and vomiting. 
2  Progesterone is elevated throughout pregnancy, but
it is not the instigator of the nausea and vomiting. 
3  The luteinizing hormone is present only during
ovulation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
86.  2  Sodium is needed to maintain body water balance;
sodium requirements increase slightly during
pregnancy to accommodate the increased blood
volume. A healthy pregnant woman should not
limit her sodium intake.
1  This could be detrimental to the client’s health. 
3  Sodium, although essential, is not a nutrient but a
mineral.  4  There are no restrictions on salt intake
during pregnancy.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
87.  1  Maintaining the sitting position for prolonged
periods may constrict the vessels of the legs,
particularly in the popliteal spaces, as well as
diminish venous return. Walking contracts the leg
thus promoting venous return.
2  A better means of improving circulation is to walk
around several times each morning and afternoon; the
client is feeling well, there are no contraindications to
working throughout her pregnancy.  4  Adequate
nourishment can be obtained during mealtimes; the
client does not require extra nutrition breaks.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period, Nursing Care During the Prenatal Period
88.  1  More information is needed before the nurse can
give a professional response.
2  Although the client’s feelings are important, at this
time she is seeking information.  3  Although this is true,
more information is needed before the nurse should
respond.  4  This is misinformation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Communication/

Documentation; Nursing Process: Assessment/Analysis; Reference:
Ch 25, Prenatal Period, Nursing Care During the Prenatal Period
89.  2  The nurse should become informed about the
cultural eating patterns of clients so that foods
containing the essential nutrients that are part of
these dietary patterns will be included in the diet.
1  Fluid retention is only one component of weight gain;
growth of the fetus, placenta, breasts, and uterus also
contributes to weight gain.  3  Calories and nutrients are
increased during pregnancy.  4  Pregnancy diets are not
specific; they are composed of the essential nutrients.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period, Nursing Care During the Prenatal Period
90.  2  Asking what she usually eats enables the nurse to
assess the woman’s level of nutritional knowledge
and gain clues for appropriate methods of
counseling.
1  A “regular” diet does not indicate that the client is
eating a nutritious diet; also, the client will need
increased protein and calories.  3  These foods may be too
expensive and different from her usual choices, leading to
nonadherence to a healthy diet.  4  If the client’s diet
includes highly seasoned foods and they are well
tolerated, they need not be excluded.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period, Nursing Care During the Prenatal Period
91.  Answer: 4, 5.
1  Beef and fish do not contain an adequate amount of
folate.  2  Milk and cheese do not contain an adequate
amount of folate.  3  Fowl does not contain an adequate
amount of folate.  4  Legumes contain large amounts of
folate.  5  Enriched grain products contain large amounts
of folate.
Client Need: Health promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
92.  2  The uterus and bladder occupy the pelvic cavity
and lie closely together; as the uterus enlarges with
the growing fetus, it impinges on the space
occupied by the bladder and thereby diminishes
bladder capacity.
1  Atony does not cause frequency; more likely, it may
lead to retention.  3  This will lead to incontinence rather
than frequency.  4  This is an unlikely occurrence; the
uterus does not impinge on this area.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
93.  Answer: 1, 3, 4.
1  During pregnancy, batterers may concentrate their
anger at the pregnancy itself and focus their assaults on
Answers and Rationales 613
the breasts, buttocks, and abdomen.  2  Control is a
CHILDBEARING AND WOMEN’S HEALTH NURSING
primary concern of the abuser, so it would be highly
unlikely for him to leave the client alone with the care
provider.  3  It is common for the abuser to control the
conversation by answering for the client.  4  Women who
are battered are at risk for stress illnesses such as GI
distress and chest pain. They are more likely to suffer
from frequent headaches and depression.  5  This is not
typical behavior of an abusive person.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period, Nursing Care During the
Prenatal Period
94.  2  A rubella titer of 1 : 2 is inadequate immunization.
A titer of 1 : 8 is considered immune. Rubella
immunization protects the fetuses of future
pregnancies from significant birth defects caused
by a rubella infection. These laboratory results are
ANSWERS AND RATIONALES
borderline for pregnancy but were taken during the
prenatal period and do not represent the woman’s
current status.
1  There is no evidence that the neonate needs a
transfusion.  3  A RhoGAM injection is not needed
because the infant also is Rh negative.  4  This is an
expected glucose level for a neonate.
Client Need: Safety and Infection Control; Cognitive Level:
Analysis; Nursing Process: Planning/Implementation; Reference:
Ch 25, Prenatal Period; Physical, Physiologic, and Emotional Changes
During Pregnancy
95.  1  Nausea and vomiting in the morning occur in
almost 50% of all pregnancies. Eating dry crackers
before getting out of bed in the morning is a simple
remedy that may provide relief.
2  Increasing fat intake does not relieve the
nausea.  3  This is not helpful; separating fluids from
solids at mealtime is more advisable.  4  Eating two small
meals a day and a snack at noon does not meet the
nutritional needs of a pregnant woman, nor will it relieve
nausea. Some women find that eating five or six small
meals daily instead of three large ones is helpful.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
96.  1  Nausea and vomiting in early pregnancy can be
relieved with a small snack of protein before
bedtime to slow digestion.
2  An antacid may affect electrolyte balance; also this will
not help morning sickness.  3  This is contraindicated,
because both fetus and mother need nourishment. 
4  Medications in the first trimester are contraindicated
because this is the period of organogenesis, and
congenital anomalies could result.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
 614 CHAPTER 28  Childbearing and Women’s Health Nursing
97.  3  This is the recommended caloric increase for adult
CHILDBEARING AND WOMEN’S HEALTH NURSING
women to meet the increased metabolic demands
of pregnancy.
1, 2  This will not meet the metabolic demands of
pregnancy and may harm the fetus.  4  This is the
recommended caloric increase for breastfeeding mothers.
Client Need: Basic Care and Comfort; Cognitive Level:
Knowledge; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
98.  1  The average weight gain during pregnancy is 25 to
35 lb (11.3 to 15.8 kg); of this, the fetus accounts for
7 to 8 lb (3.2 to 3.6 kg), or approximately 30% of
weight gain.
2  Fluid retention accounts for about 20% to 25% of
weight gain.  3  Metabolic alterations do not cause a
weight gain.  4  Increased blood volume accounts for
ANSWERS AND RATIONALES
about 12% to 16% of weight gain.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
99.  2  Because of a decrease in chorionic gonadotropin,
morning sickness seldom persists beyond the first
trimester.
1, 3  Morning sickness usually ends at the end of the
third month, when the chorionic gonadotropin level
falls.  4  Morning sickness is still present at this time; it is
related to the high level of chorionic gonadotropin.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
100.  2  This allows the client to discuss her feelings and
participate in her care.
1  This is not relevant at this time; the client needs help
with the alterations that occur in early pregnancy.  3  This
cuts off communication and does not address the client’s
concerns.  4  This cuts off communication; also it may
cause the client to worry that something is seriously
wrong.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Caring; Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
101.  1  When an Rh-negative woman carries an Rh-positive
fetus, there is a risk for maternal antibodies against
Rh-positive blood; antibodies cross the placenta
and destroy the fetal RBCs.
2  Determination of the lecithin/sphingomyelin ratio or
the phosphatidylglycerol test, not the Rh factor, may
provide information about the risk for developing
respiratory distress syndrome (RDS).  3  Testing for the
Rh factor will not provide information about protein
metabolism deficiency.  4  Physiologic bilirubinemia is a
common occurrence in newborns; it is not associated
with the Rh factor.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
102.  2  The first trimester is the period when all major
embryonic organs are forming; drugs, alcohol, and
tobacco may cause major defects.
1  Cutting down on these substances is insufficient; they
are teratogens and should be eliminated.  3  Even 1ounce
of an alcoholic drink is considered harmful; baby aspirin
may be prescribed to some women who are considered at
risk for pregnancy-induced hypertension, but not during
the first trimester.  4  Medications, unless absolutely
necessary, should be avoided throughout pregnancy, but
the first trimester is most significant.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference:
Ch 25, Prenatal Period, Nursing Care During the Prenatal
Period
103.  1  With spontaneous or stimulated activity, the fetal
heart rate (FHR) is usually between 110 and 160
beats/min. This is to be expected, and the client
should be made aware of this.
2  The heart rate for a fetus is 110 to 160 beats/min, not
twice the mother’s heart rate.  3  This implies that the
heart rate is too rapid; this is misinformation that may
cause more concerns.  4  The heart rate is rapid to
accommodate the metabolic, not nutritional, needs of the
fetus.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period, Development of the Embryo/Fetus
104.  2  Increased estrogen production during pregnancy
causes hyperplasia of the vaginal mucosa, which
leads to increased production of mucus by the
endocervical glands. The mucus contains exfoliated
epithelial cells.
1  Increased metabolism leads to systemic changes
but does not increase vaginal discharge.  3  The amount
of secretion from the Bartholin glands, which lubricates
the vagina during intercourse, remains unchanged
during pregnancy.  4  There is no additional supply
of sodium chloride to the vaginal cells during
pregnancy.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
105.  3  Dependent edema is common during the last
trimester; there is no need to lower the salt content
of the client’s diet. Teaching should be based on
optimum nutrition as well as the caloric content of
the diet.

1  Not all preferences can be included; the diet should
contain normal sodium, high protein, and sufficient
calories.  2  Immediate planning based on the nurse’s
knowledge of dietary needs is sufficient  4  Unless the
nurse thought there was a need for medical intervention,
the nurse may discuss care related to human responses.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
106.  3  Elevation of the extremities several times daily is
recommended to decrease the dependent edema.
1  Fluid intake should be encouraged because adequate
hydration maintains fluid and electrolyte balance.  111.  2  The supine position results in pressure on the vena
2  Sodium intake should not be restricted because it is
needed to balance the increased fluid volume during
pregnancy.  4  Diuretics can be harmful and are not used
during a healthy pregnancy.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
107.  3  The alpha-fetoprotein test can detect not only
neural tube defects, but Down syndrome, and other
congenital anomalies. It is a screening test that
affords a tentative diagnosis; confirmation requires
more definitive testing.
1, 2, 4  These are not detected by the alpha-fetoprotein
test.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
108.  4  The nonstress test evaluates the response of the
fetus to movement and activity. A reactive test
indicates that the fetus is healthy.
1  No injections of any kind are used during a nonstress
test; this test involves only the use of a fetal monitor to
record the fetal heart rate during periods of activity.  sources of calcium.
2  This test will not influence the activity of the fetus
because no exogenous stimulus is used.  3  This is
unlikely because it is a noninvasive test.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 25, Prenatal Period,
Nursing Care During the Prenatal Period
109.  3  A full bladder is required for effective visualization
of the uterus in early pregnancy.
1  The GI tract is not involved; this is a noninvasive
procedure.  2  The procedure is not done via the colon
and will not cause fecal contamination.  4  This
procedure is noninvasive; it cannot irritate the uterus and
initiate labor.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Answers and Rationales 615
Period; Physical, Physiologic, and Emotional Changes During
CHILDBEARING AND WOMEN’S HEALTH NURSING
Pregnancy
110.  3  When the membranes rupture, the potential for
infection is increased, and when the contractions
are 5 to 8 minutes apart, they are usually of
sufficient force to warrant professional supervision.
1  These may be early signs of labor or signs of posterior
fetal position; it is too early to notify the health care
provider. 2, 4  This is too early; the client should remain
with her family and keep moving around at home.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period, Nursing Care During the Prenatal Period
cava by the gravid uterus; this impedes venous
return, causing hypotension and decreased
systemic perfusion.
ANSWERS AND RATIONALES
1  This may or may not happen.  3  Even if this occurs, it
is not the reason for discouraging the supine
position.  4  It can lead to hypotension, not hypertension.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Prenatal
Period; Physical, Physiologic, and Emotional Changes During
Pregnancy
112.  4  Alpha-fetoprotein in amniotic fluid is elevated in
the presence of a neural tube defect.
1  Lung maturity cannot be determined until after 35
weeks’ gestation.  2  Diabetes cannot be detected via an
amniocentesis.  3  Cardiac disorders cannot be detected
via an amniocentesis.
Client Need: Reduction of Risk Potential; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Prenatal Period; Physical, Physiologic, and
Emotional Changes During Pregnancy
113.  2  The leg cramps may be related to low calcium
intake; cheese and broccoli both have a high
calcium content.
1, 3, 4  Although these foods are recommended to
maintain quality nutritional intake, they are inadequate
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 25, Prenatal Period;
Physical, Physiologic, and Emotional Changes During Pregnancy
114.  3  The greatest danger of drug-induced malformations
is in the first trimester of pregnancy during the
period of organogenesis; because a woman may not
know she is pregnant, she should be aware of this
before becoming pregnant.
1  Although adolescent girls may be aware of this, it is
not a priority concern at this age.  2  Drugs should be
avoided throughout pregnancy, but the first trimester
(period of organogenesis) is the most critical.  4  If the
client is not aware of her pregnancy, it may be too late to
start discontinuing drugs.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
 616 CHAPTER 28  Childbearing and Women’s Health Nursing
Nursing Process: Assessment/Analysis; Reference: Ch 25, Prenatal
CHILDBEARING AND WOMEN’S HEALTH NURSING
Period, Development of the Embryo/Fetus
115.  2  Cigarette smoking or continued exposure to
secondary smoke causes both maternal and fetal
vasoconstriction, resulting in fetal growth
retardation and increased fetal and infant
mortality.
1  There is no clinical evidence that smoking relieves
tension or that the fetus is more relaxed.  3  Smoking
causes vasoconstriction; permeability of the placenta to
smoke is irrelevant.  4  Although the fetal and maternal
circulations are separate, vasoconstriction occurs in both
mother and fetus.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Prenatal Period, Nursing Care During the Prenatal Period
116.  3  High levels of chorionic gonadotropin frequently
ANSWERS AND RATIONALES
are associated with severe vomiting during
pregnancy and may result in hyperemesis
gravidarum. These high levels also occur if there is
a hydatidiform mole or a multiple pregnancy.
1  Cholecystitis is unrelated to this problem.  epidural anesthesia; it is part of the general nursing care
2  Hydramnios (excessive amniotic fluid) is associated
with a multiple gestation and some fetal abnormalities.  constant process and should be recorded every 15
4  There are no data to indicate that there is decreased
gastric acid secretion during the first trimester; this is not
the cause of hyperemesis gravidarum.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 25, Prenatal Period, Nursing Care During the Prenatal Period
117.  Answer: 2, 4, 5.
1  Systemic vasodilation is not expected.  2  Blood
volume is increased to meet the metabolic demands of
pregnancy.  3  There is little variation in blood pressure
with a slight decrease during the second trimester.  4  An
increased cardiac output is necessary to accommodate the
increased blood volume needed to meet the demands of
the growing fetus.  5  Cardiac hypertrophy is a result of
the demands made by the increased blood volume and
cardiac output.  6  Erythrocyte production increases;
because the plasma volume increases more than the
RBCs, the hematocrit is lower.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Assessment/Analysis; Reference: Ch 25, Prenatal Period;
Physical, Physiologic, and Emotional Changes During Pregnancy
118.  2  Both the father and the mother need additional
support during the transition phase of the first
stage of labor.
1  This statement is judgmental; it suggests that the
father will be failing his wife.  3  The husband should be
present throughout labor to support his wife; he should
be assisted in this role.  4  This does not encourage the
husband to fulfill his role of supporting his wife during
labor.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 25, Intrapartum Period, Data Base
119.  1  Epidural anesthesia during the first stage of labor
decreases metabolic and respiratory demands and
is preferred for obese clients.
2, 4  Obese women are sensitive to systemic opioids,
which predispose them to respiratory depression; oral
medications do not have a uniform rate of absorption
and are not recommended during labor.  3  A pudendal
block does not reach the uterus, so contractions are felt;
it is used during the second stage of labor.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Intrapartum Period, Data Base
120.  1  Maternal hypotension is a common complication of
this anesthesia during labor, and nausea is one of
the first clues that this has occurred. Turning the
client onto her side will deflect the uterus from
putting pressure on the inferior vena cava, which
causes a decrease in blood flow.
2  If signs and symptoms do not abate after turning on
the side, the health care provider should be
notified.  3  This is not a specific observation after
during labor.  4  If the FHR is being monitored, it is a
minutes; if not, the FHR should be checked and
recorded every 15 minutes.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Data Base
121.  1  Respiratory depression may occur in the newborn
because the duration of action of Butorphanol
(Stadol) is  3  to  4  hours and circulating blood
levels will be high if birth occurs within that time.
2, 3, 4  These are antihistamines that have a sedative
effect and are administered early in labor to promote
sleep and decrease anxiety.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Evaluation/Outcomes;
Reference: Ch 25, Intrapartum Period, Data Base
122.  4  Nalbuphine (Nubain) is classified as an opioid
analgesic and is effective for the relief of pain; there
is little or no newborn respiratory depression.
1  Nalbuphine does not induce amnesia.  2  Nalbuphine
acts as an analgesic, not an anesthetic.  3  Nalbuphine
does not induce sleep.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Data Base
123.  2  Ambulation relieves the discomfort of preparatory
(Braxton Hicks) contractions.
1  These contractions will increase when the client is
resting.  3  These contractions are not indicative of true
labor and need not be timed.  4  Aspirin may be harmful
to the fetus because it can hemolyze RBCs.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Intrapartum Period, Data Base

124.  1  Progressive cervical dilation is the most accurate
indication of true labor.
2  With true labor, contractions will increase with
activity.  3  Contractions of true labor persist in any
position.  4  Contractions may not begin until 24 to 48
hours later.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Data Base
125.  2  Fatigue will influence other coping strategies, such
as distraction.
1  The progesterone level is decreased at this time.  3  The
client does not push during the first stage of labor;
pushing is done during the second stage.  4  This may
decrease the quality of the contractions.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Intrapartum
Period, Data Base
126.  1  Determining fetal well-being takes priority over all
other measures. If the FHR is absent or persistently
decelerating, immediate intervention is required.
2, 3, 4  Although this is important, the determination of
fetal well-being is the priority.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Assessment/Analysis; Reference: Ch 25, Intrapartum
Period, Nursing Care During the Intrapartum Period
127.  2  A station of +1 indicates that the fetal head is 1 cm
below the ischial spines.
1  The head is now past the points of engagement, which
are the ischial spines.  3  This is designated as 0 station.  150 beats/min.
4  The head must be at +3 to +4 station to be visible at
the vaginal opening.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Data Base
128.  3  Fetal heart tones are best auscultated through the
fetal back; because the presenting part is in the
right occiput posterior (ROP) position, the back is
below the umbilicus and on the right side.
1  This location should be used when the fetus is lying in
the midline in a breech position.  2  This location is
appropriate when the fetus is in the left sacrum anterior
(LSA) position.  4  This location is appropriate when the
fetus is in the left occiput anterior (LOA) or left occiput
posterior (LOP) position.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
25, Intrapartum Period, Nursing Care During the Intrapartum Period
129.  3  The contractions become stronger, last longer, and
are erratic during this stage; the intervals between
contractions become shorter than the contractions
themselves; the client needs to apply much
concentration and effort to pace her breathing with
each contraction.
1  Even clients who have been adequately prepared will
experience these behaviors during the transition phase of
the first stage of labor.  2  Administration of an analgesic
Answers and Rationales 617
at this time may reduce the effectiveness of labor and
CHILDBEARING AND WOMEN’S HEALTH NURSING
depress the fetus.  4  There is no indication that the
contractions are hypertonic.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Data Base
130.  4  This is the accepted way to determine the frequency
of the contractions.
1  This does not determine the length of a contraction. 
2  This does not indicate the frequency of contractions. 
3  This identifies the end of a contraction, but it is not
the accepted way of timing the frequency of contractions.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
131.  2  By 36 weeks’ gestation, amniotic fluid should be
pale yellow with small particles of vernix caseosa
ANSWERS AND RATIONALES
present.
1  Dark amber-colored fluid suggests the presence of
bilirubin, an ominous sign.  3  Greenish yellow fluid may
indicate the presence of meconium and suggests fetal
compromise.  4  Cloudy fluid suggests the presence of
purulent material, and greenish yellow may indicate the
presence of meconium.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Data Base
132.  3  Electronic fetal monitoring provides a continuous
graphic printout of rate patterns and periodic
changes; on this FHR strip the baseline heart rate is
1  Contractions are not sustained; there is uterine
relaxation between contractions.  2  FHR variability is
minimal, not marked.  4  Contractions are lasting 100
seconds.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 25, Intrapartum Period, Nursing Care During the Intrapartum
Period
133.  1  Because the client is attached to a machine and
movement may alter the tracings, movement is
discouraged.
2  Placement of the external monitor leads does not
interfere with the administration of sedatives.  3  An
external monitor does not interfere with breathing
techniques.  4  An external monitor does not necessitate
more frequent vaginal examinations.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 25, Intrapartum Period, Nursing Care During the Intrapartum
Period
134.  1  Variable decelerations usually are seen as a result of
cord compression; a change of position will relieve
the pressure on the cord.
2  Variable decelerations are not related to the mother’s
blood pressure.  3  Variable decelerations are not oxytocin
related.  4  This is premature; other nursing measures
should be tried first.
 618 CHAPTER 28  Childbearing and Women’s Health Nursing
Client Need: Health Promotion and Maintenance; Cognitive
CHILDBEARING AND WOMEN’S HEALTH NURSING
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
135.  Answer: 2, 1, 3, 4, 5.
2  Repositioning to the side increases uterine blood flow,
improves cardiac output, and moves pressure of the
uterus off of the vena cava.  1  Increasing IV fluids
augments uterine blood flow and improves cardiac
output.  3  Reassessing the FHR pattern enables the
nurse to determine if the FHR has returned to a safe
level without reflex late decelerations.  4  Persistent late
decelerations is a nonreassuring fetal sign; the health care
provider should be informed. 5 Documentation of
interventions and client responses includes the
information in the client’s legal clinical record and
provides communication to other care providers.
Client Need: Health Promotion and Maintenance; Cognitive
ANSWERS AND RATIONALES
Level: Analysis; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
136.  1  When the membranes rupture, there is always the
possibility of a prolapsed cord leading to fetal
compromise, which will manifest itself in a slow
FHR.
2  This is regularly done before and after the membranes
rupture; however, fetal status takes priority.  3  This is
unnecessary unless there is a marked change in the
FHR.  4  This is done routinely throughout the labor
process; at this time fetal status takes priority.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Nursing Care during the
Intrapartum Period
137.  3  The client is in the first stage of labor; she and the
fetus were assessed earlier and both are stable. At
this time the priority of care is to establish a
trusting relationship with her and her partner. This
will help to allay their anxiety.
1  This may be necessary later; however, it is not the
priority.  2  The history should be taken from the client
as long as she is capable of providing it.  4  This is not a
priority; the health care provider may have been notified
already.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 25, Intrapartum Period, Nursing
Care During the Intrapartum Period
138.  3  The priority is to assess for a prolapsed umbilical
cord. This is a life-threatening emergency for the
fetus and must be ruled out first.
1  This is done after verifying that the umbilical cord is
not visible in the vaginal introitus. 2, 4  This is not the
priority; this can be done after confirming fetal
well-being.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
139.  4  Artificial rupture of the membranes (amniotomy)
allows for more effective pressure of the fetal head
on the cervix, enhancing dilation and effacement.
1  Vaginal bleeding may increase because of the
progression of labor.  2  An amniotomy does not directly
affect the fetal heart rate.  3  Discomfort may become
greater because contractions usually increase after an
amniotomy.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 25, Intrapartum Period, Data Base
140.  3  The client is experiencing the expected discomforts
of labor; the nurse should initiate measures that
will promote relaxation.
1  The client is in early first-stage labor; pushing
commences during the second stage.  2  This breathing
technique should be used in the transition phase, not the
early phase of the first stage of labor.  4  There is no
evidence that the client’s bleeding is excessive.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 25, Intrapartum
Period, Nursing Care During the Intrapartum Period
141.  Answer: 2, 1, 6, 3, 4, 5.
2  The nurse should first stop the oxytocin infusion when
tetanic contractions occur; this should relax the uterus
and prevent uterine tetany and rupture.  1  The FHR
should be checked to determine the effect of the tetanic
contractions on the fetus.  6  After the FHR is assessed
then the maternal response to the interruption of the
infusion should be assessed.  3  Following these measures,
the primary care giver should be notified.  4  Fetal
well-being will be improved when oxygen is
administered.  5  After emergency measures have been
taken, the maternal/fetal responses should be
documented.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 26, Induction or Stimulation of Labor; Nursing Care
During the Intrapartum Period
142.  1  An acceleration is an abrupt elevation above the
baseline of 15 beats/min for 15 seconds; if the
acceleration persists for more than 10 minutes, it is
considered a change in baseline rate.
2  Early decelerations, not elevations, occur. An early
deceleration starts before the peak of the uterine
contraction and returns to the baseline when the uterine
contraction ends.  3  A sonographic motion is not a fetal
monitoring descriptive term.  4  A tachycardic FHR is
above 160 beats/min.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Integrated Process: Communication/Documentation;
Nursing Process: Assessment/Analysis; Reference: Ch 25,
Intrapartum Period, Nursing Care During the Intrapartum Period
143.  1  This slow, deep breathing expands the spaces
between the ribs and raises the abdominal muscles,
allowing room for the uterus to expand and
preventing painful pressure of the uterus against
the abdominal wall.

2  Pelvic rocking is used to relieve pressure from back
labor.  3  Panting is used to halt or delay the expulsion of
the infant’s head before complete dilation.  4  This
breathing technique is used during the transition phase
of the first stage; the client has not yet reached this
phase.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Intrapartum Period, Nursing Care During the Intrapartum Period
144.  2  Gastric peristalsis often ceases during periods of
stress. Abdominal contractions put pressure on the
stomach and can cause nausea and vomiting,
increasing the risk for aspiration.
1  Although this is true, it is not the reason for
withholding food or oral fluids during labor.  3  Although
food may cause dyspepsia, the primary reason for
withholding it is to prevent aspiration.  4  Gastric
peristalsis is decreased, not increased, during the stress of
labor and birth.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
145.  2  This is the most difficult part of labor, and the client
needs encouragement and support to cope.
1  IV fluids may need to be increased because of the
increase in metabolism.  3  Medication at this time will
depress the newborn and is contraindicated.  4  Breathing
patterns should be complex and require a high level of
concentration to distract the client.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 25, Intrapartum
Period, Data Base
146.  2  Blowing forcefully through the mouth controls the
strong urge to push and allows for a controlled
birth of the head.
1  This breathing pattern does not help to control
expulsion of the fetus.  3  This is used during the latent
phase of the first stage of labor; it is not helpful in
overcoming the urge to push.  4  This is used during
active labor when the cervix is 3 to 7 cm dilated; it is not
helpful in overcoming the urge to push.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
147.  4  As the uterus rises into the abdominal cavity, the
uterine ligaments become elongated and
hypertrophied; raising both legs at the same time
limits the tension placed on these ligaments.
1  Lifting the legs simultaneously does not affect
circulation in the legs.  2  There is already pressure on the
perineum from the head of the fetus; this maneuver eases
tension on the uterine ligaments.  3  There is no effect on
the fascia with this maneuver.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Answers and Rationales 619
Reference: Ch 25, Intrapartum Period, Nursing Care During the
CHILDBEARING AND WOMEN’S HEALTH NURSING
Intrapartum Period
148.  2  The bulging perineum indicates that the fetal head
is on the pelvic floor and birth is imminent.
1, 3  This occurs during the transition phase or at the
beginning of the second stage.  4  This describes the
progress of labor; it is not a sign that birth is imminent.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
149.  2  Because oxytocin (Pitocin) promotes powerful
uterine contractions, uterine tetany may occur. The
oxytocin infusion must be stopped to prevent
uterine rupture and fetal compromise.
1  Intense pain can be associated with strong uterine
contractions; this is not a complication.  3  This is
unrelated to uterine contractions.  4  This is not likely to
ANSWERS AND RATIONALES
occur when induction of labor is initiated.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 25, Intrapartum Period, Data Base
150.  2  The contractions in the second stage of labor are
expulsive in nature; having the client push or bear
down with the glottis open will hasten expulsion.
1  Contractions are now intense and the client will be
unable to relax; relaxation occurs between contractions.
3, 4  These breathing patterns prevent pushing and
should not be encouraged until the fetal head crowns (+4
station) and a controlled birth is desired.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Intrapartum Period, Nursing Care During the Intrapartum Period
151.  2  A pudendal block provides anesthesia to the
perineum.
1  This block affects only the perineum, not the
bladder.  3  This block does not affect muscle
control.  4  This block anesthetizes only the perineum,
not the cervix or body of the uterus.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Intrapartum Period, Data Base
152.  3  These are the classic signs and symptoms of a
vaginal hematoma.
1, 2  The signs and symptoms do not indicate this
infection; the temperature would be elevated in the
presence of infection.  4  This condition would reveal
persistent vaginal bleeding with a decreasing blood
pressure.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Evaluation/Outcomes; Reference: Ch 25,
Intrapartum Period, Nursing Care During the Intrapartum Period
153.  3  When the placenta separates from the uterine wall,
it tears blood vessels and results in a gush of blood
from the vagina.
1  The uterus should become firm when the placenta
begins to separate.  2  The fundus rises in the abdomen
 620 CHAPTER 28  Childbearing and Women’s Health Nursing
when the placenta separates.  4  The reverse occurs; as the
CHILDBEARING AND WOMEN’S HEALTH NURSING
placenta separates it descends into the vaginal introitus,
and the umbilical cord appears longer and protrudes
from the vagina.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Data Base
154.  4  Immediately after birth the fundus is palpated
midway between the symphysis pubis and the
umbilicus.
1  The gradual descent of the uterus into the pelvic cavity
takes about 2 weeks after the birth.  2  The fundus is
never elevated this high.  3  The fundus is not this high
until 1 hour after birth; when the uterus is deviated to
the right, it usually indicates bladder distention.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Intrapartum Period, Data Base
ANSWERS AND RATIONALES
155.  1  Bradycardia (baseline FHR below 110 beats/min)
indicates the fetus may be compromised, requiring
medical intervention.
2  This may be dangerous; the fetus may be compromised,
and time should not be spent on monitoring.  3  This not
the priority at this time.  4  The expected FHR is 110 to
160 beats/min between contractions.
Client Need: Management of Care; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Intrapartum Period, Nursing Care During the Intrapartum Period
156.  2  A displaced and boggy uterus usually is caused by a
full bladder; if the bladder is distended, the nurse
should have the client void and then reassess the
fundus, and if still boggy, massage until firm.
1  The oxytocin (Pitocin) infusion may need to be
increased if voiding and fundal massage are ineffective;
however, the health care provider must be notified to
change the prescription.  3  This is necessary if the
fundus remains boggy after the client has voided.  4  This
is unnecessary at this time; correcting the boggy fundus
is the priority.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Evaluation/Outcomes;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
157.  3  Before any other action is taken, the client must
empty her bladder. If she is unsuccessful despite
measures to promote urination, such as running
water, she will need to be catheterized.
1, 4  This action is useless and may be dangerous unless
the bladder is empty.  2  The health care provider should
be notified if the uterus remains boggy and above the
umbilicus after the bladder has been emptied and the
fundus massaged, if necessary.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Intrapartum Period, Nursing Care During the
Intrapartum Period
158.  4  Esophageal atresia is associated with hydramnios.
1  Cardiac defects are not associated with
hydramnios.  2  Kidney disorders are associated with
oligohydramnios, not hydramnios.  3  Diabetes in the
newborn is not associated with hydramnios.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
25, Intrapartum Period, Data Base
159.  1  This opens up an area of communication to
determine what really is troubling the mother
about feeding her baby.
2  The nurse is aware that this is not the best method
when using a bottle to feed an infant; the problem of
time should be explored with the mother.  3  Holding
can be accomplished at times other than feeding periods;
this response does not explore the client’s feelings. 
4  Although this is true, the mother should not be
challenged so directly; a more gentle explanation should
be offered.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 25, Postpartum Period, Nursing Care During the
Postpartum Period
160.  2  Rooming-in provides time for the mother and
newborn to be together; the mother can become
acquainted with the infant more quickly.
1  It is possible that the client does not want to
breastfeed; attachment can be furthered by a variety of
methods.  3  This will not promote bonding and
attachment.  4  Although visiting in the nursery is
unlimited for the parents, rooming-in is preferable.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 25, Postpartum
Period, Nursing Care During the Postpartum Period
161.  2  Family-centered childbearing should adapt care to
the client’s cultural system whenever possible.
1  This is the nurse’s responsibility.  3  This may be
useful, but the primary intervention is to address the
client’s cultural needs.  4  This does not address the
underlying problem.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 25, Postpartum Period, Nursing Care During the
Postpartum Period
162.  4  Family-centered care focuses on the whole family,
including the relatives; visiting hours in the birthing
unit are flexible.
1  This is an inappropriate intervention; family-centered
care focuses on the whole family, and the sister should be
permitted to remain.  2  Written permission is not
required.  3  There is no need for the nursing supervisor
to be summoned.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 25, Postpartum
Period, Nursing Care During the Postpartum Period
163.  3  Heparin is the medication of choice during the
acute phase of a deep vein thrombosis; it prevents
conversion of fibrinogen to fibrin and of
prothrombin to thrombin.

1  Clopidogrel (Plavix) is a platelet aggregate inhibitor
and is used to reduce the risk of a brain attack
(CVA).  2  Warfarin (Coumadin) is a long-acting oral
anticoagulant and is started after the acute stage has
subsided; it is continued for 2 to 3 months.  4  A low
molecular weight heparin (e.g., enoxaparin [Lovenox]) is
not administered during the acute stage; it may be
administered later to prevent future deep vein
thromboses.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 25, Postpartum Period, Data Base
164.  2  This action prevents the transfer of microorganisms
from the hands to the genital tract or from the
genital tract to the hands.
1  This is an inadequate number of changes; soiled pads
promote the growth of microorganisms because they are
warm and moist and provide a medium for growth.  urinary continence and may enhance sexual
3  This action interferes with the analgesic action of the
spray and does not prevent infection.  4  This action
promotes contamination of the vagina and urethra by
organisms from the perianal area.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 25, Postpartum
Period, Nursing Care During the Postpartum Period
165.  1  Retention of urine with overflow will be manifested
in small, frequent voidings. The bladder should be
palpated for distention.
2  An elevated temperature with urinary alterations
would indicate impending infection.  3  More
circulating fluid is present, causing an increased
output.  4  The client usually is thirsty and fluid intake
increases.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Postpartum Period, Data Base
166.  3  A distended bladder will displace the fundus
upward and laterally to the right.
1  This is manifested by slow contraction and uterine
descent into the pelvis.  2  If this were true, in addition
to being displaced, the uterus would be boggy and
vaginal bleeding would be heavy.  4  From this assessment
the nurse cannot make a judgment about overstretched
uterine ligaments.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Postpartum Period, Nursing Care During the
Postpartum Period
167.  3  The fundus descends one fingerbreadth per day
from the first postpartum day.
1, 2  If the fundus were at this level, the nurse should
suspect that involution has been delayed and further
investigation is required.  4  Although this is not
expected, it is a benign occurrence.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Postpartum Period, Nursing Care During the
Postpartum Period
Answers and Rationales 621
168.  4  There is extensive activation of the blood
CHILDBEARING AND WOMEN’S HEALTH NURSING
clotting factors after a birth; this, together with
immobility, trauma, or sepsis, encourages
thromboembolization, which can be limited
through activity.
1  This can be accomplished by encouraging the client to
turn from side to side and to deep breathe and
cough.  2  Bladder tone is improved by the regular
emptying and filling of the bladder.  3  Exercise during
the next 6 weeks can strengthen the abdominal muscles.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Postpartum Period, Nursing Care During the Postpartum Period
169.  1  Kegel exercises can be resumed immediately and
should be done for the rest of the client’s life
because they help strengthen muscles needed for
ANSWERS AND RATIONALES
intercourse.
2  Episiotomy sutures do not have to be removed. 
3  Bowel movements should spontaneously return in 2 to
3 days after giving birth; a delay of bowel movements
promotes constipation, perineal discomfort, and
trauma.  4  The usual postpartum examination is 6 weeks
after birth; menses can return earlier or later than this
and should not be a factor when scheduling a
postpartum examination.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Postpartum Period, Nursing Care During the Postpartum Period
170.  1  Covered ice packs promote comfort by decreasing
vasocongestion.
2, 3  Nipple stimulation precipitates the release of
prolactin, which leads to more milk production and
further engorgement and discomfort.  4  Emptying the
breasts stimulates lactation, leading to further
engorgement and discomfort.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 25, Postpartum
Period, Nursing Care During the Postpartum Period
171.  1  Although thrombophlebitis is suspected, before a
definitive diagnosis the client should be confined to
bed so that further complications may be avoided.
2  This may cause vasodilation, which could allow a
thrombus to dislodge and circulate freely. 3, 4  If a
thrombus is present, this may dislodge it and lead to a
pulmonary embolism.
Client Need: Management of Care; Cognitive Level: Application;
Integrated Process: Communication/Documentation; Nursing
Process: Planning/Implementation; Reference: Ch 25, Postpartum
Period, Nursing Care During the Postpartum Period
172.  2  The uterus responds rapidly to touch, and this
involves the mother in her care.
1  The uterus must be massaged before there are signs of
bleeding.  3  Although this may be beneficial, the client
should be taught to massage the uterus to cause it to
contract.  4  This does not actively involve the mother in
 622 CHAPTER 28  Childbearing and Women’s Health Nursing
her own care and could be unsafe if the uterus becomes
CHILDBEARING AND WOMEN’S HEALTH NURSING
boggy between the 15-minute time periods.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 25,
Postpartum Period, Nursing Care During the Postpartum Period
173.  Answer: 2, 3, 4, 1, 5.
2  The culture should be obtained before antibiotics are
given to ensure that the antibiotic does not interfere with
accurate culture results.  3  The antibiotic is the most
important of these orders and should be given as soon as
possible to counteract any infective processes, but it
should not be administered before obtaining the
specimen for the culture.  4  The acetaminophen
(Tylenol) is a comfort measure that can be administered
at any time, but does not take precedence over the
antibiotic.  1  Arranging for a chest radiograph will not
interfere with implementing any of the other orders; it
ANSWERS AND RATIONALES
may take time to schedule a radiograph.  5  The client’s
response to the acetaminophen should have lowered the
client’s temperature within 30 minutes.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 25,
Postpartum Period, Nursing Care During the Postpartum Period
Nursing Care of Women at Risk during
Pregnancy, Labor, Childbirth, and the
Postpartum Period
174.  3  This response points out reality and allows the
client to elaborate.
1  Although this is true, it does not allow for further
communication.  2  This response implies that the
nurse does not believe the client; it would probably Cesarean Birth, Data Base
cut off further communication.  4  This abdicates the
nurse’s responsibility; also, it may cut off further
communication
Client Need: Management of Care; Cognitive Level: Analysis;
Integrated Process: Communication/Documentation; Nursing
Process: Assessment/Analysis; Reference: Ch 26, The Pregnant
Adolescent, Nursing Care
175.  4  This indicates failure to resolve conflicting feelings
about pregnancy that should have been resolved in
the first trimester.
1  This response is an expected feeling in the third
trimester.  2  This response is expected in the third
trimester as the enlarging uterus limits the number of
comfortable positions that can be assumed during
sleep.  3  Concerns about the expected infant having
physical abnormalities are common in the third trimester.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Assessment/
Analysis; Reference: Ch 26, The Pregnant Adolescent, Nursing Care
176.  4  Fraternal twins may occur as a result of a hereditary
trait, but it is related to the ovaries releasing two
eggs during one ovulation; the fact that the father
is a fraternal twin would not influence the female’s
ovaries to release two eggs during one ovulation.
1  Although this response is true, it does not answer the
client’s question. 2, 3  If there is no maternal family
history of twin pregnancies, it would be a chance
occurrence that is equal to the probability found in the
general population.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
The Woman with a Multifetal Pregnancy, Data Base
177.  2  This fundal height indicates a hydatidiform mole, a
multiple gestation, or a fetal congenital anomaly;
at 16 weeks’ gestation the fundus is below the
umbilicus. It does not rise to the umbilicus until 20
to 22 weeks.
1  Foot and ankle edema is common as pregnancy
reaches term; the enlarged uterus presses on the femoral
veins, impeding the flow of venous blood from the
extremities. 3, 4  This heart rate is within the expected
range during pregnancy.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26,
Hydatidiform Mole or Trophoblastic Disease, Nursing Care
178.  4  In an emergency surgical situation when invasive
techniques are necessary, it is important to have a
consent signed as well as a history of the client’s
known allergies.
1  This is not a priority in an emergency such as this.
2, 3  In an emergency these procedures, except for the
enema, are done in the operating room; an enema usually
is not given before a cesarean, especially to a bleeding
client, because it may stimulate contractions and further
bleeding.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 26,
179.  2  This statement offers comfort measures while
giving the client an opportunity to verbalize her
concerns further if she desires.
1  This cuts off communication with the client.  3  The
client’s focus is on her prolonged discomfort; there is no
indication that she has other concerns at this time.  4  The
nurse should focus on the client, not on how other women
may feel; this may cut off communication.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring, Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Dystocia, Nursing Care
180.  1  Antenatal glucocorticoid therapy is contraindicated
when the client has an infection because the
antiinflammatory effect may exacerbate the
infection.
2  An available IV line should be maintained as well as
monitoring the intake and output (I&O).  3  This is the
usual protocol for monitoring the vital signs during
preterm labor.  4  Measures to halt labor should be
started.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 26, Preterm Labor, Data Base

181.  4  Oxytocin (Pitocin) increases the intensity and
duration of contractions; prolonged (tetanic)
contractions will jeopardize the safety of the fetus
and necessitate discontinuing the drug.
1  A bulging perineum indicates that there is complete
cervical dilation and birth is imminent; because cervical
dilation is only 2 to 3 cm, a bulging perineum is not
expected.  2  This is important throughout labor.  sulfate.
3  There is no indication at this time that a cesarean
birth is necessary.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Dystocia, Nursing Care
182.  1  Oxytocin (Pitocin) is a small polypeptide hormone
synthesized in the hypothalamus and secreted from
the neurohypophysis (posterior pituitary gland)
during parturition or suckling; it promotes powerful
uterine contractions and thus is used to induce
labor.
2  Estrogen (Premarin) suppresses the follicle-stimulating
and luteinizing hormones, thus helping to maintain the
pregnancy.  3  Ergonovine (Ergotrate) can lead to
sustained contractions, which is contraindicated during
labor; it may be prescribed in the postpartum period to
promote or maintain a contracted uterus.  4  Progesterone
(Prometrium) causes hyperplasia of the endometrium in
preparation for implantation of the fertilized ovum; later
it helps to maintain the pregnancy.
Client Need: Pharmacological and Parenteral Therapies;
Cognitive Level: Analysis; Nursing Process: Planning/
Implementation; Reference: Ch 26, Induction or Stimulation of
Labor, Data Base
183.  Answer: 1, 2, 5.
1  Oxytocin (Pitocin) is an oxytocic that initiates or
augments uterine contractions; it is used for labor
induction.  2  Misoprostol (Cytotec) is a prostaglandin
used for cervical ripening and labor induction.  x = 6000 ÷ 40
3  Ergonovine (Ergotrate) is an oxytocic used for
postpartum or postabortion hemorrhage.  4  Carboprost
(Hemabate) is a prostaglandin used for postpartum
hemorrhage; also used to induce abortion.  5 
Dinoprostone (Prepidil) is used for cervical ripening to
induce labor; also used to induce abortion.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 26, Induction or Stimulation of Labor, Data
Base
184.  4  Terbutaline sulfate (Brethine) is a beta-mimetic that
acts on the smooth muscles of the uterus to reduce
contractility, which in turn inhibits dilation and the
frequency and duration of contractions.
1  Although terbutaline may increase blood pressure and
pulse, this is a side, not a therapeutic, effect requiring
frequent assessments.  2  Terbutaline is not an analgesic. 
3  Terbutaline should stop cervical dilation, rather than
increase it.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 26, Preterm Labor, Data Base
Answers and Rationales 623
185.  3  Magnesium sulfate has a CNS depressant effect;
CHILDBEARING AND WOMEN’S HEALTH NURSING
therefore, toxic levels will be reflected by the loss of
the knee-jerk reflex.
1  The level of consciousness is decreased with excessive
magnesium sulfate.  2  There is a deceleration in the
respiratory rate with magnesium sulfate toxicity.  4  This
may be caused by increased potassium, not magnesium
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 26, Hypertensive Disorders of Pregnancy, Nursing
Care
186.  2  The client’s slow pulse and respirations and the
flushed face are signs of magnesium sulfate toxicity.
The infusion should be stopped and the IV site
should be maintained with an infusion of D5W
because an antagonist (calcium gluconate) may be
prescribed.
ANSWERS AND RATIONALES
1  This is unsafe because continuing the infusion will
make the CNS depression more severe. The health care
provider should be notified after the infusion has been
stopped.  3  These actions are unsafe. The client’s clinical
manifestations indicate a life-threatening condition.  4  It
is unsafe to decrease the rate of the infusion because the
CNS depression will worsen. The magnesium level
should be obtained, but not before stopping the infusion.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Hypertensive Disorders of Pregnancy, Nursing
Care
187.  Answer: 450 mL. Use the “Desire over Have” formula
to solve the problem by using ratio and proportion.
Desire 6 g x mL
=
Have 40 g 1000 mL
40 x = 6000
x = 150
An infusion pump is set at milliliters per hour. 150 mL is
needed in 20 minutes. There are 60 minutes in an hour;
therefore, 3 × 150 = 450 mL/hr.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 2, Medication Administration, Nursing
Responsibilities Related to Medication Administration
188.  4  Hyperreflexia of severe preeclampsia is 3+ to 4+;
therefore, a deep tendon reflex of 2+, which is an
active, expected reflex, indicates that a therapeutic
level of the drug has been reached. A diminished or
absent reflex indicates that the serum magnesium
level is too high.
1  Because magnesium sulfate is a CNS depressant, a
respiratory rate of 12 indicates that the serum magnesium
level is too high.  2  Alterations in fetal activity are not
indicators of a therapeutic magnesium sulfate
level.  3  Oliguria is a sign of severe preeclampsia; diuresis
is a therapeutic effect of magnesium sulfate administration.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
 624 CHAPTER 28  Childbearing and Women’s Health Nursing
Reference: Ch 26, Hypertensive Disorders of Pregnancy, Nursing
CHILDBEARING AND WOMEN’S HEALTH NURSING
Care
189.  4  This steroid enhances fetal lung maturity when
administered before a preterm birth.
1, 3  These are tocolytic agents used to prevent preterm
birth; this birth is inevitable.  2  Misoprostol (Cytotec) is
used for labor induction.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 26, Preterm Labor, Data Base
190.  2  This is the ideal time for chorionic villi sampling
(CVS); this allows the client time to consider other
options if a problem is discovered.
1  CVS is no longer done this early because it has been
associated with digit reduction.  3  This is too late for
CVS.  4  This is when a genetic amniocentesis is done.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
ANSWERS AND RATIONALES
Process: Planning/Implementation; Reference: Ch 26, Tests to
Identify and/or Monitor High-Risk Pregnancy
191.  3  The proliferation of trophoblastic tissue filled with
fluid causes the uterus to enlarge more quickly than
if a fetus were in the uterus.
1  Hypertension, not hypotension, often occurs with a
molar pregnancy.  2  There is no fetus within an
hydatidiform mole.  4  There may be slight painless
vaginal bleeding.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 26, Hydatidiform Mole or Trophoblastic Disease, Data Base
192.  2  At this time the products of conception are too
large for the tube to accommodate them, and
rupture occurs.
1, 3  Tubal pregnancies cannot advance to this stage
because of the tube’s inability to expand to accommodate
a pregnancy of this size.  4  The embryo is recognizable at
this time (about 2 weeks after fertilization), but it is too
small to cause the tube to rupture.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 26, Ectopic Pregnancy, Data Base
193.  3  A fallopian tube is unable to contain and sustain a
pregnancy to term; as the fertilized ovum grows,
there is excessive stretching or rupture of the
affected fallopian tube, causing pain.
1  At this stage the products of conception are too small
to form a mass; the pain is lateral, not centered.  2  The
pain is sudden, intense, and knifelike, not prolonged or
cramping.  4  Leukorrhea and dysuria may be indicative
of a vaginal or bladder infection.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Ectopic Pregnancy, Data Base
194.  1  Hemorrhage may result from retained placental
tissue or uterine atony.
2  There is no indication that the client has been deprived
of fluids.  3  Hypotension, not hypertension, may occur
with postabortion hemorrhage.  4  Subinvolution is more
likely to occur after a full-term birth.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 26, Spontaneous Abortion, Nursing Care
195.  4  About 75% of all spontaneous abortions take place
between 8 and 12 weeks’ gestation and show
embryonic defects.
1  Though possible, physical trauma rarely causes an
abortion.  2  Unresolved stress is rarely associated with
spontaneous abortions.  3  Congenital defects are
asymptomatic during pregnancy and do not usually cause
an abortion.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 26, Spontaneous
Abortion, Data Base
196.  3  Spotting in the first trimester may indicate that the
client is having a threatened abortion; any client
with the possibility of hemorrhage should not be
left alone; therefore, her admission to the hospital
ensures her safety.
1  A missed abortion may not cause any outward signs or
symptoms, except that the signs of pregnancy disappear. 
2  An inevitable abortion can be confirmed only if
vaginal examination reveals cervical dilation.  4  With an
incomplete abortion some, but not all, of the products of
conception have been expelled.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Assessment/Analysis; Reference:
Ch 26, Spontaneous Abortion, Data Base
197.  4  After a spontaneous abortion the uterine fundus
should be palpated for firmness, which indicates
effective uterine tone. If the uterus is not firm or
appears to be hypotonic, hemorrhage may occur;
a soft or boggy uterus also may indicate retained
placental tissue.
1  The nurse would do this if necessary after checking for
fundal firmness.  2  This is not the priority; the potential
for hemorrhage must be monitored.  3  This is
unnecessary; fetal and placental contents are small and
expelled easily.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Spontaneous Abortion, Nursing Care
198.  4  A correct and simple definition answers the
question and fulfills the client’s need to know.
1  This denies the client’s right to know.  2  This is the
definition of a missed abortion.  3  This abdicates the
nurse’s responsibility; the nurse can independently
reinforce information and correct misconceptions.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Spontaneous Abortion, Data Base
199.  3  Ruptured membranes leave the products of
conception exposed to bacterial invasion. Intact
membranes act as a barrier against organisms that
may cause an intrauterine infection.
1  This may occur during sex, but there is no evidence
indicating that it is harmful for the fetus.  2  This is

common because of increased production of mucus
containing exfoliated vaginal epithelial cells; intercourse is
not contraindicated.  4  Intercourse is not contraindicated
if membranes are intact; modification of sexual positions
may be needed because of the enlarged abdomen.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Premature Rupture of Membranes, Nursing Care
200.  4  A persistent occiput posterior position causes
intense back pain because of fetal compression of
the maternal sacral nerves.
1  Breech positions are not associated with back
pain.  2  The transverse position usually does not cause
back pain.  3  This is the most common fetal position
and does not cause back pain.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Dystocia, Nursing Care
201.  3  The application of back pressure combined with
frequent positional changes will help alleviate the
discomfort.
1  Although this may be comfortable for some
individuals, rubbing the back and alternating positions
usually are more effective.  2  The supine position places
increased pressure on the back and often aggravates the
pain.  4  Neuromuscular control exercises are used to
teach selective relaxation in childbirth classes; they will
not relieve back pain during labor.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Dystocia, Nursing Care
202.  3  Low back pain is aggravated when the mother is in
the supine position because of increased pressure
from the fetus.
1, 2, 4  This position helps relieve back pain.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Dystocia, Nursing Care
203.  4  Panting prevents the mother from putting pressure
on the fetal head. The nurse applies gentle pressure
against the fetus’s head as it emerges to prevent a
precipitous birth, which could result in CNS injury
to the fetus and vaginal lacerations to the mother.
1  It is impossible to pant and push at the same
time.  2  Breathing with the mouth closed promotes the
bearing down reflex.  3  Bearing down during the birth is
unsafe because both fetus and mother can be injured.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 26, Precipitate Birth, Nursing Care
204.  2  Lacerations require less suture time and cause less
perineal trauma, which can have lifelong
implications such as rectal-vaginal fistulas.
1  Lacerations are less painful than an episiotomy and
tend to heal more quickly.  3  An episiotomy causes more
Answers and Rationales 625
posterior trauma than lacerations.  4  Evidence indicates
CHILDBEARING AND WOMEN’S HEALTH NURSING
that a routine episiotomy policy results in more perineal
trauma, more suturing time, and more complications
than lacerations.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Integrated Process: Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 26, Episiotomy, Data Base
205.  3  The Centers for Disease Control and Prevention
(CDC) recommends that gloves should be worn
when there is potential contact with blood or other
body fluids.
1  Even if the client does not have an infection, gloves
are always worn when exposure to blood or other body
fluids is a possibility.  2  All blood is considered to be
potentially infectious.  4  Nurses are required to take
precautions that limit exposure; gloves must be worn.
Client Need: Safety and Infection Control; Cognitive Level:
ANSWERS AND RATIONALES
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 26, Postpartum Bleeding, Nursing Care
206.  1  Heat causes vasodilation and an increased blood
supply to the area.
2  Cleansing is done with a perineal bottle and cleansing
solution immediately after voiding and defecating.  3  Sitz
baths do not soften the incision site.  4  Neither
relaxation nor tightening of the rectal sphincter will
increase healing of an episiotomy.
Client Need: Basic Care and Comfort; Cognitive Level:
Comprehension; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 26, Episiotomy,
Nursing Care
207.  2  The nurse should position the newborn with head
slightly lower than the chest to allow mucus to flow
by gravity and then rub the back to stimulate
crying, which promotes oxygenation.
1  This is not the priority; there is no need for haste in
cutting the cord.  3  This is not the priority; the uterus
still contains the placenta and will not contract.  4  This
is not the priority; the well-being of the newborn and
mother must be confirmed before moving them.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Nursing Process: Planning/Implementation;
Reference: Ch 26, Precipitate Birth, Nursing Care
208.  Answer: 1, 2, 4, 5.
1  Increased risk for developing preterm labor is age
associated; it occurs more commonly in older
primigravidas and adolescents.  2  Mature women have an
increased incidence of multiple gestation secondary to
fertility drug use and in vitro fertilization.  3  This is not
seen more frequently in mature gravidas.  4  After 35 years
of age, mature women have an increased risk of having
children with chromosomal abnormalities.  5  Bleeding in
the first trimester as a result of spontaneous abortion
occurs more frequently in mature gravidas.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26, The
Older Pregnant Woman, Data Base
209.  2  About two thirds of neonatal deaths are associated
with preterm births; there appears to be a
 626 CHAPTER 28  Childbearing and Women’s Health Nursing
correlation with teenage and older age
CHILDBEARING AND WOMEN’S HEALTH NURSING
pregnancies, lack of prenatal care, women who are
nonwhite, and those who have chronic health
problems.
1  Atelectasis may occur from respiratory distress, which
in turn is associated with preterm births, the leading
cause of death.  3  Most infants who die from congenital
heart disease die after the neonatal period.  4  This is one
complication of a preterm birth.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Planning/Implementation;
Reference: Ch 26, Preterm Labor, Data Base
210.  Answer: 2, 4, 5.
1  The contraction stress test (CST) is indicated to assess
the influence of hypertension on the placental
circulation.  2  The CST could trigger a preterm birth in
a woman who is in preterm labor or has a history of
preterm births.  3  The CST is indicated to determine the
ANSWERS AND RATIONALES
response of the compromised fetus to labor.  4  The CST
could trigger a preterm birth in a woman who has had
the Shirodkar procedure for an incompetent cervical os
because it would exert pressure on the sutures and may
cause them to rupture.  5  The CST could trigger a
preterm birth in a woman whose membranes have
ruptured prematurely; the woman is at risk for a preterm
birth already.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference: Ch
26, Tests to Identify and/or Monitor High-Risk Pregnancy
211.  4  A positive contraction stress test (CST) indicates a
compromised fetus with late decelerations during
contractions; this is associated with uteroplacental
insufficiency.
1  Preeclampsia does not cause a positive CST unless the
fetus is compromised.  2  Ultrasonography demonstrates
placenta previa; a CST is contraindicated because it may
induce labor.  3  A CST is contraindicated for a woman
with a suspected preterm birth or a pregnancy of less
than 33 weeks’ gestation because it may induce labor.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 26, Tests to Identify and/or Monitor High-Risk Pregnancy
212.  4  It is not uncommon for adolescents to avoid
prenatal care; many do not recognize the
deleterious effect that lack of prenatal care can
have on them and their infants.
1  This can be done in the later part of pregnancy and
reinforced during the postpartum period.  2  This should
come later in pregnancy, but not before ascertaining the
client’s feelings about breastfeeding.  3  This will have to
be done, but it is not the priority intervention at this
time.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 26,
The Pregnant Adolescent, Nursing Care
213.  2  Perinatal morbidity and mortality rates are higher
with a multiple-gestation pregnancy because the
greater metabolic demands and the possibility of
malpositioning of one or more fetuses increases the
risk for complications.
1  Although postpartum hemorrhage does occur more
frequently after multiple births, it is not an expected
occurrence.  3  Maternal mortality during the prenatal
period is not increased in the presence of a multiple
gestation.  4  Adjustment to a multiple gestation and
birth is individual; the time needed for adjustment does
not place the pregnancy at high risk.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, The Woman with a Multifetal Pregnancy, Data Base
214.  1  A multiple gestation thins the uterine wall by
overstretching; thus, the efficiency of contractions
is reduced.
2  Gestational anemia is physiologic anemia that is
benign; although anemia may cause fatigue during labor,
it does not affect uterine contractility.  3  Hypertonic
contractions will cause increased discomfort, fatigue,
dehydration, and increased emotional distress, not
hypotonic uterine dystocia. Therapeutic interventions
include rest and sedation.  4  Gestational hypertension
may trigger preterm labor; it does not cause hypotonic
uterine dysfunction.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, The Woman with a Multifetal Pregnancy, Data Base
215.  2  Placenta previa is defined as an abnormally
implanted placenta in the thin, lower-uterine
segment (i.e., low-lying, partially covering, or
completely covering the cervical os).
1  This can occur at any time; it is not specific to a
low-lying placenta.  3  This can occur with a normally
implanted placenta.  4  This can occur at any time with
or without a low-lying placenta.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26, Placenta
Previa, Data Base
216.  3  Pyelonephritis often causes preterm labor,
leading to increased neonatal morbidity and
mortality.
1  Fluids should be increased; the inflammatory
process may lead to fever, dehydration, and an
accumulation of toxins.  2  Proteinuria occurs with
preeclampsia; the client’s signs and symptoms are
indicative of a kidney infection.  4  This is not relevant
to the client’s problem.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Preterm Labor, Data Base
217.  2  Health care supervision requires treatment with an
appropriate antibiotic until two cultures of urine
are negative; recurring pyelonephritis often leads
to preterm birth.
1  Preeclampsia is not preceded by specific
infections.  3  Pelvic inflammatory disease (PID) is
associated with infections of the genital, not the urinary,
tract.  4  A low-protein diet inhibits fetal development
and is contraindicated during pregnancy.

Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Preterm Labor, Data Base
218.  2  Chromosomal anomalies are not associated with a
multiple gestation; therefore, the client needs
further instruction.
1  Preterm birth with multiple gestation occurs for a
variety of reasons such as spontaneous rupture of the
membranes, abruptio placentae, and marked uterine
distention.  3  Shunting of blood between placentas can
occur with a multiple gestation if there are multiple
placentas.  4  The increased blood volume and
metabolism necessary to sustain a multiple gestation
predispose the client to hypertension.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Analysis; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 26, The Woman
with a Multifetal Pregnancy, Data Base
219.  4  Severe pain accompanied by bleeding at term or
close to it is symptomatic of complete premature
detachment of the placenta (abruptio placentae).
1  A hydatidiform mole is diagnosed before 36 weeks’
gestation; it is not accompanied by severe pain.  2  There
is no bleeding with vena caval syndrome.  3  Bleeding
caused by placenta previa should not be painful.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26,
Abruptio Placentae, Data Base
220.  2  The blood cannot escape from behind the placenta;
thus, the abdomen becomes boardlike and painful
because of the entrapment of blood.
1  Signs and symptoms of hemorrhagic shock do not
include pain.  3  This is not related to the initial pain of
abruptio placentae; eventually blood at the site of
placental separation may seep into the uterine muscle
(Couvelaire uterus).  4  This is not related to the initial
pain of abruptio placentae; it is a life-threatening
complication.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26,
Abruptio Placentae, Data Base
221.  1  The client’s clinical manifestations suggest abruptio
placentae, and her vital signs indicate that shock
may be occurring; the priority is to determine fetal
viability so that appropriate treatment may be
instituted immediately.
2  Preparing for a cesarean birth is premature until fetal
viability is determined.  3  Obtaining a blood sample
before assessing the status of the fetus is unsafe.  4  The
amount of vaginal bleeding is not relevant because there
may be hidden bleeding.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Abruptio Placentae, Nursing Care
222.  4  Clotting defects are common in moderate and
severe abruptio placentae because of the loss of
fibrinogen caused by copious internal bleeding.
1  An excessive amount of RBCs is not related to the
depletion of fibrinogen.  2  The bleeding with abruptio
Answers and Rationales 627
placentae is caused by depletion of fibrinogen, not
CHILDBEARING AND WOMEN’S HEALTH NURSING
thrombocytes (platelets).  3  Excessive globulin in the
blood is unrelated to clotting.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26,
Abruptio Placentae, Data Base
223.  3  Hypertension during pregnancy leads to
vasospasms; this in turn causes the placenta to tear
away from the uterine wall (abruptio placentae).
1  Generally cardiac disease does not cause abruptio
placentae.  2  This may cause an endocrine disturbance in
the infant but does not affect the blood supply to the
uterus.  4  This may affect the birth of the fetus but does
not affect the placenta.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Abruptio Placentae, Data Base
224.  1  Placenta previa is classically painless bleeding; the
ANSWERS AND RATIONALES
placenta partially or completely covers the cervical
os, and as the cervix dilates, the placenta separates
and bleeds.
2  Placenta accreta is an abnormally adherent placenta;
the placenta attaches through the endometrium to the
myometrium.  3  A ruptured uterus is a painful
occurrence; the fetus may be expelled from the uterus
into the abdomen.  4  There is no visible bleeding if the
abruptio is concealed; abruptio placentae is painful
because the blood accumulates between the placenta and
the uterine muscle.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Placenta Previa, Data Base
225.  3  Observation and documentation of bleeding are
necessary for implementing safe care because
hemorrhage and shock can be life-threatening.
1  Vital signs should be checked more often while there
is bleeding.  2  This is contraindicated because it may
cause further separation of the placenta.  4  The client
should be restricted to complete bed rest until bleeding
stops.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Communication/Documentation;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Placenta Previa, Nursing Care
226.  3  Abruptio placentae is associated with cocaine use; it
occurs in the third trimester.
1  Placenta previa is seen in the third trimester but is not
associated with cocaine use.  2  A tubal pregnancy is
identified in the first trimester.  4  Spontaneous abortion
occurs in the first 2 trimesters.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Abruptio Placentae, Data Base
227.  2  Prostaglandins in semen may stimulate labor, and
penile contact with the cervix may increase
myometrial contractility.
1  Sexual intercourse may cause labor to progress; it is
contraindicated for the rest of the pregnancy.  3  The
position is irrelevant; sexual intercourse is contraindicated
 628 CHAPTER 28  Childbearing and Women’s Health Nursing
for the rest of the pregnancy.  4  Regardless of the extent
CHILDBEARING AND WOMEN’S HEALTH NURSING
of penile penetration, sexual intercourse may precipitate
labor; it is contraindicated for the rest of the pregnancy.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 26, Preterm
Labor, Nursing Care
228.  1  Uterine atony often results from an overdistended
uterus; uterine contractions do not occur readily
and the uterus fills with blood.
2  This might cause a hematoma to form, but not a
hemorrhage.  3  This is unusual; it may cause some
bleeding, but not a hemorrhage.  4  This can occur in
single, not just multiple, births if the placenta has not
been carefully inspected for tears.
Client Need: Health Promotion and Maintenance; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, The Woman with a Multifetal Pregnancy, Data Base
ANSWERS AND RATIONALES
229.  4  Once the membranes have ruptured, the active
herpes infection ascends and can infect the fetus;
since herpes does not cross the placenta, a cesarean
birth prevents transfer of the virus to the fetus.
1, 2, 3  This is not an indication for a cesarean birth;
treatment is pharmacological.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Cesarean Birth, Data Base
230.  2  This is the treatment of choice for complete
placental separation (abruptio placentae). The risk
for fetal and maternal mortality is too high to delay
action.
1  A high-forceps birth rarely is used because the forceps
may further complicate the situation by tearing the
cervix. 3, 4  The fetus would probably expire if this
course of action were taken.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Abruptio Placentae, Data Base
231.  1  A multipara with a shoulder presentation is
indicative of a transverse lie; this necessitates a
cesarean birth.
2  It is not uncommon for the fetus of a multipara to be
high at the beginning of labor; early engagement occurs
more often with a primigravida.  3  With an occiput
posterior position the labor may be longer, but usually
the mother can give birth vaginally.  4  If the first twin is
in the vertex presentation, a vaginal birth will be
attempted with a double setup; if possible, the birth of
the second twin also will be attempted vaginally.
Client Need: Management of Care; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Cesarean Birth, Data Base
232.  4  It is expected that up to two perineal pads can be
saturated in the first hour.
1  A scant flow probably would not saturate even one
pad.  2  Hemorrhage would saturate more than two pads
in 1 hour.  3  This would be accompanied by heavy
bleeding and require more than two pads during the first
hour.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 26, Cesarean Birth, Nursing Care
233.  1  A first pregnancy and obesity are both documented
risk factors for a hypertensive disorder of
pregnancy.
2  The risk for a hypertensive disorder of pregnancy
increases when the client is younger than 20 years of age
and older than 35 years of age. 3, 4  This is not a
documented risk factor.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 26, Hypertensive Disorders of Pregnancy,
Data Base
234.  4  A blood pressure more than 140 mm Hg systolic
and 90 mm Hg diastolic along with proteinuria is
diagnostic of preeclampsia; assessments should be
done twice  4  to 6 hours apart.
1  Hypertension alone does not support a diagnosis
of preeclampsia.  2  Hypertension accompanied
by a headache is not necessarily indicative of
preeclampsia.  3  This can occur at any time, not
specifically in clients with gestational hypertension.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 26, Hypertensive Disorders of Pregnancy, Data Base
235.  Answer: 1, 3, 5.
1  Headache in severe preeclampsia is related to cerebral
edema.  2  Constipation is not related to preeclampsia. 
3  Abdominal pain in severe preeclampsia is related to
decreased circulating blood volume and generalized
edema.  4  Vaginal bleeding is not associated with
preeclampsia.  5  Visual disturbances in severe
preeclampsia are related to retinal edema.
Client Need: Physiological Adaptation; Cognitive
Level: Analysis; Nursing Process: Assessment/
Analysis; Reference: Ch 26, Hypertensive Disorders of
Pregnancy, Data Base
236.  4  This is a sign of CNS involvement that the nurse can
observe without obtaining subjective data from the
client. It is a sign of an impending seizure.
1, 2,  3  These are clinical manifestations of severe
preeclampsia, not eclampsia.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 26,
Hypertensive Disorders of Pregnancy, Nursing Care
237.  1  Padded side rails prevent injury during the
clonic-tonic phase of a seizure. The client must be
protected from injury if there is a seizure.
2  Although some clients have an aura before a seizure,
there is not enough time to use a call button and wait for
help.  3  Oxygen is useless during a seizure when the
client is not breathing and/or is thrashing about. 
4  Assigning a staff member to stay with the client in
anticipation of a seizure is impractical and unproductive.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Hypertensive Disorders of Pregnancy, Nursing
Care

238.  3  The danger of a seizure in a woman with eclampsia
subsides when postpartum diuresis has occurred,
usually 48 hours after birth; however, the risk for
seizures may remain for up to  2  weeks
postpartum.
1, 2, 4  This is too soon.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 26, Hypertensive Disorders of Pregnancy, Nursing Care
239.  3  Distribution of the fingers around the head will
prevent a rapid change in intracranial pressure
while the head is being born and keeps the head
from “popping out,” causing maternal perineal
trauma.
1  This will not assist with the birth of the head.  2  This
may interfere with the birth and harm the neonate.  anesthesia relieves the stress of pain, and it does not
4  This could injure the neonate.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Precipitate Birth, Nursing Care
240.  4  A position in which the mother’s head is below the
level of the hips helps decrease compression of the
cord and therefore maintains the blood supply to
the fetus.
1  This position is impossible to maintain and will not
relieve the pressure of the oncoming head on the
cord.  2  This will increase the pressure of the presenting
part on the cord.  3  The pressure of the presenting part
on the cord is not relieved in this position. Also, pressure
on the vena cava will ultimately decrease placental
perfusion.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Breech Birth, Nursing Care
241.  3  The heart rate increases by about 10 beats/min in
the last half of pregnancy; this increase, plus the
increase in total blood volume, can strain a
damaged heart beyond the point at which it can
efficiently compensate.
1  The number of RBCs does not decrease during
pregnancy.  2  The increased size of the uterus is related
to the growth of the fetus, not to any hemodynamic
change.  4  Cardiac output begins to decrease by the 34th
week of gestation.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Heart Disease, Data Base
242.  4  This is the most critical period because of the rapid
shift of extravascular fluid as it returns to the
bloodstream; this mobilization of fluid can
compromise the heart and lead to cardiac
decompensation.
1  During the first trimester the increased amount of
circulating blood volume is minimal and occurs
gradually; thus, it does not place an unusual burden on
the heart.  2  The risk for cardiac decompensation
increases as pregnancy progresses; however, the increase
in blood volume occurs gradually, and the mother is
monitored closely.  3  There is an increased risk for stress
Answers and Rationales 629
on the heart during labor; however, close monitoring and
CHILDBEARING AND WOMEN’S HEALTH NURSING
the use of agents to provide rest and pain relief have
decreased these risks.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 26, Heart
Disease, Nursing Care
243.  Answer: 1, 3, 4.
1  An oxytocin (Syntocinon) infusion is carefully
monitored for the gentle induction or augmentation of
labor.  2  A midforceps assisted birth is not needed. A
low or outlet forceps may be used to reduce the need to
push and to conserve energy.  3  The health care provider
may prefer a vacuum extraction assisted birth to reduce
the need to push and to conserve energy.  4  Regional
compromise cardiovascular function. 5 Inhalation
anesthesia is contraindicated because it could
ANSWERS AND RATIONALES
compromise cardiovascular function.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 26, Heart Disease, Nursing
Care
244.  3  Elevating the client’s head facilitates easier oxygen
exchange, and the left side-lying position promotes
venous return.
1  This is too uncomfortable; the gravid uterus will
impede venous return from the legs.  2  Although this
position is comfortable, the gravid uterus may inhibit
venous return and result in placental congestion and
supine hypotension.  4  At full term, the left side-lying
position is preferred to the right side-lying position to
enhance venous return.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Heart Disease, Nursing Care
245.  3  Clients with cardiac problems are prone to heart
failure during active labor; crackles indicate the
presence of pulmonary edema.
1, 2  This is done for all clients who are in labor. 
4  This is not necessary; although clients who are in
labor are maintained on the side to facilitate venous
return, the sides do not have to be alternated every 15
minutes.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Heart Disease, Nursing Care
246.  1  Usually as pregnancy progresses, there are
alterations in glucose tolerance and in the
metabolism and utilization of insulin. The result is
an increased need for exogenous insulin.
2  Antihypertensives are administered only to clients with
severe hypertensive preeclampsia.  3  Pancreatic enzymes
or hormones other than insulin are not taken by
pregnant women with diabetes.  4  Estrogenic hormones
are not administered during pregnancy.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Diabetes Mellitus, Data Base
 630 CHAPTER 28  Childbearing and Women’s Health Nursing
247.  3  Insulin requirements may fall suddenly during the
CHILDBEARING AND WOMEN’S HEALTH NURSING
first 24 to 48 postpartum hours because the
endocrine changes of pregnancy are reversed.
1  Insulin requirements do not suddenly increase at this
time.  2  Insulin requirements do not remain unchanged
at this time.  4  Insulin requirements do not slowly and
steadily decrease at this time.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Evaluation/Outcomes;
Reference: Ch 26, Diabetes Mellitus, Data Base
248.  4  The client should receive nothing by mouth while
heavy bleeding continues because surgical
intervention may become necessary.
1  Providing oral fluids at this time is inappropriate and
could result in aspiration if surgery becomes
necessary.  2  The nurse does not need an order to give
fluids to a postpartum client; the nurse must make an
independent judgment regarding the withholding of
ANSWERS AND RATIONALES
fluids.  3  Although oral fluids can increase the blood
volume, it would be inappropriate to provide fluids while
the client is bleeding.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Postpartum Bleeding, Nursing Care
249.  4  Multiple full-term pregnancies and births result in
overstretched uterine muscles that do not contract
efficiently, and bleeding may ensue. Oxytocin
(Pitocin) promotes uterine contractions.
1  A precipitous birth does not predispose to uterine
atony unless there is a complication.  2  Giving birth
outside the birthing area does not predispose the client to
uterine atony.  3  Multiparity does not predispose to
retained placental fragments.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Postpartum Bleeding, Data Base
250.  Answer: 1, 2, 4.
1  Overdistention of the uterus may lead to delayed or
inadequate uterine contractions.  2  An overdistended
bladder may inhibit uterine contractions.  3  Clients with
ineffective uterine contractions are treated with rest and
sedatives; although labor is prolonged, postpartum
hemorrhage is not expected.  4  Retained placental
fragments inhibit uterine contractions. 5 Mild gestational
hypertension does not interfere with uterine involution.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Evaluation/Outcomes;
Reference: Ch 26, Postpartum Bleeding, Data Base
251.  2  Blood loss depletes the cellular response to
infection; trauma provides an excellent avenue for
bacteria to enter.
1  These may create problems if hemorrhage occurs
because the hemoglobin and hematocrit are already
low.  3  Preeclampsia is not a predisposing cause of
postpartum infection; retained placental fragments cause
hemorrhage and if not removed immediately will result
in hypovolemic shock, not infection.  4  Endogenous
infections are rare; infections usually are caused by
outside contamination. Trauma and the denuded
placental site may contribute to the development of
infection.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 26, Postpartum Bleeding, Data Base
252.  2  The heartbeat can drop as low as 50 beats/min for
up to 10 days after the birth. It occurs because of
the decreased blood volume, and increased stroke
volume after the pregnancy has terminated.
1  A thready pulse may be a sign of postpartum
hemorrhage with impending shock.  3  A bounding pulse
may be a sign of hypertension. Although there may be a
slight rise in blood pressure for several days, hypertension
is not expected.  4  An irregular heartbeat may be a sign
of cardiac decompensation that requires further
investigation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 25, Postpartum Period, Data Base
253.  2  With the mobilization of extravascular fluid and the
rapid decrease in uterine blood flow, the heart of a
client with a cardiac problem may begin to fail. As
the heart fails, the respiratory rate and effort
increase in an attempt to maintain oxygen to all
body cells.
1  Although pulse rate is important, the primary
assessment should be for respiratory distress.  3  Signs
of heart failure, not hypovolemic shock, might develop
if the respiratory distress is not treated.  4  Increased
vaginal bleeding is not caused by alterations in cardiac
status.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Evaluation/Outcomes; Reference: Ch 26, Heart
Disease, Nursing Care
254.  4  Glucose-oxidase strips are used by nurses to screen
infants for hypoglycemia.
1, 2  This test is not used to screen for
hypoglycemia.  3  Fasting blood glucose levels are not
used routinely to screen newborns for hypoglycemia.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 26, Diabetes Mellitus, Nursing Care
255.  2  The infant of a diabetic mother (IDM) is a newborn
at risk because of the interaction between the
maternal disease and the developing fetus.
1  A newborn of a mother with type 1 diabetes generally
is hypoglycemic because of oversecretion of insulin by the
newborn’s hypertrophied pancreas.  3  A newborn of a
mother with type 1 diabetes is at high risk and requires
intensive care.  4  The newborn of a mother with type 1
diabetes is prone to hypoglycemia and probably will need
increased glucose.
Client Need: Management of Care; Cognitive Level: Application;
Nursing Process: Planning/Implementation; Reference: Ch 26,
Diabetes Mellitus, Nursing Care
256.  1  The pancreas of a fetus of a diabetic mother
responds to the mother’s hyperglycemia by
secreting large amounts of insulin; this leads to
hypoglycemia after birth.

2  Hypocalcemia, not hypercalcemia, occurs.  3  Edema
may be generalized, not specific to the CNS.  4  In
response to the increased glucose received from the
mother, the islets of Langerhans in the fetus may have
become hypertrophied; they are not congenitally
depressed.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
26, Diabetes Mellitus, Nursing Care
Nursing Care of the Newborn
257.  1  By demonstrating acceptance of the infant, without
regard for the defect, the nurse acts as a role model
for the parents, thus enhancing their acceptance.
2  Infants with cleft palates can remain in the newborn
nursery; they should not be hidden.  3  This is false
reassurance; it does not promote parent-infant
attachment behaviors.  4  This will delay attachment; the
parents should be encouraged to have frequent contact
with their infant.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Caring; Nursing Process: Planning/
Implementation; Reference: Ch 27, Nursing Care Common to All
Newborns
258.  4  Mothers need to explore their infants visually and
tactilely to assure themselves that their infants are
healthy.
1  This comment closes off communication with the
mother at an opportune moment.  2  A strong cry is not
indicative of a healthy newborn.  3  The “normalcy” of
the mother’s pregnancy does not necessarily have a
relationship to the health of the newborn.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 27, Parent-Infant
Relationships
259.  2  Holding, touching, and interacting with the
newborn while providing basic care promotes
attachment.
1  The nurse’s infant feeding preference should not be
forced upon the mother.  3  Although rooming-in helps
promote attachment, not all women have the physical or
emotional ability to provide 24 hour care to the newborn
so early in the postpartum period.  4  Early observation is
not adequate; this can be done only by allowing the
mother ample time to interact with her baby.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Nursing
Process: Planning/Implementation; Reference: Ch 27, Parent-Infant
Relationships
260.  1  The mother has moved into the taking-hold phase
when she takes control and becomes actively
involved with her infant and calls the infant by
name. She has completed the taking-in phase when
her own needs no longer predominate.
2  This occurs in the taking-in phase when she has the
need to integrate the experience.  3  This is the initial
Answers and Rationales 631
early action of the taking-in phase.  4  This is part of the
CHILDBEARING AND WOMEN’S HEALTH NURSING
taking-in phase.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Parent-Infant Relationships
261.  1  Attachment between parent and infant is most
successful when interaction is possible immediately
after birth; if the infant is ill, contact is limited.
2  Although the duration and difficulty of labor is a
factor, the most important factor is the physical
condition of the infant.  3  Although the effect of
anesthesia is a factor, the most important one is the
physical condition of the infant.  4  Health and
emotional status during pregnancy may be factors, but
the most important factor after the birth is the physical
condition of the infant.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
ANSWERS AND RATIONALES
Reference: Ch 27, Parent-Infant Relationships
262.  3  Parenting is a learned behavior based on past
experiences and current motivation to learn.
1  Parenting is learned, not inborn.  2  Specific marital
roles do not influence parenting behaviors.  4  Knowledge
alone does not ensure the ability to parent.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Parent-Infant Relationships
263.  4  This mother is at risk for having difficulty with
attachment because her baby did not meet her
expectations.
1  Unplanned pregnancies usually do not pose a risk for
attachment problems because the decision was made to
continue the pregnancy, allowing time to accept
it.  2  Reliving the birthing experience, whether it
involves positive or negative feelings, occurs during the
first few postpartum days during the taking-in phase.
Unless there are other emotional problems, these feelings
are resolved during this phase, and then the mother
moves into the taking-hold phase, which initiates the
attachment process.  3  Ambivalent feelings during the
first trimester are common and usually resolve during the
second trimester.
Client Need: Psychosocial Integrity; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 27,
Parent-Infant Relationships
264.  2  This immunity is developed from an antigen-
antibody response in the mother that is transmitted
to the fetus.
1  This is acquired by an individual in response to a
disease or an infection.  3  This is acquired by an
individual in response to small amounts of antigenic
material (e.g., vaccination).  4  This is conferred by
the injection of antibodies already prepared in another
host.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Adaptation to Extrauterine Life
265.  3  A quiet, alert state is an optimum time for infant
stimulation.
 632 CHAPTER 28  Childbearing and Women’s Health Nursing
1  Bright lights are disturbing to newborns and may
CHILDBEARING AND WOMEN’S HEALTH NURSING
impede mother-infant interaction.  2  This position is
used for the sleeping infant.  4  Physical and behavioral
assessments are not the priorities; they can be delayed.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Planning/Implementation; Reference: Ch 27, Parent-Infant
Relationships
266.  Answer: 9. A value of  1  is assigned to the color
category (acrocyanosis); a value of  2  is assigned to
the heart rate that is within the expected range of
100 to 160 beats/min; the flexed extremities reflect
healthy muscle tone; and a lusty cry represents the
other two categories—reflex irritability and
respiratory rate—each of which is assigned a value
of 2. The Apgar score is 9, demonstrating a healthy
newborn.
Client Need: Reduction of Risk Potential; Cognitive Level:
ANSWERS AND RATIONALES
Analysis; Nursing Process: Assessment/Analysis; Reference: Ch
27, Adaptation to Extrauterine Life
267.  1  The heart rate is vital for life and is the most critical
observation in Apgar scoring.
2  Respiratory effort rather than rate is included in the
Apgar score; the rate is very erratic.  3  This may or may
not be present at this time and is not a part of Apgar
scoring.  4  This is not a part of Apgar scoring but should
be assessed later.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Adaptation to Extrauterine Life
268.  3  The newborn’s heart rate varies with activity; crying
can increase it to 180 beats/min, whereas deep
sleep may lower it to 80 to 100 beats/min; a rate
between 110 and 160 beats/min is the average.
1, 2  The heart rate of an alert, noncrying newborn that
is above 160 beats/min indicates tachycardia.  4  The
heart rate of an alert, noncrying newborn that is below
110 beats/min indicates bradycardia.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Adaptation to Extrauterine Life
269.  1  The initial response is a reflection of the startle
reflex; when the stimulus is repetitive, the response
to the stimulus decreases; this decrease in response
is called habituation and is expected.
2, 4  This is not necessary because the neonate’s response
is expected.  3  The infant is responding to noise and
therefore hears.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Adaptation to Extrauterine Life
270.  Answer: 1, 3, 4.
1  Full-term neonates have a flexed fetal position, which
conserves heat.  2  Insulin is not stored in the liver and is
not involved with maintaining neonatal body temperature.  eventually disappear.
3  Brown fat is deposited at 28 weeks’ gestation and
continues for the rest of the pregnancy; when the
newborn’s body becomes cool, the sympathetic nervous
system stimulates the breakdown of brown fat, on dark-skinned infants.
which releases heat as a by-product.  4  Peripheral
vasoconstriction helps to conserve heat by keeping the
central core warm and preventing heat from dissipating.
5  The sympathetic, not parasympathetic, nervous system
is involved in thermoregulation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Adaptation to Extrauterine Life
271.  4  The expected breathing patterns are abdominal
and irregular in rhythm and depth (alternates
between shallow and deep); the expected rate
ranges from 30 to 60 breaths/min.
1  Newborns’ respirations are irregular and
abdominal.  2  Newborns’ respirations are
abdominal.  3  Newborns’ respirations are irregular.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Knowledge; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Adaptation to Extrauterine Life
272.  2  Cyanosis, choking, and coughing are signs of
aspiration and hypoxia. Suctioning and
oxygenation are needed.
1  Crying may add to the distress.  3  The water may be
aspirated and intensify the problem.  4  This is unsafe;
the newborn is showing signs of a blocked airway.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Adaptation to Extrauterine Life
273.  1  The mucus must be removed to maintain a patent
airway and promote respirations and gaseous
exchange.
2  Oxygenation is ineffective if the airway is obstructed. 
3  Documentation is important, but it is not the
priority.  4  This is done to aspirate stomach contents,
not to clear the airway.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Nursing Care Common to Newborns
274.  2  The Moro reflex is a sudden extension and
abduction of the arms at the shoulders and
spreading of the fingers. This is followed by flexion
and adduction of the arms with the index finger
and thumb forming the letter “C”; the infant
may cry.
1  Extension and abduction, not adduction, is the
first part of the Moro reflex.  3  Although the reflex
response includes adduction of the arms, the toes are not
involved.  4  Although the reflex starts with extension of
the arms, the fingers fan out before forming the “C”
position.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/
Analysis; Reference: Ch 27, Nursing Care Common to
Newborns
275.  1  Milia are common, are not indicative of illness, and
2  Lanugo is fine, downy hair.  3  This is a lay term for
milia; it is not used when documenting.  4  These are
bluish black areas on the buttocks that may be present

Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Nursing Care Common to Newborns
276.  3  The tonic neck reflex (fencing position) is a
spontaneous postural reflex of the newborn; it
persists until the third month.
1  The Moro reflex is exhibited when a sudden change in
equilibrium causes extension and abduction of the
extremities followed by flexion and adduction.  2  The
Babinski reflex is exhibited when the examiner runs a
finger up the lateral (small toe side) undersurface of 1  Rooming-in may not be instituted immediately after
the foot from the heel to the toes and then across the
ball of the foot; the toes separate and flare out.  4  The
palmar grasp reflex is exhibited when the fingers flex
around a person’s finger as it is placed in the infant’s
palm.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Nursing Care Common to Newborns
277.  3  Bacteria, especially Escherichia coli, produce
substances necessary to synthesize prothrombin.
1  This is an orange bile pigment produced by the
breakdown of hemoglobin.  2  Bile salts are manufactured
in the liver, not synthesized by bacteria.  4  This is
secreted by the gastric glands, not synthesized by
bacteria.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Adaptation to Extrauterine Life
278.  4  In 36 to 48 hours the newborn will have ingested
an ample amount of the amino acid phenylalanine,
which if not metabolized because of a lack of a
specific liver enzyme, can result in excess levels of
phenylalanine in the bloodstream and brain,
resulting in mental retardation; early detection is
essential to prevent this.
1  The infant will have a vitamin K injection soon after
birth to prevent bleeding problems.  2  Blood is
withdrawn from the heel soon after birth to test for
hypoglycemia.  3  Necrotizing enterocolitis is a disorder
that can affect preterm infants. It is not identified by a
test.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 27, Adaptation
to Extrauterine Life
279.  1  Phenylalanine is an essential amino acid necessary
for growth that may be absent in infants with
phenylketonuria (PKU); testing is done on all
neonates born in the United States.
2  Untreated PKU can lead to retardation; the test will
not identify retardation.  3  PKU is a genetic, not a
chromosomal, disorder.  4  This is done at the same time
as PKU testing, but thyroid deficiency is a problem
related to a hormone deficiency, not to PKU.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 27, Adaptation
to Extrauterine Life
Answers and Rationales 633
280.  2  Hypoglycemia causes CNS and sympathetic nervous
CHILDBEARING AND WOMEN’S HEALTH NURSING
symptom responses.
1, 3, 4  These are not signs of this problem.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Adaptation to Extrauterine Life
281.  4  There is a sensitive period in the first minutes or
hours after birth during which it is important for
later interpersonal development that the parents
have close contact with their newborn.
birth.  2  Taking-in is a maternal psychologic behavior
described by Reva Rubin that occurs during the first 2
postpartum days.  3  Taking-hold is a maternal
psychologic behavior described by Reva Rubin that
occurs after the third postpartum day.
Client Need: Psychosocial Integrity; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
ANSWERS AND RATIONALES
Reference: Ch 27, Parent-Infant Relationships
282.  1  Some maternal oxytocin crosses the placenta and
induces the secretion of fluids that have
accumulated in the fetal breasts (sometimes called
“witch’s milk”).
2  This usually is manifested as white, adherent patches
in the oral mucosa (thrush).  3  This is uncommon and
usually undetectable in the newborn period.  4  Evidence
of infection would not appear so rapidly after birth.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 27,
Nursing Care Common to Newborns
283.  3  Newborns’ eye movements are uncoordinated and
the eyes appear crossed as they try to focus. As the
eye muscles mature, the apparent strabismus
disappears.
1  This discounts the mother’s concern and is demeaning. 
2  Although this is true, the mother should be given an
explanation for the apparent strabismus.  4  This is
misinformation that will increase the mother’s anxiety.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Caring; Communication/
Documentation; Nursing Process: Planning/Implementation;
Reference: Ch 27, Nursing Care Common to All Newborns
284.  2  Teaching the mother by example is a
nonthreatening approach that allows her to
proceed at her own pace.
1  Learning does not occur by schedule; questions
must be answered as they arise.  3  Mothers need
demonstration of appropriate mothering skills, not
just a discussion.  4  Although emotional support is
required, the plan should encourage independent
caregiving.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 27,
Nursing Care Common to Newborns
285.  2  The antibodies in human milk provide the infant
with immunity against all or most of the pathogens
that the mother has encountered.
 634 CHAPTER 28  Childbearing and Women’s Health Nursing
1, 3  These are present in commercial formulas.  momentary closure of the glottis increases the length of
CHILDBEARING AND WOMEN’S HEALTH NURSING
4  Complex carbohydrates are not required by the
infant.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 27,
Adaptation to Extrauterine Life
286.  Answer: 1, 3, 4.
1  These infants have low glycogen stores.  2  These
infants are not at risk for developing hypoglycemia. They
are at risk for congenital cardiac defects.  3  These infants
have low glycogen stores.  4  These infants are prone to
hyperinsulinemia; often they have mothers who have
diabetes, which exposes them to high circulating glucose
levels while in utero. After prolonged exposure to high
glucose levels, hyperplasia of the pancreas occurs,
resulting in hyperinsulinemia. 5 These infants are not at
risk for developing hypoglycemia.
ANSWERS AND RATIONALES
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 27,
Adaptation to Extrauterine Life
287.  4  The congenital absence of a blood vessel in the
umbilical cord is often associated with life-
threatening congenital anomalies. There should be
two arteries and one vein.
1  It is too soon to determine if the newborn needs
prolonged follow-up care; the second Apgar score 5
minutes later determines this.  2  This is the average
weight for a full-term newborn.  3  The expected glucose
level in a healthy newborn is 40 to 69 mg/dL.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 27, Nursing
Care Common to Newborns
288.  Answer: 5
Weak cry = 1; heart rate of 90 bpm = 1; some flexion of
extremities = 1; grimacing = 1; and acrocyanosis = 1.
Client Need: Reduction of Risk Potential; Cognitive Level:
Analysis; Nursing Process: Assessment/Analysis; Reference: Ch
27, Adaptation to Extrauterine Life
289.  4  This is related to neonatal morbidity and mortality;
by 5 minutes the healthy neonate is relatively
stable with an Apgar score of 8 to 10 and requires
routine care.
1  The presence of cerebral palsy is not related to the
Apgar score. It is rarely diagnosed in the newborn.  Client Need: Health Promotion and Maintenance; Cognitive
2  Genetic defects may or may not be apparent at this
time. They are not related to the Apgar score.  3  This has
not been proven, although research continues in this
area.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Adaptation to Extrauterine Life
290.  Answer: 1, 2, 3.
1  Nasal flaring occurs because of the stress of breathing;
the flaring nostrils allow more air to enter the respiratory
passages.  2  Sternal retractions occur when accessory
muscles of respiration contract during the stress of
breathing.  3  Grunting respirations occur as the glottis
closes and reopens at the height of inhalation; this
time oxygen and carbon dioxide are exchanged in the
alveoli.  4  Newborns have irregular respirations with
periods of apnea.  5  Cyanosis of the hands and feet
(acrocyanosis) is typical of all newborns at the time of
birth.  6  This is within the expected range for heart rates
of healthy infants.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 30, Cardiac
Malformations, Data Base
291.  Answer 1, 4, 5.
1  This is an important part of record keeping for all
newborns.  2  The neonate’s Apgar score (7/9) does not
indicate a need for oxygen.  3  Newborns are either
breastfed or formula fed. Glucose water is not offered
first.  4  All newborns are evaluated upon admission to
the nursery.  5  All newborns should be kept warm to
maintain a stable body temperature.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Nursing Care Common to Newborns
292.  4  If the woman perceives a negative viewpoint about
breastfeeding from significant others, she may be
tense and the let-down reflex may not occur; a
positive attitude from significant others toward
breastfeeding promotes relaxation and the let-
down reflex.
1, 2  This has no influence on lactation.  3  Milk or milk
product intake during pregnancy has little influence on
lactation.
Client Need: Psychosocial Integrity; Cognitive Level: Application;
Integrated Process: Teaching/Learning; Nursing Process:
Assessment/Analysis; Reference: Ch 27, Breastfeeding, Data Base
293.  1  The question should be answered directly in the
class. However, the mother’s statement indicates
some concerns about breastfeeding that should be
explored privately later.
2  This is false reassurance; successful breastfeeding
requires mastery, and some women have difficulty. 
3  Although the nurse perceives the client’s concerns, this
response is inappropriate in a class with others present.
The nurse should elicit more information privately later. 
4  The infant’s suckling and emptying of the breasts will
determine the amount of milk produced.
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 27,
Breastfeeding, Nursing Care
294.  3  Most average-sized infants regulate themselves to
an approximate 3- to 4-hour schedule. However,
wide variations do exist.
1  Some of the episodes of crying do not indicate that
the infant is hungry; the mother will learn the
difference.  2  It is best to allow the infant to set the
schedule.  4  Although this is true, this does not answer
the mother’s question concerning when she will have free
time.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;

Nursing Process: Planning/Implementation; Reference: Ch 27,
Breastfeeding, Nursing Care
295.  4  Breastfeeding by a mother with human
immunodeficiency virus (HIV) is contraindicated
because breast milk can transmit the virus to the
infant.
1  Breastfeeding by a mother with mastitis is not always
contraindicated; during antibiotic treatment lactation can
be maintained by pumping the breasts and discarding the
milk. When the infection has resolved, breastfeeding can
resume.  2  Breastfeeding is not contraindicated with
inverted nipples because a breast shield can provide mild
suction to help evert a nipple.  3  Breastfeeding is not
contraindicated for a client with genital herpes. The
newborn may contract the infection during a vaginal
birth, not via breast milk.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 27,
Breastfeeding, Data Base
296.  1  Air-drying nipples after feedings limits irritation
and disruption of skin integrity.
2  Application of soap to breast tissue may result in
drying and cracking.  3  Plastic liners trap moisture
against tissue and may cause skin breakdown.  4  Wearing
a brassiere continuously, except for bathing, is
recommended for 2 to 3 weeks to provide support to
breast tissue structures.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Evaluation/Outcomes; Reference: Ch 27,
Breastfeeding, Nursing Care
297.  3  Frequently the emotional excitement of going
home will diminish lactation and/or the let-down
reflex for a brief period. When the mother is aware
that this may happen and knows how to cope with
it, the problem is apt to be a minor one and easily
overcome.
1  This is false reassurance. Many factors (stresses) inhibit
lactation, and the client should be aware of this.  2  This
is false reassurance. The milk supply may diminish or
stop under stress.  4  This is contraindicated. Lack of
breast stimulation during formula feeding could diminish
lactation.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Teaching/Learning;
Nursing Process: Planning/Implementation; Reference: Ch 27,
Breastfeeding, Nursing Care
298.  3  Soap irritates, cracks, and dries breasts and nipples,
making it painful for the mother when the baby
sucks; also, it increases the risk for mastitis.
1  The client should empty the breasts at each feeding to
keep milk flowing.  2  This is a permissible and often-
used technique of breastfeeding.  4  This elicits the
rooting reflex, causing the infant’s head to turn toward
and touch the mother’s breast.
Client Need: Safety and Infection Control; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 27, Breastfeeding,
Nursing Care
Answers and Rationales 635
299.  1  More frequent breastfeeding stimulates more
CHILDBEARING AND WOMEN’S HEALTH NURSING
frequent evacuation of meconium, thus preventing
resorption of bilirubin into the circulatory system.
2  Phototherapy is the treatment for hyperbilirubinemia,
and it is maintained continuously; it does not prevent
the development of hyperbilirubinemia.  3  It is not
necessary to formula feed. Early breastfeeding tends to
keep the bilirubin level low by stimulating GI
activity.  4  Increasing water intake does not limit the
development of hyperbilirubinemia because only small
amounts of bilirubin are excreted by the kidneys.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Breastfeeding, Data Base
300.  1  Typically six to eight wet diapers a day indicate
adequate fluid intake.
2  This may be a sign of inadequate nutritional intake.
A breastfeeding infant usually sleeps 11 2 to 2 1 2 hours
ANSWERS AND RATIONALES
between feedings because breast milk digests rapidly. 
3  The number of bowel movements per day is not
related to the amount of milk ingested, although
breastfeeding infants do defecate more frequently than
formula-fed infants.  4  The length of nursing time at
each breast does not indicate the amount of milk being
ingested.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Integrated Process: Communication/
Documentation; Nursing Process: Assessment/Analysis; Reference:
Ch 27, Breastfeeding, Nursing Care
301.  1  When the breast is pushed into the infant’s mouth,
a typical response is for the mouth to close too
soon, resulting in inadequate latching-on.
2  This facilitates latching-on and maintains the
infant’s head in correct alignment, which promotes
sucking and swallowing.  3  This will stimulate the
rooting reflex and promote latching-on.  4  This
prevents trauma to the nipple when removing the
infant from the breast.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Evaluation/Outcomes; Reference: Ch 27, Breastfeeding,
Nursing Care
302.  2  Infants require about 73 mL of fluid per pound and
60 calories a day per pound for growth. The infant’s
weight of 6 lb × 73 mL of fluid = 438 mL. If fed every
4 hours the infant will have 6 feedings; 438 ÷ 6 =
73 mL; 73 ÷ 30 (30 mL/oz) = 2.4 oz. Therefore, the
infant should be offered 2 to 3 oz per feeding.
1  This amount of formula is inadequate for this
newborn. 3, 4  This amount of formula is excessive for
this newborn.
Client Need: Basic Care and Comfort; Cognitive Level: Analysis;
Nursing Process: Planning/Implementation; Reference: Ch 27,
Formula Feeding, Nursing Care
303.  4  Cow’s milk is more difficult to digest because it is
meant to meet a calf’s, not an infant’s, nutritional
needs. It is not recommended until after the infant
is  1  year old. Formula is preferred if the mother is
not breastfeeding.
 636 CHAPTER 28  Childbearing and Women’s Health Nursing
1  Cow’s milk contains more protein and more
CHILDBEARING AND WOMEN’S HEALTH NURSING
calcium.  2  Cow’s milk contains more protein and fewer
carbohydrates.  3  Cow’s milk contains more calcium.
Client Need: Basic Care and Comfort; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 27, Formula
Feeding; Data Base
304.  Answer: 4, 1, 2, 3, 5.
4  The bag should be removed, and the mouth checked
for secretions and suctioned, if necessary, to clear the
airway.  1  Repositioning the newborn’s head may open
the airway.  2  Opening the mouth slightly reduces
resistance to the positive pressure of the pumped
air.  3  Reapplying the mask may create a better seal
when the bag is compressed again. 5 After nursing
interventions are implemented, the neonate should be
reassessed for a response.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
ANSWERS AND RATIONALES
Nursing Process: Planning/Implementation; Reference: Ch 27,
Respiratory Distress Syndrome, Nursing Care
305.  1  RhoGAM must be given within 72 hours postpartum
if the client has not been sensitized previously,
irrespective of the length of the gestation.
2  It would be useless at this time because antibodies
have been produced already.  3  RhoGAM is always
indicated at the termination of a pregnancy, even with a
short-term pregnancy.  4  RhoGAM is always indicated at
the termination of a pregnancy, even with fetal demise.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Hemolytic Disorders, Data Base
306.  4  There is an apparent ABO incompatibility because
the mother is O and the infant is B; incompatibility
can cause jaundice within the first 24 hours.
1  The information provided does not indicate neonatal
sepsis.  2  Rh incompatibility is not a factor because the
mother is Rh positive.  3  Jaundice in the first 24 hours is
not physiologic; it is pathologic.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Hemolytic Disorders, Data Base
307.  2  The neonate’s age is critical because the
development of jaundice before 24 to 48 hours
after birth may indicate a blood dyscrasia
(pathologic jaundice, hyperbilirubinemia), requiring
immediate investigation. Jaundice occurring
between 48 and 72 hours after birth (physiologic
jaundice) is a consequence of the expected
breakdown of fetal red cells and immaturity of the
liver.
1  Unless the jaundice was pathologic (occurring in the
first 24 hours of life), this is not necessary.  3  First, the
age of the neonate must be ascertained to determine if
this is physiologic or pathologic jaundice; then the nurse
should obtain a sample of heel blood to determine the
serum bilirubin level.  4  Bilirubin studies should be done
first to determine whether the serum level warrants
phototherapy. This therapy requires a health care
provider’s order.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Hemolytic Disorders, Data Base
308.  4  RhoGAM will prevent sensitization from Rh
incompatibility that may arise between an
Rh-negative mother and an Rh-positive newborn.
1  This is unnecessary because only the mother’s and
infant’s Rh factors are relevant.  2  This is unnecessary; if
a transfusion were needed, it would be for the newborn,
not the mother.  3  There is no incompatibility;
incompatibility might occur if the mother were O
positive and the newborn had type A, B, or AB blood.
Client Need: Pharmacological and Parenteral Therapies; Cognitive
Level: Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Hemolytic Disorders, Nursing Care
309.  3  Development of jaundice within the first 24 hours
indicates hemolytic disease of the newborn.
1  These may or may not be present during the first 24
hours; they are dependent on the bilirubin level.  2  This
may or may not be present during the first 24 hours;
usually it develops later.  4  Serum bilirubin levels are
expected to accumulate in the neonatal period because of
the short life span of fetal erythrocytes, reaching levels of
7 mg/100 mL the second to third day when jaundice
appears (physiologic jaundice).
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Hemolytic Disorders, Data Base
310.  2  This is the sign that differentiates between these
two conditions; cephalohematoma does not extend
beyond the suture line.
1  Pain is not associated with either condition.  3  This is
unusual; it should decrease in size.  4  Bruising can occur
with either condition.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Application; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Cranial Birth Injuries, Data Base
311.  4  A rapid birth does not give the fetal head adequate
time for molding; therefore, pressure against the
head is increased and blood vessels may burst.
1, 3  This results from excessive pulling on the head and
shoulders during a difficult birth.  2  This is more likely
to occur in a footling breech birth.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Evaluation/Outcomes; Reference: Ch 27,
Cranial Birth Injuries, Data Base
312.  4  Intracranial bleeding may occur in the subdural,
subarachnoid, or intraventricular spaces of the
brain, causing pressure on vital centers; clinical
signs are related to the area and degree of cerebral
involvement.
1  This is caused by hypocalcemia; it is manifested by
exaggerated muscular twitching.  2  This is a defect of the
spinal column that is observed at birth.  3  An elevated
potassium level causes cardiac irregularities, not the
irritable behavior observable with CNS involvement.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Cranial Birth Injuries, Nursing Care

313.  4  With Erb-Duchenne paralysis there is damage to
spinal nerves C5 and C6, which causes paralysis
of the arm.
1  The grasp reflex is intact because the fingers usually are
not affected; if C8 is injured, paralysis of the hand results
(Klumpke paralysis).  2  There would be a negative Moro
reflex only on the affected side.  3  There is no
interference with turning of the head; usually injury
results from excessive lateral flexion of the head as the
shoulder is born.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Evaluation/Outcomes; Reference:
Ch 27, Neuromusculoskeletal Birth Injuries, Data Base
314.  3  Gentle massage and manipulation of the arm
muscles help prevent contractures. The parents can
perform them at home.
1  This is dangerous because it may lead to permanent
contractures.  2  The length of the arm will not change
on a daily basis.  4  Passive range-of-motion exercises
should be delayed for 10 days to prevent additional
injury to the brachial plexus.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Integrated Process: Teaching/Learning; Nursing
Process: Planning/Implementation; Reference: Ch 27,
Neuromusculoskeletal Birth Injuries, Nursing Care
315.  4  The brachial plexus is injured by excessive pressure
during a difficult birth or during a vaginal breech
birth.
1  Erb palsy is an injury that occurs during the birth
process; it is not acquired before or after birth.  2  Erb
palsy is a birth injury, not a genetic problem.  3  Erb
palsy is a birth injury to nervous tissue, not a tumor
arising from muscle tissue.
Client Need: Physiological Adaptation; Cognitive Level:
Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Neuromusculoskeletal Birth Injuries, Data Base
316.  4  Injury to the brachial plexus, clavicle, or humerus
during birth prevents abduction and adduction
movements of an upper extremity.
1  Children with Down syndrome exhibit the expected
Moro reflex.  2  This is not considered a cause; however,
if the cochlea were undeveloped or the eighth cranial
(vestibulocochlear) nerve were injured, it would affect
equilibrium and response to the test.  3  These injuries
usually cause a symmetric loss of the Moro reflex.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Neuromusculoskeletal Birth Injuries, Nursing Care
317.  3  Opioid withdrawal affects the CNS and respiratory
systems.
1  These may occur in a newborn with thyroid
deficiency.  2  These may indicate that the newborn is
experiencing cold stress or respiratory distress.  4  These
may occur in a newborn affected with syphilis.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Substance Dependence, Nursing Care
318.  2  As the opioid is cleared from the newborn’s body,
signs of withdrawal become evident. Tremors,
Answers and Rationales 637
irritability, difficulty sleeping, twitching, and
CHILDBEARING AND WOMEN’S HEALTH NURSING
convulsions result.
1  Dehydration is secondary to inadequate feeding; it is
not a direct result of opioid withdrawal.  3  Muscle
hypertonicity, not hypotonicity, occurs.  4  Opioid
withdrawal results in signs of excessive stimulation.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference: Ch
27, Substance Dependence, Nursing Care
319.  1  This conjunctivitis occurs about  3  to  4  days after
birth; if it is not treated prophylactically with an
antibiotic at birth or within  3  days, chronic
follicular conjunctivitis with conjunctival scarring
will occur.
2  Human immunodeficiency virus (HIV) in the
newborn does not manifest itself with conjunctivitis. 
3  High oxygen concentrations given to severely
compromised preterm infants cause vasoconstriction of
ANSWERS AND RATIONALES
retinal capillaries, which can lead to blindness; there are
no data to indicate that this infant was preterm, severely
compromised, or received oxygen.  4  This chemical
conjunctivitis occurs within the first 48 hours and is not
purulent.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 27,
Ophthalmia Neonatorum, Data Base
320.  1  Chlamydia trachomatis is associated with the
development of pneumonia in the newborn.
2  Purulent conjunctivitis at this time suggests a
chlamydia infection, not an allergic response. 
3  Boric acid solution will not treat this problem; a
prescribed antibiotic is required.  4  This would be done
eventually; however, the priority is to monitor for signs
of pneumonia.
Client Need: Physiological Adaptation; Cognitive Level: Analysis;
Nursing Process: Assessment/Analysis; Reference: Ch 27,
Ophthalmia Neonatorum, Data Base
321.  2  Because physical signs of congenital syphilis are
difficult to detect at birth, the infant should be
screened immediately to determine if treatment is
necessary.
1  This is a congenital defect that occurs in the first
trimester; Treponema pallidum does not affect a fetus
before the 16th week of gestation.  3  This is found in
children with Down syndrome, not congenital syphilis. 
4  This does not manifest in the infant with congenital
syphilis until about 3 months of age.
Client Need: Reduction of Risk Potential; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 27, Syphilis, Nursing Care
322.  3  Because neonates are unable to shiver, they use the
breakdown of brown fat to supply body heat; the
preterm infant has a limited supply of brown fat
available for this breakdown.
1  This is not specific to preterm neonates; all newborns
are unable to use shivering to supply body heat.  2  The
breakdown of glycogen into glucose does not supply
body heat.  4  Pituitary hormones do not regulate body
heat.
 638 CHAPTER 28  Childbearing and Women’s Health Nursing
Client Need: Health Promotion and Maintenance; Cognitive
CHILDBEARING AND WOMEN’S HEALTH NURSING
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Preterm Infant, Data Base
323.  1  The preterm infant has a reduced glomerular
filtration rate and reduced ability to concentrate
urine or conserve water.
2  All systems of the preterm neonate are less developed
than in the full-term neonate.  3  The opposite occurs;
urine is very dilute.  4  The fluid and electrolyte balance
of preterm infants is easily upset.
Client Need: Health Promotion and Maintenance; Cognitive
Level: Comprehension; Nursing Process: Assessment/Analysis;
Reference: Ch 27, Preterm Infant, Data Base
324.  3  Immaturity of the respiratory tract in preterm
infants is evidenced by a lack of functional alveoli,
smaller lumina with increased possibility of collapse
of the respiratory passages, weakness of respiratory
musculature, and insufficient calcification of the
ANSWERS AND RATIONALES
bony thorax, leading to respiratory distress.
1  This is not a common occurrence at the time of birth
unless trauma has occurred.  2  This is not a primary
concern unless severe hypoxia occurred during labor; it is
difficult to diagnose at this time.  4  This may be a
problem, but generally the air passageway is suctioned as
needed.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Assessment/Analysis; Reference:
Ch 27, Preterm Infant, Data Base
325.  4  The moisture provided by the humidity liquefies
the tenacious secretions, making gas exchange
possible.
1  Caloric intake is increased; the amount, number, and
type of feedings are related to the metabolic rate. 
2  Infants should be positioned side-lying rather than
prone; the prone position is associated with apnea and
sudden infant death syndrome (SIDS).  3  This is not a
routine action; the concentration of oxygen depends on
the oxygen concentration of the neonate’s blood gases.
Client Need: Physiological Adaptation; Cognitive Level:
Application; Nursing Process: Planning/Implementation;
Reference: Ch 27 Preterm Infant; Nursing Care