21 Nursing Care of A Family Experiencing A Sudden Pregnancy Com

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Chapter: Exam21
Instruction:
Name: __________________________ Date: _____________
Multiple Choice
1. A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which
action would be the priority for this woman on admission?
A) performing a vaginal examination to assess the extent of bleeding
B) helping the woman remain ambulatory to reduce bleeding
C) assessing fetal heart tones by use of an external monitor
D) assessing uterine contractions by an internal pressure gauge
Ans: C
Client Needs: Safe, Effective Care Environment: Management of Care
Cognitive Level: Apply
Page: 539
Feedback: Not disrupting the placenta is a prime responsibility. An internal monitor, a vaginal
examination, and remaining ambulatory could all do this and thus are contraindicated.
2. What would be the physiologic basis for a placenta previa?
A) a loose placental implantation
B) low placental implantation
C) a placenta with multiple lobes
D) a uterus with a midseptum
Ans: B
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Remember
Page: 548
Feedback: The cause of placenta previa is usually unknown, but for some reason the placenta is
implanted low instead of high on the uterus.
3. A woman in labor is at risk for abruptio placentae. Which assessment would most likely lead
the nurse to suspect that this has happened?
A) sharp fundal pain and discomfort between contractions
B) painless vaginal bleeding and a fall in blood pressure
C) pain in a lower quadrant and increased pulse rate
D) an increased blood pressure and oliguria
Ans: A
Cognitive Level: Analyze
Page: 561
Feedback: An abruptio placentae refers to premature separation of the placenta from the uterus.
As the placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation.
4. A woman of 16 weeks' gestation telephones the nurse because she has passed some
“berry-like” blood clots and now has continued dark brown vaginal bleeding. Which action
would the nurse instruct the woman to do?
A) “Maintain bed rest, and count the number of perineal pads used.”
B) “Come to the health care facility if uterine contractions begin.”
C) “Continue normal activity, but take the pulse every hour.”
D) “Come to the health facility with any vaginal material passed.”
Ans: D
Page: 561
Feedback: This is a typical time in pregnancy for gestational trophoblastic disease to present.
Asking the woman to bring any material passed vaginally would be important so it can be
assessed for this.
5. A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What
would be the most likely cause of these symptoms?
A) premature separation of the placenta
B) preterm labor that was undiagnosed
C) placenta previa obstructing the cervix
D) possible fetal death or injury
Ans: A
Page: 561
Feedback: Premature separation of the placenta begins with sharp fundal pain, usually followed
by vaginal bleeding. Placenta previa usually produces painless bleeding; labor contractions are
more often described as cramping.
6. A pregnant client has an Rh-negative blood type. Following the birth of the client's infant,
the nurse administers her Rho(D) immune globulin. The purpose of this is to:
A) promote maternal D antibody formation.
B) prevent maternal D antibody formation.
C) stimulate maternal D immune antigens.
D) prevent fetal Rh blood formation.
Ans: B
Page: 533
Feedback: Because Rho(D) immune globulin contains passive antibodies, the solution will
prevent the woman from forming long-lasting antibodies.
7. A woman who is Rh negative asks the nurse how many children she will be able to have
before Rh incompatibility causes them to die in utero. The nurse's best response would be that:
A) no more than three children is recommended.
B) as long as she receives Rho(D) immune globulin, there is no limit.
C) only her next child will be affected.
D) she will have to ask her primary care provider.
Ans: B
Page: 535
Feedback: Because Rho(D) immune globulin supplies passive antibodies, it prevents the
woman from forming antibodies. Without antibodies that could affect the fetus, the woman could
have as many children as she wants.
8. A woman has been diagnosed as having gestational hypertension. Which symptom for this
condition is the most typical?
A) increased perspiration
B) weight loss
C) susceptibility to infection
D) blood pressure elevation
Ans: D
Page: 547
Feedback: The symptom of gestational hypertension is blood pressure elevation (140/90 mm
Hg) identified after 20 weeks' gestation without proteinuria.
9. A woman is being admitted to the obstetric unit for severe preeclampsia. When assigning
room placement, which area would be most appropriate?
A) Beside the supply room
B) Near the staff elevator
C) Across from the nurse's station
D) At the end of the hallway
Ans: D
Page: 547
Feedback: A sudden noise can trigger a seizure in a severely preeclamptic woman. Room
placement, therefore, should not be near a high traffic area or noise, such as by a supply room,
the staff elevator, or nurse's station.
10. A woman develops HELLP syndrome. During labor, which prescription would the nurse
question?
A) Prepare her for epidural anesthesia.
B) Assess her blood pressure every 15 minutes.
C) Assess the urine output every hour.
D) Urge her to lie on her left side during labor.
Ans: A
Client Needs: Physiological Integrity: Physiological Adaptation
Page: 555
Feedback: A consequence of the HELLP syndrome is poor blood coagulation. Epidural
anesthesia is not recommended when blood coagulation is in doubt.
11. A woman is admitted with a diagnosis of ectopic pregnancy. For which procedure should
the nurse prepare?
A) bed rest for the next 4 weeks
B) intravenous administration of a tocolytic
C) immediate surgery
D) internal uterine monitoring
Ans: C
Client Needs: Physiological Integrity: Physiological Adaptation
Page: 534
Feedback: Ectopic pregnancy means an embryo has implanted outside the uterus, usually in the
fallopian tube. Surgery is usually necessary to remove the growing structure before the tube
ruptures or to repair the tube if rupture has occurred already.
12. A woman at 32 weeks' gestation is admitted in preterm labor. On the nurse's admission
assessment, which of following findings would cause the nurse to question the administration of
a tocolytic agent?
A) Cervical dilation of 5 cm
B) Strong, regular contractions
C) Fetus in a breech presentation
D) A spontaneous abortion in an earlier pregnancy
Ans: A
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Page: 534
Feedback: If cervical dilation has progressed too far already, labor cannot be halted. Tocolytics
usually are not begun if cervical dilation is over 3 to 4 cm.
13. A pregnant patient is diagnosed with placenta previa. Which action should the nurse
implement immediately for this patient?
A) Assess fetal heart sounds with an external monitor.
B) Help the patient remain ambulatory to reduce bleeding.
C) Assess uterine contractions by an internal pressure gauge.
D) Prepare for a vaginal examination to assess the extent of bleeding.
Ans: A
Client Needs 2: Physiological Integrity: Physiological Adaptation
Page: 538
Feedback: For placenta previa, the nurse should attach external monitoring equipment to record
fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine
contractions are contraindicated. A pelvic or rectal examination should never be done with
painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta
previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to
both mother and child. To ensure an adequate blood supply to the patient and fetus, the patient
should be placed immediately on bed rest in a side-lying position.
14. The nurse is preparing an education session on the 2020 National Health Goals to prevent
complications of pregnancy. What should the nurse include as the best preventive measure to
eliminate complications of pregnancy?
A) Encourage all pregnant patients to have prenatal care.
B) Suggest all pregnant patients keep weight gain to a minimum.
C) Recommend all pregnant patients engage in exercise most days of the week.
D) Counsel all pregnant patients to select low-fat dairy products rich in calcium.
Ans: A
Client Needs: Health Promotion and Maintenance
Client Needs 2: Physiological Integrity: Basic Care and Comfort
Page: 525
Feedback: Encouraging all women to come for prenatal care is the best preventive measure for
eliminating complications of pregnancy. Weight gain, exercise, and calcium intake are not
identified as specific measures to prevent complications of pregnancy.
15. The nurse is concerned that a pregnant patient is experiencing abruptio placentae. What did
the nurse assess in this patient?
A) Increased blood pressure and oliguria
B) Pain in a lower quadrant and increased pulse rate
C) Painless vaginal bleeding and a fall in blood pressure
D) Sharp fundal pain and discomfort between contractions
Ans: D
Page: 540
Feedback: Abruptio placentae is characterized by a sharp, stabbing pain high in the uterine
fundus as the initial separation occurs. Manifestations of abruptio placentae do not include
increased blood pressure, oliguria, pain in the lower quadrant, increased pule rate, painless
vaginal bleeding, or a fall in blood pressure.
16. A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood clots
and dark red blood from the vagina. What should the nurse direct the patient to do at this time?
A) Begin immediate bed rest.
B) Count the number of perineal pads that are saturated with blood.
C) Continue with normal daily activity and monitor pulse rate every hour.
D) Seek immediate medical attention and bring the expressed vaginal material.
Ans: D
Page: 531
Feedback: Gestational trophoblastic disease is abnormal proliferation and then degeneration of
the trophoblastic villi. The embryo fails to develop beyond a primitive start. At approximately
week 16 of pregnancy, vaginal bleeding will begin as spotting of dark-brown blood accompanied
by discharge of the clear fluid-filled vesicles. The pregnant patient who begins to miscarry at
home needs to bring any clots or tissue passed to the hospital because the presence of clear
fluid-filled cysts identifies gestational trophoblastic disease. The patient needs to seek immediate
medical attention and not stay at home on bed rest, count perineal pads, or continue with normal
activity and count pulse rates every hour.
17. The nurse is reviewing the plan of care for a pregnant patient experiencing a threatened
miscarriage. Which outcome would be appropriate for this patient?
A) Bed rest is maintained until all bleeding stops.
B) Less than one perineal pad is saturated per hour.
C) Bleeding spontaneously stops within 24 to 48 hours.
D) Normal coitus is resumed 1 week after the episode.
Ans: C
Client Needs 2: Physiological Integrity: Reduction of Risk Potential
Page: 531
Feedback: For a threatened miscarriage, an outcome for care would be that all bleeding would
spontaneously stop within 24 to 48 hours. Bed rest is not recommended for a threatened
miscarriage because blood will pool in the vagina. Vaginal bleeding that saturates a perineal pad
in 1 hour is an emergency and could indicate an incomplete or complete miscarriage. Normal
coitus should be withheld for 2 weeks after a threatened miscarriage.
18. A pregnant patient with a history of premature cervical dilatation undergoes cervical
cerclage. Which outcome indicates that this procedure has been successful?
A) The client delivers a full-term fetus at 39 weeks' gestation.
B) The client's membranes spontaneously rupture at week 30 of gestation.
C) The client experiences minimal vaginal bleeding throughout the pregnancy.
D) The client has reduced shortness of breath and abdominal pain during the pregnancy.
Ans: A
Page: 537
Feedback: Premature cervical dilatation is when the cervix dilates prematurely and cannot
retain a fetus until term. After the loss of one child because of premature cervical dilatation, a
surgical operation termed cervical cerclage can be performed to prevent this from happening in a
second pregnancy. This procedure is the use of purse-string sutures placed in the cervix to
strengthen the cervix and prevent it from dilating until the end of pregnancy. Evidence that this
procedure is effective would be the client delivering a full-term fetus at 39 weeks' gestation.
Spontaneous rupture of the membranes could indicate that the procedure was not successful.
Vaginal bleeding could indicate another health problem or that the procedure was not successful.
This procedure does not impact the patient's respirations or amount of abdominal pain while
pregnant. These manifestations could indicate another health problem with the pregnancy.
19. A patient recovering from an uneventful vaginal delivery is prescribed Rho(D) immune
globulin (RhIG). What should the nurse explain to the patient regarding the purpose of this
medication?
A) It prevents fetal Rh blood formation.
B) It stimulates maternal D immune antigens.
C) It prevents maternal D antibody formation.
D) It promotes maternal D antibody formation.
Ans: C
Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies
Page: 537
Feedback: Rho(D) immune globulin (RhIG) is given to Rh-negative pregnant patients to
prevent the formation of maternal antibodies to the Rh-positive blood type of the developing
fetus. This medication does not prevent fetal Rh blood formation, stimulate maternal immune
antigens, or promote maternal antibody formation.
Multiple Selection
20. A pregnant patient is diagnosed with preterm labor. What should the nurse teach the patient
to help prevent the reoccurrence of preterm labor? Select all that apply.
A) Drink 8 to 10 glasses of fluid each day.
B) Report any signs of ruptured membranes.
C) Remain on bed rest except to use the bathroom.
D) Lie flat on the back should uterine contractions occur.
E) Engage in mild activities of daily living with frequent rest periods.
Ans: A, B, C
Client Needs: Physiological Integrity: Basic Care and Comfort
Page: 542
Feedback: To reduce the onset of preterm labor, the nurse should instruct the patient to drink 8
to 10 glasses of fluid each day to remain hydrated. The patient should also report any signs of
ruptured membranes and remain on bed rest unless using the bathroom. Should uterine
contractions begin, the patient should be instructed to lie on either the right or left side to
increase blood return to the uterus. The patient should not engage in any activity other than bed
rest with bathroom privileges.
Multiple Choice
21. The nurse is evaluating care provided to a patient in the third trimester of pregnancy who
has been diagnosed with gestational hypertension. Which finding indicates that treatment has
been successful for this patient?
A) Urine protein 0
B) Increased perspiration
C) Weight gain of 1 lb/week
D) Diastolic blood pressure 20 mmHg over normal level
Ans: A
Page: 552
Feedback: Manifestations of gestational hypertension include elevated blood pressure, edema,
and proteinuria. Absence of protein in the urine indicates that treatment has been successful.
Increased perspiration is not a manifestation of gestational hypertension. A weight gain of 1
lb/week in the patient who is in the third trimester of pregnancy is an indication of ongoing
edema. A diastolic blood pressure that is 20 mmHg over normal level is an indication of ongoing
hypertension.
22. A pregnant patient is being admitted for severe preeclampsia. In which room location
should the nurse place this patient?
A) Near the nursery
B) Next to the elevator
C) In the back private room
D) Across from the nurse's station
Ans: C
Page: 552
Feedback: With severe preeclampsia, hospitalization is required so that bed rest can be enforced
and the patient can be observed more closely. A patient with severe preeclampsia is admitted to a
private room so that rest is undisturbed. Noises such as a baby crying, elevator doors opening
and closing, and conversation from the nurse's station is sufficient to trigger a seizure. A private
room will help reduce the likelihood of seizure development.
23. The nurse is monitoring a pregnant patient who is receiving intravenous magnesium sulfate
for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What
should the nurse do?
A) Check fetal heart rate.
B) Measure blood pressure.
C) Stop the current infusion.
D) Increase the infusion rate.
Ans: C
Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies
Page: 554
Feedback: When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon
reflexes are absent. Checking the fetal heart rate and measuring blood pressure could waste time
and provide the patient with more magnesium sulfate. The infusion rate should not be increased
because this could lead to cardiac dysrhythmias and respiratory depression.
24. The nurse is identifying nursing diagnoses for a patient with gestational hypertension.
Which diagnosis would be the most appropriate for this patient?
A) Risk for injury related to fetal distress
B) Imbalanced nutrition related to decreased sodium levels
C) Ineffective tissue perfusion related to poor heart contraction
D) Ineffective tissue perfusion related to vasoconstriction of blood vessels
Ans: D
Page: 551
Feedback: In gestational hypertension, vasospasm occurs in both small and large arteries during
pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the
fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational
hypertension does not affect heart contractions.
25. A pregnant patient is developing HELLP syndrome. During labor, which order should the
nurse question?
A) Assess urine output every hour.
B) Prepare for epidural anesthesia.
C) Position on the left side during labor.
D) Assess blood pressure every 15 minutes.
Ans: B
Page: 555
Feedback: In the HELLP syndrome, patients develop low platelet counts. With a low platelet
count, injections such as epidural anesthesia are contraindicated. This is the order that the nurse
should question. The patient's urine output should be assessed every hour because renal failure is
a complication of this syndrome. Positioning on the left side during labor will help blood flow to
the uterus. Assessing blood pressure every 15 minutes is appropriate for the patient with this
syndrome.
26. A patient is admitted with a diagnosis of ectopic pregnancy. For what should the nurse
anticipate preparing the patient?
A) Immediate surgery
B) Internal uterine monitoring
C) Bed rest for the next 4 weeks
D) Intravenous administration of a tocolytic
Ans: A
Page: 534
Feedback: An ectopic pregnancy is one in which implantation occurred outside the uterine
cavity, usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture.
The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to
remove or repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The
patient does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the patient
is not in labor.
Multiple Selection
27. The nurse is preparing discharge instructions for a pregnant patient experiencing preterm
rupture of membranes. What should the nurse include in this teaching? Select all that apply.
A) Avoid douching.
B) Resume regular coitus.
C) Take a tub bath at least once per day.
D) Expect malodorous vaginal discharge.
E) Measure oral temperature twice a day.
Ans: A, E
Page: 547
Feedback: The patient with premature rupture of membranes is at risk for developing an
infection. The nurse should instruct the patient to avoid douching and measure oral temperature
twice a day. Coitus and tub baths should be avoided because these could introduce an infection
into the uterus. A malodorous vaginal discharge could indicate infection and should be reported
to the health care provider.
28. The nurse is concerned that a pregnant patient is developing polyhydramnios. What did the
nurse assess in this patient? Select all that apply.
A) Tense uterus
B) Sudden weight loss
C) Extreme shortness of breath
D) Difficulty hearing fetal heart rate
E) Uterus larger than expected for gestation week
Ans: A, C, D, E
Page: 557
Feedback: Polyhydramnios is an excessive amount of amniotic fluid. The first sign of this
disorder may be a rapid enlargement of the uterus. The uterus becomes tense, and the patient
experiences shortness of breath because of the uterus pressing on the diaphragm. Auscultating
the fetal heart rate can be difficult because of depth of the increased amount of fluid surrounding
the fetus. The uterus will be larger than expected for the patient's gestational week.

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